29926 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-ELECTRICAL PERMIT'NO. 22 6
9 9
RUII,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L VY G v
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SAN]IARY NO. APPLICATION SUBM ITTAL DATE
o49 M WIJ DR . G rho 9-�/
OWNER'S NiK HONE: CONTRACTORS NAME: LIC NO:
Z
C �f4/67 91- NIC CONTROL#
limp'.RCHITECTIENGINEER: V LIC NO: ADDRESS: O /
CONTACT. PHONE: BUILDING PERMIT INTO
r ^ , • we7 �� El Consultant Fees Paid by Applicant(Initial) BLDG t1.liCr PLUM ECx
O LICELN•SEE CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE +IJP•`•
I hereby afttm that;'in licensed under provisions of chapter 9(commencing 1 B DESCRIPTION
wan til Section OOX))of Division 3 nine Buslnexsand Profeaiens Ciale mW my license is RESIDENTIAL:
I+IOp w PERMIT ISSUANCE
<FLL� L one Class Jeffect. ❑SFDWL ❑KITCHEN REMODEL
-U License Class Lic.N APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE PIPE
1-Z WDale Cmaraetnr
ARCHITECTS DECLARATION ❑MUIITI-UNIT E3 STRUCTURAL
ZFpt Z lunderstand my plateshall be usedseepublle records PANELS MODIFICATION
O24O UPT0200AMPS ❑INTERIOR ❑CHIMNIiYREPAIR
F uAf"'q Licensed Professional 201-1000AMPS- IMPROVEMENT
gai:m•,.4t OWNER-BUILDER DECLARATION OVLR 1000 AMPS ❑BATH RF.MODEDREPAIR �Eh10LIT10N
C C Q I hereby am am ffirm NI exempt from the Contractors Limine Law far the
O LU following reason.(Section]031.5,Busiws,and Professions Cade:Any city or county SIGNS ELECTRICAL [IOTHER
3 LLa which rcyuims in permit to construct,ahnq improve,demolish.or repair any swnure
F'LLOJ prionoit issuance,also rcyuires the upplicwnlor such permino RleasigneJ smtemem SPEC1ALCIRCUDUMISC.
than he is licensed pursuant .,he pmvrsionsofthe Commences License Law(Chapmr9
Ise.14 (rommencingwith Smtion7M))ofDivision3 ofthe Buonessand Professions Code)or TEMP.METER OR POLE.INST. COMMERCIAL'
LM c�t than he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDGIADDTTTON ElDEMOLI'T'ION
7,�(( Section 0031.5 by any applicant for a perma subjemapp
s the licant ur..,l penally of POWER DEVICES
ly�q ❑TENANT ❑FOOD SERVICE
F_ZY °t more than rive hundred dellnrs($300) IMPROVEMENT
=60 L as owner of the property,or my employeas with wages as their sole compcnsanion. SWIMMING POOL ELECTRIC
�E.as willd.flac ork.and thestrvc.re is omitnerdoulmoTemd forsec(Sm.9(164,Business DOTTER
I�il�% and Profession,Code:The Contmeor's Licenu Law does not apply tat an owner of OUTLETS-SWITCHES-FIXTURES
a 3 properly who builds or improves thereon,and whe does such work hlmsel Ior through
H, we employees,provided that such improvements are not intended or offered for NEW RESIDEN'T'IAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one yearnfcomplction,the SQ.FT FLOOR AREA VSQ.bT.
po -builder will have the burden ofproving than he slid not build or improve for purr- n
soof sale.).
O 1,os owner of the property,am exclusively cmalonin,with licensed umuacmrs to TOTAL:
construct the project(Sec.9044,Business and Professions Code:)The Commemr's Li. �pp��/�
cause law does not apply uranowner ofproperty who builds orintprovesthereon.and QTY. PLUMBING PERMIT FEE NAY 30
who contracts for such projects with.Contmmor(s)licensed pursuant to the Cootmemes v /ggc
License Law. PERMIT ISSUANCE ��j' {1
❑ I am exempt under Sm. .H&P C for this reason Lri E,V
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE (t�Y
T hereby affirm under penalty of perjury one of the following reductionskaCC .
,.firm
. idedfar by eco#.37W of Bic Labor
Cock. the
Wformace of the
DRAINS-MOOR,ROOKAREA.COND. STORIES TYPE CONSTRUCTION
cation......idhi for by Section issued. o(thc Tabor Code,for the performance of the
work forwhich Hills permit is rker FIXTURES-PF;H TRAP
I have and will ode,lot Workers Compensation work
whi h required by Section
31W of the Labor Code,lot performance of the work for which this panni#is issued GAS-EA.SY$TF.M-I INC.4OUTLETS. OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.: GnS-EA.SYSTEMd)VER4(EA)
CERHFI CATE OF EXIiMPUON FRQh1 WOR KERS'
COMPENSATION INSURANCE GREASE/INDUS"TRI.WAST[INTERCEPTOR BUILDING IVPdON IT S
(This section need not be completed it'the Permit is for one hundreidollars(SIN)) GREASETRAP
ser loss) PIANCHECK F7_,'
loriify than int he perturnmernf me work for which this penin is issued,)that l SEWER-SANITARY-S'IORM EA.20X)FT.
rn
not tploy any Person in any bounce nn as It)become subject m the Workers Compen- ENERGY ITE
ZZ cation laws of Califomia.Dane WATER HEATER WNEST IELECTR
O Applicant GRADING
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING
become subject no the Wmkcr's Compensation provisions of the Labor Codes You moa SOILS FEE
WQ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
72 CONS'rRUCTON LENDING AGENCY NEW RESIDENTIAL PUMPS. SQ,EL PAID I
am Receipt#
U 0 l hereby affirm that there is a construction lending agency for the perfomutnce of
U. F the work for which his permit is issued(Sri.3099,Ci v.C.) TOTAL
Lenders Name�� Lendees Addoa, TOTAL. BUILDING FEE D ice'
I certify that 1 have read this application and state that the above information is
N correct.T agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby amhorire reprcsemmives ofnhi.scityto enmrupon the SEISMIC FEE
atheve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep fanatics,the Chy of Cupamnc against ELECTRIC FEE
habilinics,judgments,costs and expenses which may in any way arrow against said City ALTER OR ADDTO MECH.
PLUMBING FEE
in Consequence of the granting of this pernot.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 10.000CF%U
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IO.OtX)CFM) CONSTRUCTION TAX
Signature of Applieam/Cotnmemr Date EXHAUST HOOD GAIMUCf) HOUSINGMITTGATIO'FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplia.m.,furore building occupoolu eor handle harmdon.material HEATING UNIT"TO 100,M)BTU)
I`
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cotte.Section 25532fa)7 HEATING UNIT(OVER 100,00)BTU)
0 Yea []No VENTILATION PAN(SINGLE RFSID) PAID
Will thea applicant or future building occupant use a Henn or devices which Dtne Recoil x
pp y pan yuipt BOILER-COMP QHP OR 100,000131U)
emit hm.ardmu,air ammmiwms as defined by the Bay Arca Air Quality Management .ro 3 • G
Lis
BOILER-COMP(OVER 100.000 BTU)
❑Nn read the lr.uudusmaterials rcquirenmms under Chapter 6.95ofthc Cali AIR CONDITIONERISSUANCE ATE
&Safery Code,Sections 25505,25533 ad 25534.1 understood that if the NEW RESIDENTIAL MECH. SQ.IT.
non currently have a tenant,that it is my respomsful ly to notify the acupents wmenns which must be met poor m issuance ofa Certificate ofOecuWncy.....ad.gent Dare I TOTAL: ISSUED BY:
OFFICE