29356 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 2 9 I1 5 6
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL L,�/1 ,</ FVC
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAOON SUBMITTAL DATI.
10&(, � Elk�,� ,9ye� y
OWNS-=L , sx �1 P14N5 -190 CO RAf3i R' NAME: L4 YN0:
\VY'---_' l` NIC CON'1'ROLp
CHITECI'/ENGINEER: LIC NO: ADDRES,: ❑
0 2A 7Spa xsr2� BIw�
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ r Rr ❑
provisions o p g QTY ELECTRIC PERMIT FEE
I hereby aRw that I ran licensed under t,Co e. v my(commencing JOB DESCRIPTION
FOoZ with Seninn]IXMO of Division ofthe Business and Pmfeesions Code.and my license is RESIDENTIAL:
IZ in full force and effect. PERMIT ISSUANCE
W F ❑SPDWL KITCHEN REMODEL
�F.UZU License Class 1.iaN APPLIANCES-RESIDENT T[A], [I ADDITION ; PLUMBING RE PIPE
y Q WDate m
Comcaa
A. ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
F to PANEIS
Z O tt Z 1 understand my plans shall be used ss public records MODIFICATION
OZ—O UP TO 2W AMPS ❑INTERIOR [I CHIMNEY REPAIR
P�FI�a]I Licensed Professional 201-IfIW AMPS IMPROVF,MP.NT
�x5G�6 OWNF: xemDERDECLARAr10N OVER 1000 AMPS O BATH REMODELIREPAIR [I DEMOLITION
yy 6C' 1 hereby affirm that I nmmexempt from the Contractors License Law for the
W 3 i U following norma(Seaton]onstru t.alter, and Professions Code:Any city or county SIGNS ELECTRICAL COFFER
u1 LL� which requires a pewit to conswct,altaq improve,demJish,or repair any structure
FH1 poor to iu issuance,also requires the applicant for such pewinn file a signed samnum, SPECIAL IIT/MISC.
f;!(o0 that he is licensed pursuanno the provixionsot the Cnmmcmrs License Law(Chapter 9
W�00 (ecmncreing with Section7(m(o of Division Sof the Bovines,..it Pmleasions Cale)or TEMP.AqZVRDOLE DIST. COMMERCIAL:
116 c C that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION C DEMOLITION
_to Serono]031.5 by any applicant for a pewit subjects the applicant to a civil penally of POWER UE
�' rethen five bunJreJ dalton(S5o0). []TENANT FOOD SERVICE
E �' r n1O IMPROVEMENT
Sap 01,a9 owner of the property.or my employees with wages as their sole compcnemom. SWI 1 .PROLE C
will Jo the work,and the santamrc is nm scrodelorofEred for sale(See.]Btq Business El OTHER
mand Profession,CWe:The Comracmr's License Law docs not apply to as owner of OUT L I:' CHES-P
propsny who builds or improves Overrun. wu
an,and who does such work himself or ttgM1
his own anployces,provide]that such improvements arc not intended or officered for NEW RP_SIDENT .EL R SQ FT.
sde.ILhowever,thebuildingm improvement issold withinone ycv of completion,the SQ.FT FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
poseofwlcJ.
I.as owner of Ne pmpeny,am exclusively contracting with licensed contractors to TOTAL:
common the project(Sec.704,Business and Professions Codc:)The Contractors Li- APR
c se Low ricesno,applytoanowncrmfoopcnywho build.,orimprove,theteon.and QTY, PLUMBING PERMIT PEE APR e199
who contras¢forsuch projects witha contmnur(s)licensed pursuanno the Contractors 6
License Low. PERMIT ISSUANCE.
E] I ant exmnPl under Sec ,B&P C for th,ne.on C11 I/I' C,t
Omer r ALTER-DRAIN&VENT-WATER(HiG VALUATION
Ume
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby anion under,penalty of perjury one of the following declarations:
C'I have and will maintain a Cenifcam or Con¢m to self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,CONT, STORIES TY PE CONST RUCTION
sation,m provided for by Sectio 3700 of the Labor CWe,for the portorntmtm of the
work for which this#conn is issoW. is, FIXTURES-PER TRAP
C I have and will maintain Workers Compcnsalion hisamones.as required by Section
37M ofthe labor Code,for Ne performance ofthe work for which Ms pewit is issued. GAS-CA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Wor Compen-tion lnwmncec rand Policy nY 1T
Carrier: "t--fie-�...--a��cPnllcy No.: t' y7U57- GAS-IiA.SYSTEM-OVF,RJ(EA)
CERDFICATI7 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASrJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Do.,sation need not M completed if the Permit is for one hundred dollars(5100) GREASETRAP
or lcuJ YLANCHECK FEE
I certify that in the perRtrmance ofthe work for which this pewit is issued l shall SEWER-SANITARY-STORM EA.200 FT.
� O NOTICE APPLICANT.If1aRer making this Exemption.
Compen- ENERGYFEEnotreipla
O Z sation Laws of California.Dole WATER HEATER WNENI'11;LECFR GRADING FEE
Z y g p you should WATER SYSTF,MOREATING
f-' ; become subject m the Worker"Compensation provisions of the Labor Code,you must SOILS FEE
Wforthwith comply withsuch provisions,this permit shall he Jeemedrevoked. 1 WATER SERVICE
P
CONSTRUCTIONLENDINGlending agency
NEW RESIDENTIAL PLMIi. SQ.FT PAID
L)z Dam Receipt X
U Q work
affinmhm there twee (Site inn len ding vgcncy for the performance of
0U. f" the work for which this permit is issued(Sec.7097.Civ.CJ
Lender's Name TOTAL:
' �L) Lender's Address - TOTAL:
r I sonify that I have orad this app(ciouou and we out the above Inlin'n anim is BUILDING FEE
FNcorrect.(ugrce to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT PEE
L) Z building eamawction,vad hereby authorirc represvmmivesof his city to crom.foon the SEISMIC FEE
above-mentioned propcny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
litbilitics,judgmenls,costs and expenses which may in any way creme against said City ALTER OR ADD TO MECIL
in consequence ofthe gramfng of this permit.in FEE
APPLICANT U ERSANUS ANO .1.C . PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,000 CFM) MECHANICAL PEE
O ATI S.
I' AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signor ire of ApplicanJCnnn;t Date EXHAUS'FHOODOVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS NAT ERIALS DISCLOSURE
Wall the applicant or future building occupant store or handle haouctrux material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupcnin,Municipal Code,Chapter 9.12,and the Heath and Safety
Code,Section 25532fa)T HEATING UNIT(OVER 100,1100 BTU)
❑Yes CNo PAID
VENT'iLATION PAN(SINGLI?RESIT) Dote Receipt#
Will the applicum or future building cV,ofont use equipment or devices which
m}hoeallous air contaminants a defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 100.000 BTU) TOTAL:
Dninct? BOILER-COMP(OVER 100,000 BTU)
❑Yes CNo
1 have rwJ the htutNnnx maierinlx lcyuiremcros under Chapter fi 95 nl'the Call- AIR CONDITIONER ISSUANCE DA
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RLSIDENTIAL MECH. SQ.Fr.
building docs not currently have a terun6 that it is my responsibility to notify the occupant
of Ne requirements which most be mct prior m issuance of a Certificate of Occupancy.
Owne,a authorized agent Date TOTAL: ISSU EU fly
OFFICE