29592 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL- PERMIT NO.
' BUILDING DIVISION ` APPLICATION/PERMITPLUMBING-MECHANICAL 29592
BUILDING PROJECT IDENTIFICATION
BUILDIN ADDRESS: SANITARY NO. APPLICA3'ION SUBMITTAL GATT
0P2Qa6
OW 'S ONE: p• AC 'S A B: Q^�
— o Air J L' NIC CONTROLp
ARCHITECTENGINEER: LIC NO: I )R 'S: s
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FE - ❑
1 hereby affirm that 1 an licensed under p...mislaid Chapter 9(commencing JOB DESCRIPTION
O�Z with Section7")of Division Sof Ne Businessand Professions CM[, it licenu is
OO y PERMIT ISSUANCE RESIDENTIAL:
in full furca and effect
J U~ License C ss tic.p 0 SFDWL 0 KITCHEN REMODEL
U Dam Corrector APPLIANCES-RE9ID8NTIAL
�ZyCj ❑ADDITION � ❑PLUMBING REPIPE
A CHITECI'S DECLARATION
FOO' �� PANELS ❑MULTI-UNIT []STRUCTURALZ O rn Z 1 understand my plans shall be used os public records MODIFICATION
OZ-0 UP TO 280 AMPS 0INTERIOR ❑CHIMNEY REPAIR
FSI:; Licensed Professional 201-IAMAMPS IMPROVEMENT
3 ..1 OWNER-exempt frDEthe Cow ION OVER IWOAMPS C BATH REMOOELIREPAIR EIDEMOLMON
6 1 hereby affirm that 1 am exempt from the Caouaet`ds License Lew for the
aU fallowing reason.(Semon]071.3,Busineasmd'Prf -ibn6deMn day rcwunty SIGNS ELECTRICAL []OTHER '
LL a. which requires a permit to cont f.Imjsnssc" m '7 ape •is amucume
primtoi,iommue.als euun'h' ntf' m r la¢mem SPECIAL CIRCUTDMISC.
y�'p- thin he is licensed pun amt h'Pmvmi t um rn .hrpmr9
III '0 (smarawaingwiNSecv •f�i 'm 1 m 'esfiio 1V TEMP.METER OR POLE IN COMMERCIAL:
SG,�K that he is exempt donee ma t m an•' n E]NEW BLDG/ADDITION EIDEMOLITION r
x�e lilt Sation]031.56yanyap i' rl in d Ij am '"a ry I POWER DEVICES
41^rn — p w ❑TENANT ❑FOODSERVICE
not mote than five bun a
Q ❑I,as owner 0(the n 1 m «; �Ft SWIMMING POOL ELECTRIC IMPROVEMENT
CC will m Nework,end cru Sm1 []OTHER
W and ProfessimsC e o hr 1 tier of OUTLETS-SWITCHES-F
foreplay who builds smpmso them I kT trtxlf or ugh
his own employees, rAded r mmended m one rcd for NEW RFSIDENTIALELECTR Q PT.
We.If.however the wuddmgom d' i'n'ane yew ofcomplction.rhe SQ.FT.FLOOR AREA $/SQ,FT.
owner-builder will hgylibdb m th d(dml builder improve far four.
paseofsale.).
Las owner of the property,e,n t'blusively cantrurin8 with licensed cammctors m TOTA . C ✓/i�
construct the project(Sec.7044,Business and Professions Code:)The Convector's Li-
cense law does not apply to an owner M property who builds or improves themon.oml QTY PLUMBING PERMIT FEE `./f 'ar
who contracts for such projects with a commissions)licensed pursuanu0 the Contractors
License law: PERMIT ISSUANCE h t. 996
0 I am exempt mmdm Sec. ,B&P C for this reason U."_ p•
Owner
ALTER-DRAIN&VENT-WATER UA) VALUA-TfON
Dme
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
leiI hereby affirm under penalty of perjury one of the fallowing declarmions:
O l have and will maintain a Certificate of Consentto self-insure for Worker's Coupon. DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPECONSTRUCTION
some,as provided for by Section 37M of the Labor Code,for the performance of the -
far hand
th I permit is issued. FIXTURES-PER TRAP
1
have d IItain Workers Compensation Insurance,as required by Seen.. -
of fill t wmainfCMe,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP "APN
My We, f m�Ehsuti o once carrier ad Pnliey2i rjr�.��/ n GAS-13A.gYS'IEM�OVBR4IP.A) ,
Carrier: �� Policy Na: V•i - YU
CERTIFICATE OFEXEMNIONPROMWORKERS' -
COMPENSATION INSURANCE GRRASFIINDUSTRL WASTE INTERCEPTOR
(This section need not his completed if the permit is far ono hundred dollars 1$100) BUILDING DIVISION FEES
or less.) GNEASE]'RAP I
PLANCHF.CK FEE t
Toy an,that inthe performance o.111,bwork for which this the W is issued,Cdlstill SBWP.R-SANITARY
not employ n nn manner so us am Mamma suh'ca In the Workers'Cam m- STORM EA, FT.
Z wrion LawsofCalifornia.Dole ) pot ENERGY FEE
6 I WATER SVS'fNM(fN ,
00 Applicant WA'HiN I IEA]'ER WNENT/HI.EC1'R GRADING EEE
4 � NOTICE TO APPLICANT.Jr.after mi ibis Certifcum m f Emulsion,you should
/ EATING
F" S become subject m the Workers Compensation provisimms of the lamhar Cale,you our SOILS FEE i
t� forthwith comply with such provisions or this permit shell he deemed revoked WATER SERVICE
�zCONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.Ff. PAID
U O l hereby affirm that is a congimich lending agency for the Performance of Date
IL the work for which this permit is issued(See 3097,Civ,C.) -
0 U Lender's Name OTAL:
LLI Lender's Address TOTAL:
1 certify thus I have mad this applismom mm smte that the above information is BUILDING FEE
Vaj correct.I agree t comply with all city and county ordinances and state laws relyingto QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authodre represenstives of this city team,upon the SEISMIC FEE
above-mentioned propeny for insp oma purposes. PI3RM1'T ISSUANCE'
(We)agree to save,indemnify and keep harndcse the City of Cupertino against ELECTRIC FEE.
Iiabilities,judgmems,costs and expenses which may in any way same against mid City ALTER OR ADD TO MECH.in consequence of the griming of this permit. PLUMBING FEE
APPI CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOU F.REGULATI WS. MECHANICAL FEB 1
1A 1A f IrlQ^ AIR HANDLING UNIT(OVER 1(I,fgq CFM) CONSTRUCTION TAX
Signature of Applica ormacmr Dam EXHAUST HOOD(W/DUCT HOUSING MITIGATION FEE
[JAZARDOUS MATERIALS DISCLOSURE.
Will theappleant or future building occupant smrc or handle hamrdous material HEATING UNIT DID I00,000 BTU)
in defined by the Cupertino Municipal Code,Chapter 9.12,and the Heads and Safety
CMe,Section 25532(a17 , HHATING UNIT(OVER I0TONT BTU) -
El yes ❑No VENTILATION PAN(SINGLE RFSID) PAID
Date Receipt p
Will the applicant or future building occupant y A equipment or devises Mwhich anagement'
mit hmamomu air contnminanmvdefinedb the Re Area Air yBOILER IW,IXIOBN)' -
( y y Quality TOTAL:
DisWn40Yn CNo BOILER-CHIMP(OVER 10d"BTU)
I hareed use e haumateriels ateriels re whernera under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
f nam Health&Safety Code,Sections 25505,25333 it 25534.1 makrstvtd that if the NEW RESIDENTIAL MECH. SQ.FT.
building does art runway have a termor,that it is my responsibility ro nmify the ceaupam
of the requirements which must be mer prior to issuance of a Certificate of Occupancy.
Owner or authomzed agent Dam ] ISSUED BY:
j - OFFICE _