30029 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY of CUPERTINO BUILDING-ELECTRICAL. ,PERMITNO. O O
- BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJEITI'IDENTIFICATION
29
BUILDING ADDRESS: - SANITARY NO, APPLICATION SUBMITTAL DATE
s QA
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: L NO;
t- . t^ NIC CONTROL
ARCHITF.CTAESGINEER: LIC NO. ADDRESS: ❑
rn InlL uAlff C/ni
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees can
Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
33 an ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FIiE
I hereby nffiem Nat I an licensedunder pron visioof Cheerer 9(commeraing JOB DESCRIPTION
d'z iN Sation](70p)of Division7of the Businasand Prnfesxions Code,nodus licemcis
00 w y PERMIT ISSUANCE RESIDENTIAL
F� infill force and effect. ❑SFDWL ❑KITCHEN REMODEL
�U License lou Lic.M .n
APPLIANCES UemCanwcwriJ o-w n ❑ADDITION [I PLUMBING RE-PIPE
1-, L ARCHITECTS DECLARATION PANELS - C MULTI-UNIT ❑STRUCTURAL
z O'z 1 understand my plans shell od used as public recoNs MODIFICATION
OzYJQ UPT0200AMPS - C3 INTERIOR ❑CHIMNEY REPAIR
Licensed Pm&ssi...I 201-1000AMPS IMPROVEMENT
OWNER exempo fr DECLARATION Contractor's
ON OVER 1000AMPS [I BATH REMf�QEI/R^PAI , MOLITION
yGyC 6 I hereby affirm that 1 R-exempt from the RATImor's License Law for the 0C/�
P(a6V following reaxm.l$ation 1031.5.Business unJ PmlessinnsCode:Any city nr county SIGNS ELECTRICAL F1 OTHER
LLLL17=O which requires o permit to conswa,ulleq improve,demolish,or repair any structure
primmus issuance,alsompiders theappiicam formch pcmtittofdea signed statement SPECIAL CIRCUIT/MISC.
} that be is licensed personal n the provisions ofthe Cantmmor's Liceaw LawlChapmr9
p0 (commencing with Section]00(mof Division 3ofthe Business and Professions Cade)ar TEMP.METER OR POLE INST. COMMERCIAL:
q e C
that he is exempt therefmm and the basis for the u11egW exemption.Any audition of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for.permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�} not am than five hundred dollars($5170).
Q �1.as owner ofthe property,or my employees with wages as their side compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
O will do the work,and the structure is not intended oroffered for sale(Sec.71100,Business []OTHER
and Pmfasiam Code:The Convenors License Law does nm opply'm an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.IL however,the building or improvement is sold within one year ofcumpdetion,the SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pan
pose of mala.). LO
❑ I,as owner of the property,am exclusively enntmeting with licensed contractors to TAL:
cansaact the project(See.70,14,Business and Professions Cd,:)The Contractors Li-
censeLwdoesnotupplytoanownerofpropertywhobuildsorimprovesthereon,and QTY PLUMBING PERMT FEE Jy O 1.796q(I(][
who contracts fmsuch proaa
projects with a cuneodq UN 1 licensed pursuant to the ConuamMs ll
License Law. PERMIT ISSUANCE
❑lamexemptonler .Sec. ,B&PCfermisreason f'r v 11
ALTER-DRAIN&VENT-WATER(EA) ;tL 'ION
Owner - UIO
• WORKER'S COM PENSATION DECLARATION BACK FLOW PROTEGE DEVICE -
1 hereby ill mai under penalty of perjury one of the following Workers Con
have and will for b in a Certion 37 0 of the sent toLabor
Code,
for Worker's cempen- DRAINS-FLOOR.ROOK AREA,GOND. STORIES TYPECONSTRUCrION
ben,as provided for n Section d. of the Labor Cade,for Ne performance of One
irk for which this permit is issued. FIXTURES-PER TRAP n �oantli
1 have and will maintain Workers ante ofibe w Insurance.ast hhis per by Section 1 UP W
3700 Ohba Ohm Cede,for the performance of the work forwhichthis permit is iswul. GAS-Ep.SYSTEM-I INC.00l1TLFTS OCC.CROUP ANN
My War nm aria m aaicr and Policy 'M 09Ig{�d OAS—EA.SYSTtiM-OVER4(CA7
Corti¢ s n Policy Na., 1 V( .Yf
CE TIPI AT8 OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRCASP/INDUS'1'RL WASTE INTERCEPT OR
(This section need not becompleted if the permit is furore hundred dollars($100) BUILDING DIVISION FEES
ar less.) GREASC TRAP PIANCHECK FEE
I certify that in the performance of Ne work forwhieh this permit is food.I shall SEWER—SANITARY—STORM EA.200 ff.
CZ not employ troy person in any manna sec om�h'ct m Ne Worker'Compen- ENERGY MEsans.Laws WATER HEATER WNENT/L'LT:LTR
0 CZ Applicant - GRADING FEE
r NOTICE TO a mr m a enificale of Exem tion,you shoulJ
N P{Ta a become subject the Worker's Compensation provisions of Lehr Code,you must WATER SYSTEM/IRHATING SOILS FEF.
forthwith complyy with such proMdeemed or this permit shall deemed revakeJ, WATER SERVICE
Q
� CONSTRUCTIONLENUINGAGENCY NEW RESIDENTIAL PLM SQ.FT. PAID
hereby fthi that isaconstruction agency frthe Performance of
Doe ReceiptMU O the worfar which Nis pcnadis issued(See097.Co.
Cd
U Lender's Name TOTAL:
UJLemlars Achdre. - TOTAL.:
Qw I I certify Out 1 have read Nis application moisture that the above im momma on is BUILDING FEE
(A corect.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U,'� building conswaion.and hereby euthoriu repmmnmtives of Niaxitymcnmr upon the SF"ISMICFER
`n above-Illcationed property for inspection purposes.
(We)agree w save,indemnify end keep harmless the mCity of Cupertino,funst PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD'TO MECH.
in consequence of the granting f t
ohis permit. PLUMBING PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO IO."CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Sign ature.fApplica eContmcwr Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 101yX70 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cala Section 25532(a)7 HEATING UNIT(OVER Usy"BTU)
El Year PAID /� O^_
/V a VENTILATION FAN(SINGLE.HESIU) Dam Receiptar /4/ r/U
Will the opplicaut r future building occupant use equipment or devices which
emit hostabous air contamirums a defined by the Bay Area Air Quality Management BOILER-COMP CIR OR 100,000 BTU)
T
LDistdct? �S BOILER'-COMP(OVER 100,(X10 BTU)
El es y�s(7,e read the hamnlnns materials acquirements under Chapter 6.95 of the Cali- AIR CONOITIONF.RISSUANCE DATE
&Safety Cade.Sections 25505,25533 and 5530.I understand thus if Ne NEW RESIDENTIAL MECH. SQ.PT.
s not currently have a retro Nat it is my responsibility to modify the occupantmcut,which must brriar to isa...ofn Certi�' i Igeni Dna TOTAL: ISSUED BY:
OFFICE