29328 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO. /� I� /�(�
BUILDING DIVISION APPLICATION/PERMIT PI.UMIMNG.M. IIANI'A29328
I,
BUILDING PROJECT IUENTIFIGkTION V
OUILDING ADfiSS: �� R SANITARY NO. AI'PP�LIICATION SUBMITTAL DATE
6 V /.�, O
00 R5 NAME: PHONE O J O LIC
1 LC1I n �y NIC CONTROL Xw
�RCHRECf/ENGINEER: LIC NO
'ADDRF `i' / ❑
CONTACT: YHONF:: BUILDING PERMIT INFO
�1y�1rr� 6Q'��� � ' ID�� ❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB �MfCy
J — LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE `�`'(�
I hereby union that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�a'Z with Scetia 7000)"I'Div fthc Business and rofcs'ons Cede,and my licensees RESIDENTIAL:
FOO info emnd )"I' PERMIT ISSUANCE
t-z CSFDWL CPLUMBIKITCHEN REMODEL
aVV Lt hs.N APPLIANCES-NISIDIiN'1'IAL DDITION El PLUMBING RE-PIPE
u,a og m camamm
ARCHITECTS DEC[A TION PANELS CMULTI-UNIT [I STRUCTURAL
Z O`,iz i undoomad my plans shall he used as public records MODIFICATION
t7z=0 UP TO 200 AMPS CINTERIOR [I CHIMNEY REPAIR
F F'W License)I'rofessiomsl 201-IOW AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
�^a Q 1 hereby affirm that I am exempt from th,Comment's License Low for the OVER 1000 AMPS C BATH REMODEUREPAIR C DEMOLITION
a-L V following reason.(Section 7031.5.Business and Professions Code:Any city mentally SIGNS ELECTRICAL ❑OTHER
ala
0 ya which requires a permit to construct,alter,improve,demolish,or repair any structure
F.4'.x..1 priorto its issuance,also requires the applicant u,nich penning filensigneJ sbnamor SPECIAL CIRCUS UMISC.
that he is licensed pursuant to the provisions of the Comractnrs License Law(Chapter 9
HOC (commencing with Section 7")of Division J ofthe Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
a ca that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
NSection 7031.5 by oily applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES CTENANT [I FOOD SERVICE
oat more than tout hundred dollars($500/.
�z6 IMPROVEMENT
pias owner of the property,or my employees with wages as theirsole compensation. SWIMMING POOL ELECTRIC
El OTHER
willdo lhcwork. nd thevtmcture iuun intendedoroffcreJ onsale(See.7044.Business
a
413 ad and Professions Cade:The Coniracmr'x Eittnse Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property,who builds or improves mcreon,and who does such work himself or through — N
his own employees,provided that such improvements are not Intended nr offered for NEW RESIDENTIAL ELRCTR SQ PT
sale.If,however,the building or imp rovcurrent ismld withinaneycar.(completion,the SQ.FT.FLOOR AREA SISQ.FI'.
mer-builder will have the burden of proving that he did not build or improve for put-
Dtse made), l/O_
C 1,n owner of the property.not exclusively contracting with licensed comment,w
onsuuct the project(Sec.7014.Business and Professions Cade:)The Contractors Li.
ase Low does not apply to an owner ofptopny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commelons)liccmed pumaant to the Contractors
License law. PERMIT ISSUANCE
C l am exempt under Sec. ,B se P C for this reason
ALTER-DRAIN IS,VEMr-WATER(EA) VALUATION
Owner Uam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE olai
I hereby affirm under penalty of perjury one of the fallowing declarations: s
I have and will maintain a Certificate of Conscm to sdLimurc lox Worker's Compos DRAINS-FLUOR,ROOF AREA.C014 STORIE' 'TYPE CONSTRUCTION
radon,as provided for by Section 3100 of the Labor Cale,for the perf nam nce of the
,,,it for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required Ity Section
of the laMr Cole,for the pedonnence of the work for hills rmit i issued. GAS-EA.SYSTEM-I UI TSS OCC.GROUP APN
orkcr' t'yjon In,. aowneradd is u
artier, a GAS-EA.SYSTEM-OVER4(EA \
CERTIFICCOMPENF�N INSURANCE TION RKF L,�// `/�J9 GREASEANDUSTRL WASTE INTERCE\ � pU N UI
(This sect too reed act be completed Hone permit is lixanch tYCJ�tIIII/((S l ll)) BIDN FEES
GREASE.TRAP ,� PLANCIfiiCK -
an less.)
I codify that in the performance of the work for which this permit is inuN,l Shull SEWER-SANITARY-STORM EA.2001T.
not employ any person in any manner.so as to become subject to the W,rinco''Compen- ENERGY F
O 2 smion lows of Cut Em iu.Dore WATER SEEM Bit WNL'NT/ELIiCTR GRADING FEE
Z 2 Applicant
(z) NOTICE.TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEMITREATING SOILS FEE le
a5 ho:ume subject to the Worker's Cmupruncoon provisions of the Lubar Calc,you must
U.1 forthwith forthwith comply with such provisions or this permit shallM deemed revoked. WATER SERVICE
P. 0 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V0 I hereby affirm thanhem is a nmsuvction lending agency forth,perommaneeof Dote Roc- t#
the work for which this permit is issued(Sec.3110,Co,C)
OF Lenders Nene TOTAL:
V Lenders Address
1 comfy that 1 have road this application and state tha the above information is BUILDING FEF: , /^
.F. tai) concoct.I Isms,to comply with all city and county ordinances and.state laws relaing to QTY. MECHANICAL PERMIT FEE
V ,7. bmaurg,olormtin 1,and hereby mahodm rcpmscmntivu of this caym error upon the SEISMIC FEE
above-mentioned property far inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Collection.gaunt ELECTRIC FEE
15 94.0ts
liabilities.judganco"'cows and expenseswhich maymany way recroeagainslsaid City ALTER OR ADDTO MECH,
in nscquence of gmntiagof hi.spcmtit PLUMBING FEEAPPLICANT U D:RSTAN AND WILL COMP WITH ALL NON-POEN AIR HANDLING UNIT ITO 10.0(10 CFM)
SOURC7 : 1 T10N / MECHANICAL PEE `
AIR HANDLING UNIT(OVER IQ000 CPM) CONSI'RUCTION TAX
Signawr hcaHAZAtmaor Dmc EXHAUST HWD(W]DUCD HOUSING MITIGATION FEE
HAZARDO S g occup DISCLOSURE
Will the applicant or fume building stacupam stow or handle hamrdnus material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupeninu Municipal Cale,Chapter 9.12,and the Health and Safety - t
Cade,Section 25,532(a)'! HEATING UNIT(OVER 100.000 BTU)
Yes No 'Y1G6r /
C C VENTILATION FAN(SINGLE RESIDE LAID. 1Dat lqqReceipt#
Will the applicant nr future building occupant use equipment or Devices which BOILER-COMP(3HP OR I00,(MIB BTU) rU 1
mit brrardoux air contaminunu m defined by the it'ay Arca Air Quality Management 'IU L'.
�DISIIICQ BOILER-COMP(OVER 100.000 BTU) 0111 Vr VUr L1111I0k
❑Yes FIN.
Ihave re:W Oto M1avvdous materials requirements under Chapter 695 of the Cali AIR CONDiI'IONER ISSUALI TE
forms Health&Safety Carle.Sections 25505.23533 and 25534.1 understand tha if the NEW RESIDENTIAL MECH. SQ.FT /
building does not curently have a brant,mot it is my responsibility to notify the mention Sys
of the requirements which most be IN prior w isomeric of a Compoac of(Rcupuncy. In 04,
K{//J
Owner or authorized agent Dab T( ISSUED BY:
OFFICE