29620 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /� /N�Y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L \62O
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Zoo Ot'solLi
OWNER'S NAME CONTRACTOR:S NAME: LIC NO:
G I A NIC CONTROL#
1RCHITECTENGINEER. LIC NO O ADDRESS: ❑
0 1a'1 o'TU1 Li53'7
CONfAC1: PHONE: BUILDING PERMIT INFO
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lrl_uK1�T ❑ Consultant Flails Paid by Applicant(Initial) BLDG r:LO PLEB MECx
LICIT SED( NT CFUR'S DECLARATION •N QTY ELECTRIC PERMIT FEE
QngZ I hereby affirm thin I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Se 7000)of Division 3 of the Business and Professions Cook,mad my loess,is
�� in full force and efe PERMIT ISSUANCE RESIDENTIAL
�Uzed AZO A DWL \v ❑PLUMBIKITCHENR EMODF.I.
U Li,ems Cm, Lica APPLIANCES—RISIUENTIN. []ADDITION' ❑PLUMBING RE-PIPE'
�a a Date corer-atom
A IITECTS DECL ❑MULTI-UNIT ❑STRUCTURAL
F rn PANELS
ZOo`^Z lundersmnJm plain shall hto used us lie recd MODIFICATION
OZ�� UP TO 2IXIAM1IPS ❑INTERIOR ❑CHIMNEY REPAIR
PC=FW Licensed Professional 201-1000AMPS IMPROVEMENT
X J OWNER BUILDER DECLARATION OVER IINa)AMPS ❑BATH REMOD° EPAIR ❑DEMOLITION
W 6 1 hereby affirm that 1 um exempt from the Comments License Law for the
aU following reaaon.(Swtion 703L5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL. ❑OTHER Nt7. w. lee LL13 a.y which requires a permit to construct.al¢r.improve,demolish,or repair any structure -
0�' prinnnins i...ance.nlsn requires the appliamllbr such Pcmrit to Bleu signal munemcm SPECIALCIRCUIVMISC.
that he is licensed pursuant to the provisions of the Coloratura license Law(Chapter 9
�IYQD (commencing with Section 7")of Division 3 of the Business and Professions Cade)or TEMP.METER OR POLE INST.
6 that he is exempt therefrom and the basis for the alleged exemption.Any violation of LDG/ADDITION ❑DEMOLITION
oI Section 903156 applicant lin a permit subjects theapplicant to a civil It f POWER DEVICES
^va yang aerially "AN El FOOD SERVICE
not more than five hundred dollars($5 W).
F Z Y JMyROVEMIiN'I'
_ a%Cl ❑L
owner olthe progeny,or my employees with wages as theirmle compensation, SWIMMING POOL ELECTRIC --'#1•C•.
F- will do the work,and theswcture is not intended or intoned for sale(Sm.DWI.Business flEfj�
W^ and Professions Core:'I he Cnnlruclors License Law does in apply 1.an owner of OUTLETS—SWI FCIIES—FIXTURES
6 3^ property who builds or improves former,and who does such were,himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale If.however the building or improvement is sold within one year ofamopletian,rhe SQ.FE FLOOR AREA ESQ.FT.
tor-builder will have the huNcn of proving that he did not build or improve for par-I �"a p
psureofuale,. 4
10
L as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the pro)ecn(Sec.]BW,Business mW Professions Code.)The Convectors Li Oct
crave Law does not apply to an owner ol property who builds or improves thercon,and QTY. PLUMBING PERMIT 17EE e�rya ,j 01996
who contracts fm such projects with a connections)licensed pursuant to me Contractor's
License Law. PERMIT ISSUANCE
E]I am exempt under Sec. ,11&P C for this reason hL�f
Owner Dae ALTER—DRAIN&VENT—WATER(EA) raiGTION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECP.DEVICE V�
I hereby anion under Penally of perjury one of the following declarations: LA
I have and will maintain a Certificate of Consenuoself-imam for Workers Compel- DRAINS—FLOOR.ROOF.AREA.COND. STORIES 'TYPE CONSTRUCTION
sari..,as provided Iia by Section 3700 of the Latin Code.(.,,be performance of the
work for which this Permit is issued. FIXTURES—PERT RAP
NI have and will maintain Worker's Compensation Insurance,as restrict by Seminn
37M ofine Labor Code.for the Performance ofthe wink for which this Permit is ism W. GAS—EA.SYS CEM-1 INC.S OUTLETS OCC.GROUP APN
My WoS�T q ptm Ions p�5 and Politoy� o bar are
Currier PI711..lAlAFiI'1I1N Policy Nn.'L�t/�IXT�uDu�rSGAS—IiA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
his section need not completed If the permit is for one hundred dollars($100)
Ped
GREASETRAP
or less.) PLANCHECK FIT,
(certify mainthe st-fismaranymrineof as to
suamork far bjech tt to danNnikem' ashall SEWER—SANITARY—STORM EA. FT.
not employ any person in any mm�ner so as to become wbjaue me Worker'Compel- ENERGY FEE
C) Z sure.Lows of California.Dae WATER HEATER WNENTIL ECTR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a ' Fecome subject to the Worker's Comperominn provisions of the Labor CWe,you must SOII S FEE
fonhwim comply with such Previsions or permit shall be decriedrevoked WATER SERVICE
a �
7Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLh1B. SQ.FT. PAID Date Receipt#
UQ l for
rwhichirn thatthereis issued
construction0 lending agency for the performance of
the work for which this pemsil is issued(Sea 30Y],Co,C.)
� f•' Lathers Name TOTAL:
UWLender'sAddress TOTAL:
nd
I redid,that I have rethis upplier ion and mane than the above information is BUILDING FEE
T�i1
concert,I agree to csanply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V z building construction.and hereby authorize mpresenatives of this city to enter upon he SEISM IC FEE
uhove-memioned property for in.xpeetion purposes. PERMIT ISSUANCE
(We)agree m m
save,indenify and keep h tr iless the City of Cupertino against ELECTRIC HE
Iiabilitiesjudgmenls.costs ant expenses which may in any way uccmcagainm said City ALTER OR ADDTO MECH.
in consequence of the granting of this Permit. PLUMBING FET:
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CFM) MECHANICAL FEE
SOURCE RI!GULA'I'IONS,
AIR HANDLING UNIT(OVER 10.000 CF.N) CONSTRUCTION TAX
Slgnmmeol'Ap,herm/Conuacmr [)ale EXHAUST HOLD(W/DUC`O HOUSING MITIGATION FEF,
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupant store or handle bararduus munnal HEATING UNIT CFO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 255.121#)1 HEA9'ING UNIT(OVER IW,0f10 BTU)
Yes No
C]Yes
VENTILATION PAN(SINGLE RESID) PAID Date Receipt
Will the applicant.,fume,building occupant use equipment or devices which
emit hrrnNous air comaminan x as denineal by he Day Arca Air Quality M....carrot BOILER—COMP OHP OR 100.000 BTU)
'I'O'I'AL:
District'
E]Yes 0 N BOILER—COMP(OVER 100.000 BTU)
I have read the hazudous materials requirements under Chapterfi95of the Carl- AIR CONDITIONER
ISSUANC ATE
fomiz Health&Safety Cede,Sections 25505.M533 end 25511.1 ualerstwW that if the NEW RF_SIDENTIAL MUCH. SQ.PF.
building does non currently haven tenant,that it is my resp.nsibll ty to nmify the occupant
of Or re,mornema which omd Fe men no,m..sconce or.clemnicute ol'Ocepunay.
Owner or authorized agent [)am T ISSUED BY:
OFFICE I