29621 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFLCdrION 29621
BUILUINGADDRESS: SANITARY NO. APPLICATION SUIIMI FTAI.DAPI'.
80-74 u
OWNER'S NAME: PHONE: CONTRACTORS' - ME: LIC NO:
M YMy( � NIC - COMROLp
Olt>RCIIITECT/fiNGINEER: LIC NO ADDRESS: ❑
0. ;o la1 CIU 3
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant F"s Paid by Applicant(Initial) BLDG ELECT PLUMB MM
❑ L11 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF,
I hereby affirm that I am licensed Linder provisions of chapter 9(commeming JOB DESCRIPTION
WOO thSndon 91X0)of UivisionJof Ne Businessend Professions Csde,and my licenseis
F�� irnrfull force anti B PERMIT ISSUANCE
mF C2 O SFDWL ❑KITCHEN REMODEL
�UU Linen Cl.sc 1,ic'N APPLIANCES-RES1DIiNT1AL ❑ADDITION ❑PLUMB ING R F.PI Pit
y Q W Data Cuntranor
fog iai A CHITECTS DECLAI PANELS
El MULTI-UNIT ❑STRUCTURAL
p v l understand my plaru.chall he...d as public ads MODIFICATION
OZ=p UP TO 200 AMPS C3 INTERIOR [I CHIMNEY REPAIR
W Licenced Prom..lmhit l 201-1000AMPS IMPROVEMENT
�ydw; OWNER-BUILDER DECLARATION OVER 110BAMPS C1 BATH REMODEL/REPAIR DEMOLITION
C C Q I hereby affirm that 1 and exempt from the Cominach is License Law for the
uKj3 p�,U following reason(Section V(HI.S,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
y which requires a permit to consumer,niter,improve,demolish.Lir repair any"'acture
0�'
prime.asis..Limaown myuires the applicant for such Permian file aligned statement SPECIALCIRCUIT/MISC. S,
yy that he is licensed pursuant the provisions of the Commnor'.s License Law(Chapter 9
COMMERCIAL:
C O (cat he is sem ith Scrota and of basis for the
theeged exempt on,Any
'TEMP MIiTER OR POLE INS'1'.
d 6 ey that be is 31.5 bT therefrom and are basis for the alleged exemprion.Any violmian of ❑NEW BLDG/ADD ❑UI'..MOLITION
,MN Seminn]p3 L5 by any applicam Pordpermitsobjects the applicant to;, penalty of POWER DEVICES
T more than five hundred dol 5500). ❑TENANT Cl FOOD SERVICE
F=Q ❑has owner of the property,or my employees with wages ac their sale compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the s'uc"e is not intended ordiercd for sale(Sec. Business DOTTER
W and Professions Code:The Coneracorzs License Law does not apply n)an owner of OUTLI2 rS-SWI TIES-FIXTURES `�
a 3 his own corn builds Lir improves thereon,and who ins such work intended«Ifti Through
hisownowever,th,building hatstach mens isemenmam on yew ofLirpletio.fficnal for NEW RI?. ' T LC:LECfR SQ ET.
sue.If,however,the building or improvement is wild within one year ol'n+mpletion.the SQ.FII FLOOR AREA Is/SQ,Pl'.
mer-builder will have the burden of proving that he did not build or improve for put
grvc of"sled.
Fl I,v owner of the property,am exclusively contracting with licensed contractors to - 'f AI.: Z
consumer the project(Sec.7844,Business and Professions Calc:)The Conuamor s Li-
censeLaw does nmapply manownet orproperty whobuilds orimproves thereon,and QTY. PLUMBING PERMIT PEP,
who contracts for such pmjecor with a contestants)licensed pursuant m the Contractor's
License Law. PERMIT ISSUANCE
❑I ten exempt under See .B&P C Iia this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam
WOR KERS COMPENSATION DECLARAION BACK FLOW PROT ECC DI?VICE 0Odd
T
OF1I bemby st16m under penalty of pepury one of the following dedarvi...:
Ihm'e anti will mainmina Ccnificmc ofCnnmm meelf-insure for Workers Cnmpcn- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
smion,u provided far by Section 37I0 of the Labor Code,lir,the pert nanothcc of the
RN ark far which this Permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,Lia required by Section
J Wnf the Labor Code.for the performance of the work for which Nis permit is issued. GAS-17A.SYSTEM-I INC.40UTI.InS OCC,GROUT' ANN
My Work<� Co�mpc ,W �Im��u a�r�tw�i�f ��i�mmul Policy BBn/a
Carziera%VXz3 HYY0.'KA CIm Policy Nor: OtJ GAS-P.A.SYSTEM-OVER 4TA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRLWASTE INTERCEPTOR
Qhix semina and not hcttnnplmcd if the permit is(atone hundrNdollars(S I(gB SD IVISION FEES
less) GREASE TRAP PLANCHECK FE FEE
I certify that in the performance of the work for which Nis Permit is issued.I shall SEWI7R-SANITARY-STORM EA.200 FT.
not unmloy wry person in any runner so as in heroom subjectto the Warkerc'Compen- ENERC
Z variant laws of California.Date WATER HEATER WNENT/ELECTR
ZQ APPlicmw GRADING FEF.
NOTICE TO APPLICANT.It,afro making..his G.afdi,wa of EscaTe it you should WAT UR SYS'11iM/1'REATINOF V r a_n
become srhjmt m the Worker.Carpe,wion provisions of the Labor Code,you mLou 5016 iIIEG
fall fonbwito comply witbsuch...visions or this permit shall be deemed revoked. WATER SERVICE
4s CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SUET. PAID
:D zU O Ihereby affirm That there is a constructed lending agency for the Performance of Dam Receipt
F the work fm which this permit is iswM(Site 309'1,Cls.C.)
(L Lenders Name
TOTAL:
U Leadc',Address TOTAL:
I eerilyNat 1 have read Nisupplieotion ad rate rta he BUILDING FEF.
' aoata6ovc infnnnmion is
E^
Incorrect.l agree to comply with all city and county ordinances and"rate laws relating to QTY. MECHANICAL PERMIT FEE
U Z bai Wing con.arom, n.mmd herebya thnram repm"entmh'cs of this city In eme,ti The SEISMIC FEF.
abtwe-mentioned property fninspcc-ion purposes. PERMIT ISSUANCE ,i— ELECI RIC IEE
(We)agree m save,indemnify and keep hermdcss she City of Cupertino against
liabilities.judgments,cows Laid expenses which may in any way accme against said City ALTER OR ADD TO MECH. '
PLUMBING FEE
APLICAe a of theUNDERSTANDS
of ANpe WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT(TO 10.00)CPM) Z
SOURCE R[CUfA'1'IONS. MECHANICAL.FEE
AIR HANDLING Usti'r(OVER 10,0011 CFM) CONSTRUCHONTAX
Signamreof Applicant/Comractnr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe oddiewal or future huildi.,eccupamnmm or handle hazmdous material HEATING UNIT(TO Bliko0 BTU)
as defioal by the Caperton Municipal Gde,Chapter 9.12,and the Ikith oad Safety
Code.Station 25532(x)° HEATING UNIT(OVER 101.000 BTU)
❑Yes E)No PAID
VENTILATION FAN(SINGLE RESID) Dam Receipt e
Will the applicant in furore building oc<upam use cyvipmem or devices which
emit haeallom air conmminLaws as darned by the Buy Arca Air Quality Management BOILER-COMP(JHP OR I W.qO BTU) TOTAL:
District, BOILER-COMP(OVER 100.000 BTI!) 01 go
❑Yes ❑No
I have re:WNe hawrdea,mmeriul.crcyuirements under Cha¢'r695of the Cali- AIR CONDITIONER 0 ISSUANCE DATE
forma Health&Safety Calc,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building Nes not currently have a tenant,that it is my responsibility to notify the ncupxot
of the requiremerax which mus he mer prior it)issuance of a Cerileate of Occupancy.
Owner U,auNUrired agcot Data TOTAL: it ED BY:
OFFICE