29077 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PFPLUMBING-an!CHANIC$I. A 0 �]
BUILDING PROJECT IDEtiTTIFICA9'I'ION 1
BUILDIN%/Al)I)NIitiS: �� 1 , / //� gf _ ��.}T�yr��((�({f5f.� SANITARY NO, APPLICATION SUBMITTAL DATI
OWNER'S 5r(g l//— V VI/I/O is l///'/�` CONTR V /1//-'J LIC]If]: N/C COM Lp
4RCHITECf/ENGI EER: LIC NO: h✓rW�/\ AD FSK6 p_ `•LTL-/Y/•Y,c„n r ❑
CONTACT': PHONE: ✓h BUILDING PERMIT INFO
3Go�/lo ❑ Consultant Fecs Paid by Applicant(Initial) BLDG CT PLUMB XLICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby eRi,m firm 1 am licensed under Provisions of Chapre,9(commencing �7 JOB DESCRIPTION
WOO with
fall mM)ofDivviiissiionn 3 offhe Business and Profession,Code.end ory license is PERMIT ISSUANCE 3 ' ❑SFDWENTIAL: ❑KITCHEN REMODEL
W-I- Lieenm Cl ez lieM 5Z
Q U - AI'1'LIANCES-RESIDIXUAI. -1 ADDITION ❑PLUMBING RF.-PIPL
hGL Date ��OonlmEor
ARCHITECTS DECLARATION ❑MULTI-0NIT ❑STRUCTURAL
F.O ti PANELS MODIFICATION
Z p Nn Z 1 understand my plans shall be used as public rcrords UP TO 2M AMPS
OZ�O ❑INTERIOR ❑ 1 EMOLITION
NF 'REPAIR
W Licensed Professional 201-111MAMPS IMPROVEMENT
C -J OWNER-BUILDER DECLARATION El BATH RE.IAOD 1 D
C Q 1 hereby affirm thatI am exempt Gni the Contractor',Licenm Law for the OVER 1000AMPS
:)LU fallowing reassm,f5cctlan]U3 L5.Bnsincvc unJ Vnmfvssionx Codc:Any oily or cmmty SIGNS ELECTRICAL ❑OTHE
Is13 LL y which requires a permit lo,mourccl,alta,improve,demdisb,m repair any arucare
prior to its issuance.also requires the applicant for such parniuo file,a signed statement
thSPECIAL CIRCUIT/MISC.
f y at he is licensed pronuam m the pr oixbm of me Connectors License law launder 9
�mo (commencing with Section 7")of Division 3 ofde Business and Professions Cede)or TI?MV METER OR POLE INST. COMMERCIAL:
=M29 3( that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by any applicant((it a permit subjects the applicant n a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
ZQnot nmory than rise hundred dolma,,($510. 1 IMPROVEMENT
❑I,as awnerofth,property,army employee%with wages its their%ole cnmpenxntion. SWIMMING POOL ELECTRIC
will Jo the work,and me structure is not intended or offered for Sale(See.]OW.Business ❑OTHER
aim and Professions Cede:The Contractors License Law tees not apply to 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 are not intended or offered for NEW RESIDENTIAL ELFCTR SQ FT.
sale.If,however.the building or improvement is sold within one year ofcompletion,be SQ.FT.BOOR AREA SISQ.FT.
er-builder will have rhe hanlen if proving that be did not build or improve for pur-
Imscofsule.),
❑ I.as owner of the property,am ex,ii,ively contracting with licensed counselor,m TOLL:
Camara"IM1e project(Sm](ked,Businecv'and Profession,Cede:)The Cnnlrocwrs Li-
nseLaw does not apply toanowner ofpropertywho builds orimproves thercon.and QTY. PLUMBING PERMIT FEE �s
who contracts for such projects with a contractors)licensed pursuant o rise Contractors
License Use PERMIT ISSUANCE G
exempt under Sec. .B is P C for mi%reason 5
•l.
ALTER-DRAIN&VENT-WATER(13 '•r f .VALUATION
Owner Data p vV
WORKERS� COMPENSATION DECLARATON HACK FLOW PROTECT.DEVICE
Iimrunder ismaby Perjury one of dmf following declarations -
7.
❑Ihave and will maintain
abdicate ofCnseada . umfio-Workets Comped- DRAINS-FLUOR,ROOFAREA,CONDgTORI3 v
TYPE CONSTRUCTION
uon,az Provided for by Section 1]9)ofthe laborCade.for
me perform nc<of he
kk for which orper
is mit is issued FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
31X1 of the Labor Code,for the performance of the work for which this permit is issued. GAS-HA SYSTEM-I INC.4 OUTLETS C.GROUI' APN
My Worky�;C yss- Saba 1 cc"mic,and Palicynt "...s /t/Y�
Comer(.wIf-�✓I�un Entry No_ V� GAS-LA.SYSTEM-OVERJ(EA) Y„s7
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASEANDUSTL WASTE INTERCEPTER
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe Permit is forme hundred dollars(SIM) GREASETRAP
PLANCHECK FEE
or less.)
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM F.A.200 FT.
not employ any pvrsnn m any manna,so as to he"mme subjm to the Workers'Cian em. ENERGY FEE
OZ nation Laws of Culifureat.Date WATER HEATER W/V13M/IiLECTIR GRADING FEC
Z O Applicant
y NOTICE TO APPLICANT If,afree making this Certificaa of F.'andsmn,you should WATER SYSTENVOREATING
a ; become subject to me Workers Compensation provisions of the Lobo,Code,you must SOUS FEE
foMwim comply with such provisiomor this Pc.,,,,bull M deemed revoked. WATER SERVICE
Q
S Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PhMl1. SQ,m'. PAID
Dum
I hereby off,nI ma Ili.is aeonsauetian lending agency for the performance of race
W.O the work for which this Tzrmi)is issued(Site 3097,Cie C) TOTAL:
Q U Lenders Name 40
TOTAL:
rLender's Addresx
C 1 certify that 1 have read this application and seat e that the above informtion is BUI INC
.H. N core".I agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
V Z building smonnction,and hereby city memer upon the EhIiC IC PEE' 1
above-mentioned prnpeny liar 1'E
r Inspection purposes. RMI"T ISSUANCE, ;�/ t
(We)agree to save,indemnify and keep handless the City of Cupertino against
liubilides.Judgmelns,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of rhe gutting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CFM) MECHANICAL EEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER FLOW CFNl CONSTRUCTION TAX
Signature of APPllcuntlQmtm"m Dec EXHAUSTI IOODIW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE O
Will the applicant or future building occupant stmt or handle hazardous..lest HEATING UNIT(TO 100,000 BTU)
ven defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Code,Section 25532od? HEATING UNIT(OVER Hat."BTIL
E3 Via, VENTILATION FANS INGLE RESID) PAID Dam fteceipnp
Will he applicant or fulum hui1cm,ammp:mt use opop rent it devices which
ami apO1LIiR-COMP(3HP OR 11111,11110 BTU)
L;
m m haaJous air contaminanw s defined by the Buy Area Air Quality Managcmrnt TOTAL;
District? BOILER-COMP(OVER 100.000 BTU)
❑Yes No
I have read me harardous maenads requirements under CTapter ti 95 of the Cali" AIR CONDITIONER I ISSUANCE DATE
forts Halm&Safety Cede,Seminns 235U5,25537 and 2553J.1 unJemand That if me NEW RESIDENTIAL MECH. SQ.FT.
building does nil currently have a fraud,that it is my respmsihility 1.roof the use pant
ofine mems xl be m"prior tn"'ar.of n Cuml crap:
emhmircd agent a, IOTA IS.
OFFICE �Z 1