29708 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P12RMU NO. /Y JO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L I
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMI'TT'AL DATI
�"' zi/22 or.�.oy �,, #2 6
ER'S NAME. 1.11ON17: CONT CTOR'R NA ' LIC NO:
1 Ja,-r,YN"J✓T((Q M X`)-SOIL N/C CON'T'ROL p
�RCHITECI'/ENGINEER: LIC NO: Gam'^ ADDRESS: ❑
CONTACT: PHONE: B U ILDING PERM IT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB F:C
y `Fa
LICENSED I a CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arfimt Inas L am fieenaed ander pawan,na of Chapter 9(commencing JOB DESCRIPTION
wpZ with Section 7011(0 of Dmmun3ofthe Business and Tradesmen,Cale,and my license is RESIDE
F O in full fnrremdeffeel. PERMI'I'ISSUANCE
WF OSFDWL 0 KITCHEN REMODEL
U U Licennc Class hie,p
rFZW Dote Contractor nPP1.lANCliS-RESIDENTIAL. CADDITION CPLUMBING RIi-PIPE.
F>V� ARCHITECTS DECLARATION PANELS 0MULTI-UNIT ❑STRUCTURAL
z p y Z 1 ond,onerd my plans shall be used as public records MODIFICATION
0--40 OTTO 200 AMPS PRIOR 0CHIMNEY REPAIR
F-W Licensed Professimml2111-IINN)AMPS PROVLMENT
ayEj OWNER-BUILDFR DECLARATION
PKC OVER 1ggrAMPS CH RF:MODEVREPAIR DDEMOLITION
W Q I herchy affrtn Nm 1 am exempt from the Contrecmr's Licennc Law for the
following reason(Section 7031.5.Business and Professions Cale:Any city or County SIGNS ELECTRICAL "?OTHERM�
Y1 s3 W y which requires it permit to cansaucL alter,improve,demolish,or repair any xlmelore
I... prior to its issuance.also requires the applicant for such prron to file a.signed.statement SPECIALCIRCUIT/MIS
sh ���—�
f y
not he is licensed Fusion to the provisions of the Contra mor's License Law(Chapter 9 •.S`i
m�00 (commencing with ss an
Section 7000)of Division 3 of the Busined Profession, P.ssion,Code)or TEMMETER EIN$T. COMMERCIAL:
a thin he is exempt merefmno and the basin for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
I Section 7031.56 applicant for permit the applicant art a civil II f POWER„Co by app tenni d pP penalty ❑'TENANT ❑FOOD SERVICE
FZ} not tore than five hundred dollars($50(h. IMPROVEMENT
6 1-)I,as owner of the property.or my employees with wages as their sole compensation, SWIMMIN LELE
p=.� will do the work,and the wmclure is not intended or offered forsale(Sec.7044.Business ❑OTHER
�so and Professions Code *I Contractor's Lhcnsc Law does not upply to an owner of OUTLET'S-SWITgips- 'I
pmperty who builds or improves thereon,and who dors such work himself or through
his own employees,provided that such improvements we not intended or offered!for NEW RESIU L ' IT.
sale.If.however,the building or iniprovemcm is sold within one year afcompletion,the SQ,FIT.FLOOR AREA $/SQ.Fr.
enbuilder will have the burden of proving that he did not build or Improve lin par- EQ <7 ll 0
poac of eale.).
01.as owner of the property,am exclusively contracting with licensed contracmrsto TOTAL: w /
construct are project(Sec.701 Business and Professions Code:)The Cooaemr's Li- /\V®
c se Law duos not apPlybon owner or ,penywnohuildsorimpn)veslhemon.and QTY. PLUMBING PERMIT FEE �/
who Canvaets r,whpnrjea, 'In C tmCao(sl liceawd pursuant m the Connecto's 1T'"O
License is PERMIT ISSUANCE (✓N k77N7
l e a a pl a err Se B& C for this reason
Dal ALTER-DRAIN&VENT-WATER(EA) /n OVALUATION
Own C"� r
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following declarations:
❑I have and will maintain aCertificam ofConum to self-insure for Workers Compete- DRAINS-FLOOR,BOOK.ARFA,GOND. STORIES TYPE CONSTRUCTION
sation,as Provided for by Section 3700 of the Labor Cale.for the performance of the
work for which this Nradit is issued FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 11
37M of the LaMn Cod,for the perf.mon ncc of no work for which this Ferrtdl is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS O(l7C.GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(FA)
CERTIFICA'1'li OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRI.WASTE IN'I ERCEPTOR
fThi,scnio.need on,beeomplaW Ether p[m,ic is foliar hundraldollms(S DO) BUILDING UIV[SI P[ES
or less.) GREASE TRAP PLANCHECK FLT. �
I certify that in the Performance ofthe work for which this Permit is issued,l shall SEWER-SANITARY-STORM FA.2(m F'.
na employ any person in any manner so u
as a,he tom s.hjeco the Worker'Conrpca- ENERGY THE
C) Z moon Lawsof California.Date WATER ItE- TER WNENTIELECTR
Z O Applicant GRADING FEE
IA NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTF,MIIREATING
a ; h onow subject to the Workers Cori,,aution powimom of the Lulmr Code,ynu mew SOILS FEE
forthwith c.mply wear such provisions orchis permit shall he deemed mvokcd. WATER SERVICE
Uj a0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
U 0 1 wadi,affirm that inanmmmction lending agency Tonhem
perfnmnceof U Receipt
the work for which This parndl is issued(Sec.3097.Civ,CJ
U Leaders Name TOTAL:
Lenders Address TOTAL:
1 cerady that 1 have read this application and state that the above information is BUILDING FEE
%i cameCl.I agree to comply With all City mW county onliomes and stem laws relaam,In QTY. MECHANICAL PERMIT FEE
C.) Z building conslmnion,and hereby amhorim rep wimtives of this cilym enter upm toe I SIi1SMIC THE
shave-mentioned property for inspection purposes. PERMIT ISSUANCEl'
(We)agree m save,indemnify keep harms the
lesCity of Cupertino against ELECTRIC FEE
and
Iiubilitov.judgmems.costs and expenses which may in any way accrue ugxinm said City ALTER OR ADD TO MECH. If Oil l'
in consequence of the grunting of this permit. VLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,UM)CFM) MECHANICAL 1�
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER III,INN)CFM) CONSTRlICT10 TA%
51gnmureof Applicant(usimm or Dam EXHAUST HOOD IW/DUCT) HOUSING MIFIs,]ON FEE
HA]ARDOUS MATERIALS DISCLOSURE it
Will the applicant or future building occupaasmre or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Mrmicipil CIJe,Chapter 9.12,and the Heahh and Safety
Cede,Section 25532(x)'! HEATING UNIT(OVER I W,INN)RIC)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Wil the o Iicant nr Nom building t use equipment or devices which Dae Receipt X
pp dby the
Arco
BOILER-COMP(3HP OR I o'con BTU)
noir hxnaNnua air mntamimnaa rte def ncd by the I{uy Arru An Quality Mxnxgenanl
TOTAL:
Dinrict/ BOILER-COMP(OVER IW.M BTU)
L
CNo r Will V
mad the hazardous materials requirements under Chapter695 of the Cul,- AIR CONDITIONER ISSUANCE DATE
&Salty Code.Samions 25505,25533 mal 25534.1 understandthus if the NEW RESIDENTIAL MECH. SQ.ITnot cunemly have a tenant,Thal it is my responsibility m witty the tccupannment which must be met prior to issuance of a Certificate of Occupancy.
ariacda t halm TOTAL: ISSUED BY: _
gen
OFFICE