29066 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, O
BUILDING DIVISION APPLICATIONME �9
RMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICA'PION
BUILDING A11RE11: SANITARY NO. APPLICA'TIONSURMI'ITALDA9f
OWNER M : O CO T 'SNA I J�'(f `a
(� N/C CONTROLM
\RCHITEC A NGIN ER: LIC NO: • ADDRESS: V ❑
CONTPHONE: BUILDING PERMIT INFO
I _405* ElConsultant Fees Paid by Applicant(Initial) BLDG 12LECT PLUMB MFCH
rm ❑ ❑ ❑
.1 NSF.D CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby al net 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
„P,0Z Ih Section] in
fine Buxinacaund Pru amtlyf J lylicemeis RESIDENTIAL:
�� wt full force an effc PERMIT ISBUANCE
VI
W �SFDWL [I KITCHEN REMODEL.
I-ZwQkt, License Cla�: Care P ---- APPLIANCES-RESIDENTIAL ❑ADDITION []PLUMBING RI:PIPE
!n Q 6 Dae Coamcll
ARCHITECTS DEC A ❑MULTI-UNIT ❑STRUCTURAL
zptt2Z lundrsmndmyplenaehellbemed as publiclecurds PANELS MODIFICATION
oz-, UP 10200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Lice coed Professional 2U1-IIIW AMPS IMPROVEMENT
OWNER-escranBUILDER
uldi rat mucamTION OVER 1000 AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
C 6 1 rate affirm that I am exempt from th onion,Cas Licema ty o for the
O d U following mason.Section 7011.5,Business and Pros on,Calc:Any city or county SIGNS ELEC RICAL ❑OTHE
LLl O F which requires a permit m,construct,alter,improve,d coolish.or repair any sWclure
prior In v,issuance,also requires the applicant for nnn to fie a signed statement SPECIAL CIRCUIT/MISC.
E y Ihal he is licensed puavannu the provi.uons ofthe Cant actors License Ione(Chapter 9
W IS00 (commencingwith Smtion7")of Division3oflhe Bu.- %sand Pmfessions Cadgor TEMP.METER OR -INST. COMMERCIAL:
C.d o C that he is exempt therefrom and the basis for the alleged xemplion.Any violation of ❑NEN'BLDG/ADDITION ❑DEMOLITION
�y
Section 7031.5 by any applicant for a permit subjects thea Iicammacivilpenaltyof POWER D I'.S ❑TE,NANT ❑FOOD SERVICE
not am than fvc hundred dollars($5011).
IMPROVEMENT
=6 wiLmawnerof Ne the sumy,mmyemntended or offered
for ici(Sm.compensation, SWIM G •CTRIC
H
willdmhc work,and the ordure is not intended or for sale(Sce.]U44.8oainns ❑OTHER
23 and Professions Cale:The Contractors License Law dues not apply m if owner of OUTLETS-SWITCH -FI%TURES
property who builds or improves t anon,and who Jae.,such work himself or through
his own cwever the building
that such mens is said
w are not immndctl or offered lie NI?W DBNT1Ah BLE SQ Pf.
sale.ILbower will hvilthe burau ofproving that hwiid none buildyear
or improvetiomthe SQ,�.IB,OORAREA &SQ.FT
owner-builder will have the burden of proving that be did not build or improve for par-
pose of xda.).
❑1,as owner of the property,am exclusively connecting with licensed contractors m TOTAL:
construct the project(Sri.9044.Business and Pmfesxionx Cade)The Contract..'.LI- JAN 18 1996
nm Law does not apply roan owner nfpmyperwho buildth
s or improve. eann,and QTY. PLU BI�'- MIT FEE
who contracts for such projects with a contractods)lieenssd pursuant to the Contractors
❑tom exempt underStt. .B&PC h,r Ibis rmmn Licama .. PERMITISSUANCEUs*Ln MVV
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dale
��l
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT DEVICE
la
I hereby arm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate ofConxnt to self-insure for Worker's Compen. DRAINS-FLOOR.ROOF,AREA.COND.
STORIES TYPE CONSTRUCf10N
salon,as pall far by Section 3]0X1 of the Labor Cede,for the partbrmance of the
work for which this Permit is issued. FI%TORES-PER TRAP
Fl I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the boCo}*}��-fnrlhepcnmrmm.flhewarkmr ,h�tbii/s(/peon is issue. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wnrk s tpol lAM�E a l:e carticrandyN .. — �-/d ,�0
Cartier: kkk�WN//''''������•� Policy Nu.. GAS-EA.SYS'1'EM-OVER 4(EA)
CERTIFICAtE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS'I RL WASTE IN'[HRCEPTOR BUILDING DIVISION FEES
('Otis section need am becomm
pleled if the petit is for one bundled dollars(3 100) GREASETRAP
of]a.,) PLANCHECK PER
I certify that in the penetrative ofthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 Ff.
not employ any Person in any manner,..,ns ,,am m.subjecuothe Workers'Certain.
FEE
Z .Z nation Laws of Cullfnrnit.Dam WATER HEATER WNENT/EI.BCTR
Applican GRADING FEE
N. NOTICE TO APPLICANT:If,afar making this Cenilicae of Exemption.you should WATER SYSTEM/TREATING
h become subject o the Workers Compenwtio r provisions of the Labor Code,you must SOILS FEE
forthwith comply with such prvtslons or this Permit%hall 1w deemed revoked. WATER SERVICE
L Q
7z COtJS0N1.ENDINGAGENCY NEW RFSIDEN PIAL PLMB. SQ.lel', PAID Date Ramipla
(.J 0 Ihertby affirm thauhem ere is isaconstruction lending agency for Ne penommnce of
the..,it for which this pemtit is issued(See.3097.Civ.C.)
D. F" Leacce"Name TOTAL:
L) Lcndm,Address '10'FAL:
p+ a FLUf� 1<enily the 1 have read this application and state that the about information i• BUILDING FE
it, coned.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
VZ building conslruclion.and herebyauthorie u,examnntivesofthis city to enter upon the SEISMIC FEE
abav-mentioned prapcny for inspmtinn purposes. PERMIT ISSUANCE
0Wc7 ag m%ave,indemnify and keep ham0cm the Cly of Cupeni l,against ELECTRIC FEE
liabilitim,judg cis.co,o unJ expenses which cony in mry way acrncegain said City AL]'BR OR ADD TU MECH. PLUMBING FEE
n"cyucnc o renting of this permit.
APPLICAN l ) 2STANDS AND WILL COMPLY 'Ttl ALL )N- "INT AIR HANDLING UNIT TD 10,000 CFM)
SOURCLR,G Ir S. / M[C1IANICAL PEE i
141 AIR HANDLING UNIT(OVER I0k000 CFM) CONSTRUCTION TAX
Signal..of App,canUConuacum m EXHAUST HOOD(W/DUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building acupant swat or handle hewrdws mamal HEATING UNIT(TO 100,030 BLV)
as defined by the Cupertino Municipal Code.Chapter 9.12,and Be He.kh and Safety
Code.Section 25532(t)P HEATING UNIT(OVER 100,k)t BTU)
[:]Ye, E]No PAID
vIiNT1LAT10N PAN(SINGLE REgID) Dam RreeiplM
Will the applicant or future building am:cupause equipment or devices which
mit hazardous air contaminate,a%defnN by the Buy Ama Air Quality Management BOILER-COMP(JHPOR 100.000 BTU)
Diarict3 TOTAL:
❑Yes El No BOILER-COM('(OVER 100,000 BTU) f Olt
[Ini. Il ave re id h—dwsmteHalsr uimmnnuMrC pter6950(Ne CWi- AIR CONDITIONER ISSUANCE DATE
1dang
ma Health&Safety Cole.Sections 25505,255]3 add 255M.1 muldsland that if the NEW RESIDENTIAL MECIL SQ.PT
dinsoat mently have a tenant,that it is my res,monility to notify the occupant
emyuiminentswhiebtnustbemetprmrt( iesaancofnCenilcumofOccpancy 'im,mrulhonuda6ent Doc TOTAL] ISSUED BY:
OFFICE