29884 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. FERMI INO. f�(] H H
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL LJ
BUILDING PROJECT']IDENTIFICATION
BUILDING ADDRESS: ,p e�'— SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS NAME: PHONE: CONTRACTOR NAME: LIC NO:
NIC TROL at�
�ARCHIT[CT/ENGWEER: LIC NU: AUDRIiSS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LUG 13LECT FLU H MECH
LICENSED CON'TRACTOR'S DECLARATION TY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
'0Z with Section 7000)o'Division 3 ofthe Business and Professions Cade,and my license is
FSB in full fineeand effect. PERMIT ISSUANCE
W FDWh ❑KITCHEN REMODEL
FFQ--UU License Class Carne APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RI}PIPE
N 6 a Dam Commcmr
0 ARCHITECTS DECLARATION PANELS
❑MULTI-UNIT ❑STRUCTURAL.
Z O y z I malcromnd my plans shall formed i Imblic mcurds MODIFICATION
UP TO 2(m AMPS
O0. ❑INTERIOR ❑CHIMNEY REPAIR
[F-F W Licensed Promsoi...I 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
C' -I
OVER INN)AMPS C BATH REMODMAEPAIR [I DEMOLITION
Q 1 hereby affirmNat 1 ten exempt from the Caramcnoia Licence Law far the
3 a F f.11.wing mason ( y city Section 7031.5.Business and Professions Code:Anor county t SIGNS ELECTRICAL Q OTHER -
a y which requites a permit to mnstroct.alter,improve,Demolish,or repair any awmum
prior to its issuance,also requires the applicant for such permit to rile o signed statement SPECIAL CIRCUIT/M ISC. jifUr. 9 A _
that he is licensed pucwunt to the provisions of the Contractors License Law(ChapterY 44
X00 (commencingwith Section TNNB.fDivisinn3 elide,Bromessand ProfessiuraCale)of TEMP.METER OR POLE INST. COMMERCIAL: Iy
6 a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION O DEMOLITION
Section 7031..5 by any applicantfor a permit s.bjens the applicant to a civil pemlty of FEWER DEVICES V
y []TENANT -OFOOD SERVICE
nt more than rive hundred dollar,($5IX0. V
H Z Y IMPROVEMENT
_ ❑Lathe work,
the pestruct r myemployers with wage s r their axle compensation. SWIMMING POOL ELECTRIC
will pr the work,and the structure is not intended Livens o Law tth for saleSee.
to an Business []OTHER
and Noksxnms GWe,The Contractors License Law dues not apply n�an owner of OUTLETS-SWITCHES-FIXTURES
L w.. pmperry who holds or improves thereon,and who does such work himself nr through
his own employees,provided that such improvemenu am not intended or ortered for NEW RESIDENTIAL ELEC R SQ ET.
sale.If,however the building or improvement is sold within one yearofcumplitunn,the SQ.FT.FLOOR AREA $/SQ.PT.
owmashailder will have the burden of proving that he did not build or improve for puts 1 /�.,
posem-le.). ` }8r1
❑L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See.70,14,Business and Profession,Cade:)The Contmmor,Li.
cense Law does not apply to an owner of paTerty who bunds or Improves themom and TY. PLUMBING PERMIT FEE J
whocommns for such projects wit a conwemr(s)licensed pursuant w the Contractors
License Law. PERMIT ISSUANCE
lamexemptunder Sec. ,It&PCfmth,,m.son
Owner DALTER-DRAIN&VENT-WATER IEA) VALUATION
L �N3
WORKER'S COMPENSATION DECLARATION
N HACK FLON'PROTECf.DEVICE - ally
1 hereby affirm tinder penalty of perjury one of the following dedawtinno: 1
have and will maintain a Cenilicate of Comentto self-insum for Worker's Compete DRAINS-FLOOR,ROOF,AREA,CON D. STORIES TYPH CONSTRUCTION
wrier,as provided for by Section 37M of the Labor Cale,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
E] 1 have sad will maintain W..It o Cnngmrooatit Inotarme,as required by Section
37Mofthe labor Cale,for the performance tithe work for which this posit is issued. GAS-CA.SYSTEM-I INC.J OUTLETS (JCC.GROUT' APE
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Pal icy No.: GAS-EA.SYSTEM OVER 4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS If
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thi.,section need not bocmnpletcd ifthe permit is Torose M1undred dnllats(SI00) GREASE TRAP
nr less.) PLANC111iCK FEE
Loy any that inthe n anylitumnecoff,
as
becomork e
subjewhich this permit is issued.Concon SEWER-SANITARY-STORM LA.2fN)PI'.
not employ any perwn in any manner m as m biome subject m the Workers'Compen. ENERGY FEE Jag—
C) scion Laws of Culifvem Dam WATER HEATER WNEN-VELEM GRADING HE
Z O Applicant
V) NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMTREATING
a ; become s.bjw 1.the Worker's Compensation provisions of the Labor Cale,you must SOILS FEE
Fkl forthwith comply with such...visians onhis permit shallbodeemed revoked. WATER SERVICE
0
a CONSTRUCTIONLF,NDING AGENCY NEW R SIUENTIAI.PCMB. SQ.FIt PAID 7 Z Ihertby affirm that
them isaconstruction lading agency for the performance,of Dare ccciplM
L)� the work for which this Permit is issued(Set.3097,Civ.C.)
O ULenders Nuns TOTAh:
I,.tiers Address
'F" U.1 I certify that 1 have mad this application and scam that the above information is BUI TEF' Val eneem.1 agree m comply with all city and county on inunees:ted scare laws miring ,, QTY MECHANICAL PERMIT FEE
V Z building construction,and hereby outhori'm representatives of this city to enter upon the SI.ISM IC FEE.
shove-mentioned property for inspection purposes. PERMIT ISSUANCE'
(We) tux nify and keep hatmles,the City of Cupertino against ELECTRIC E
lubilitic.s' d coax ante proseswhichmuyimmywayacemeagain.tsaid City ALTER OR ADD TO MECH. PLUMBING
incon ,ramin, this pemtit.
APE ERSTA.' S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10.0g)CFM) MECHANICAL
SOI' C LATIO
re`�a Z}, Y-T R ' AIR HANDLING UNIT(OVER IO.IXNICFM)
110 CONSTRl1CT1ON'1'
e fAppll1m on.,., Date EXHAUST HOOD OYMUCT)
HOUSING MITIGATI N FEE
HAZARDOUS MATERIALS DISCLOSURE
W'Ithe applicant.,future buildingoccuputn store or handle herardnu,mamrbd HEATING UNIT(10 100.0h)BTU)
m defin by the Cupertino Municipal Code.Chapter 9.12,and th<Health and Safety
ection 25532(a)'! HEATING UNIT(OVER 100.00f)BTU)
❑Ycs No PAID
VENTILATION PAN SINGLERESIU) Dace ReemptN
Wit]the applicant or future building occupatn use equipment or devices which
emit hazardous air contaminants..;defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
Dialaicf! BOILER-COMP HOVER 1 W ifus)BTU)
❑Yes ❑No
I have read Nc hamedous materials requirements under Chapter b.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 25530.I under....nd that if the NEW RESIDENTIAL MECH. SQ.ET.
building does nm currently have a tenant,that it is my nesp.nsibility to notify the occupant
of the mquirennenm which most be met prim to issuance of a Certificate of Occupancy.
Goes,or auhmimd.,cut Dam _N ISSUED
OFFICE