29554 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull,
IHNO•IiLRCTHIL'AI, PERMIT NO. ^ r q
BUILDING DIVISION APPLICATION/PERMIT PLUMIIINO-MECHANICAI.......
L Vh 4
Bun,DINGPROdnCTIEIIWI]F[C ]TON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL HATE
P ►�l-- Pse-,_ :
OW ER'g AME: PHONE: CON ROOT R'. NAME: �. LI .�10:
O SIC CONTROL p
ARCHIT' T/F. GINF.EI LIC NO'. AI FSS: E3
S I",
CONfACE PHONE: Is BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
MxzI ion 70 alarm that 1 em lOh.Bo undo pnrvioans of Chapter 9(commencing JOB DESCRIPTION
, 00 with Saran T)pp)of Division 3ofthe Business end Professions Coalition]my license is RESIDENTIAL,
Op in force and PERMIT ISSUANCE _
t�Z t .... OSFDWL ❑KITCHEN REMODEL
aV Littn rCl s LIc.X APPLIANCES-RESIDENTIAL
h60. Da¢ Cnmactnr ❑ADDITION ❑PLUMBING RE-PIPE
p.GmRCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
s�Z 1iunder and my plans shall tuuxd.s public months MODIFICATION
pZ— - UPT0200AMPS
Licensed Professional El INTERIOR ye�nIMNCY REPAIR
�eEa OWNER-BUILDER DECLARATION 201-I(Np AMPS IMPROVEMENT
OOCC I hereby vffrm that I at esentpt from the Contmetoii.License Law for the OVER]"AMPS ❑BATH REMODELiREPAIR 0 DEMOLITION
O
( ,3,U RAI. ting mason.(Section]031.5,Business and 1'rofeas]ons Code:Any city or county SIGNS ELF.C]RICAL ❑OTHER
W F which requires a permit m comwa,alter,improve,demolish,or repair any structure
qFq O priorlobsissuroce,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
2, a� the he is licenxcJ pnrsnanuothe provisions nllhe Canmtelafs Licen+e Law(Chans,9
1m55a1 (commencing with Section]WO)nf Dlvision.1urine Businessand Professions Code)or TEMP.METER OR POLE INS'T. COMMERCIAL:
6{y o a that he is exempt therefrom and the basis far he alleged exemption.Any violation at' ❑NEW BLDG/ADDITION ❑DEMOLITION
iLLCI t°• senion7031.5n,nry appream for a permit subjects the applicant to a civil penalty of POWER DEVICES
❑TENANT ❑FOOD SERVICE
not more than rive t h he ropedred d.lumo, y craft. IMPROVEMENT
CI ❑ Lathe rk,moUlrourro mAnotintended wlthwages a<iheiSes.compensation, SWIMMING POOL 131.IiLTR]G
windo the work,and the swmurc is nm intended nndfercd far wle(Sec.]044,Business []OTHER
,3 and Probes firms Cale:The Contexture'.License Low does at apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds nr improves thereon,and who does such work himself or through
his own employees,provided that Such improvements are not intended or offered for NEW RESIDENT IAL ELECIR SQ FT.
aide.If,however the building or improvement is sold within one year ofcompletion,the SQ,PPE FLOOR-AREA S'SQ,FT.
owner-builder will have the human of proving that neutrino[build or improve torpor- .a, Is a e �•
pont of sale.).
El I,as ownerof the protan,am uclusively comruaing with IicensM contactors to TOTAL:
construct the pmjea(See.7044,Business and Professions Codw)The Commences Li- APR 11 1996
cenre
se Law does not apply to an owner of property who builds or improves theon,and QTY, PLUMBING PERMIT FEE
who contrneb forsuch pmjeem with a contactonsilicenud pursuant to the Centectofs
Licen.law. PERMIT ISSUANCE
L] Iame.emptundaSce. ,B&PGforNisreawn G��Y Ur WE LfsIIIyU
Owner Date - AI.TF.R-DRAIN&VENT-WATER B-A) VALUATION
WORKER'S COMPENSATION DECLARAHON _ BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will marmin a Certificate of Comand to self-insure for Worker's Compcn- DRAINS-FLOOR,ROOP,AREA,COND.
satins,as provided for by Section 37110 of the 1sMn Cotte.for the performance of to STORIES TYPE CONSTRUCTION
work for which this permit is issued, FlXTURES-PCR TRAP
El]have and will mummin Wnrkefs c m7nsata n Nuance,as mquired by Section -
3]00ofthelaborCMS.fortheperf ft a nrkfnr which this pe t;;issued. GAS-EA.SYSTEM-I IN C.4 OU MEETS OCC.GROUP APN
My War nen lnsur. umler II'Iquy ; GAS-EA.SYSTEM-OVER 4(EA)
Camixr: �� Na:
�CL TII9CATEOFI:%EMI'TI(1NIBO W R
PCNSATIONINSURA ' GREASPJINDUS'TRL WASTE IMTCNCEPIOR BUILDING DIVISION FRES
(Thissection sol cnmpleted ifthe permit is mt "1 GREASETRAP
or IessJ PLANCHECK FEE
terrify atinflcpedrn con(thcwork fin whidt this permit i.isuM,l shall SEWER-SANITARY-STORM FA.21X1 IT.
not emplo won in anyn t .oases 11suhjento the Wnrkcrn Compen- ENERGYME
Z satin n' 't f mia.Do WA'T'ER HEATER W/VENT/ELECTR
y�0 p0, - - GRADING FEE
q 5� ICE TO APPLIC .If,older,making thi •en Exemption,you should WATER SYS]'EldrTREATING
ar > become subject to the W rkeh Cntnpene' n nvismns of the horCMe,you must SOILS FEE
Li) forthwith comply with ch pravisinn.v or is emtit xI Bit deemed revoked WATER SERVICE
Q
CONSTRUCf10 ,ENDING AGENCY NEWRESIDCNfIALPLMIL SQ.FT. PAID
Dam Receipt
L)� Iherehy affirm the there i.aamstectien lending agency Tonne perfonnanceof 4
Lks H the work for which this permit is issued(Sce.3097,Civ,C.)
Q Lender's Name TOTAL:
r U fender's Address TOTAL:
I certify that I have mud this application and state thatthe above information is BUILDING FEE
nFa (A cortect.i agree to comply with all city and county ordinances and state laws relatingm QTY MECHANICAL PERMIT FEE
G Z building construction,and hereby authariu representatives ofthis city to enter upon the SEISMIC FEE
above-rnemio property for inpurpopurposes.pection puns.
( agree.com. ndm
cnify and kmp harmth
less e City of Clspertina against PERMIT ISSUANCE ELECTRIC FEE
Iiabili' ,judgments,casts and eateries which may in any wayaceme against said City ALTERORADDTOMECH.
in sequenceofthe ing of this permit. PLUMBING FEE
/ PLICANT ON :I 'TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(IO 10,000 CFM)
MECHANICAL FEE
RCE RCGP, fl 'S.
de 00—W,1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCfIONTAX
gn anu0mirrecmr ate EXHAUST D(WMuCfI
HAZARDO ATERIAIS DISCLOSURE
HOUSING MITIGATION FEE
ill the applicant or tutu h riding occupant store or handle hanimmus material HEATING UNIT(TO 100,1X0 BTU)
es deft . by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
CMT .tion 25532(.)'1 HEATING UNIT(OVER 100,000 BTU)
❑Ycs C]No VENTILATION PAN(SINGLE RES]D) PAID
Date Retelptit .
Wndonsl the air contaminaant or nts its
building by the nt Buy use equipment Qu Or devices when BOILER-COME(3HP OR 100,(%0 BTU)
t?mit haarJnus air amtatninams ns defined by the Huy Amu Air Quality Management
v Di...let 9 BOILER-COMP(OVER 100,015)BTU) _ TOTAL
❑Yes Fl No
I have read the hazlm]ans na.crials mquher¢nm under Chapter 6,95 of the Can- A]R CONDI]'ION HR ISSUANCE DATE
fool.Health&Safety Code.Sections 25305,25133 and 29534.1 understand that if the NEW RESIDENTIAL MSCIL SQ.1T. _�)
buium,dons not..art,hove ntenau.that h is my mspnnsibility to roafytheswcupant - v`/
of the mquircments width musthe met prior to Issuance of o Certificate of Occupancy. �_ ^,
Owner or authorized agent - Date ]D'I'AL: ISSUED
OFFICE