29351 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. �� ���
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJEU-T inENTIFICA'ITON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNI' 'S AME: ]ONE 11 R'S AMI!: LIC NO:
Ce - f_ _ NIC CONTROL#
\NCI TECI'/EN iINF. N: V 1 CNO ADDRESS: W 1V10 ❑ /N,
CONTACT: PHONH: BUILDING PERMIT INF
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT IyL'mq r.LEc}y
LICENSED CU R TORS DECLARATION QTY ELECTRIC PERMIT FEE 1O`• 1Fs�T'� (`(�J{� (3ui
I hereby affirm Nm I am livers unJer pmvisinre of Chapter 9(commencing JOB DESCRIPTION
C 00 ith$m110a]BIIO)al Divn3nf the Business and Professions Cods.end mylicenxis RESIDENTIAL,
a�0: w PERMIT ISSUANCE ❑SF WL ❑KITCHEN REMODEL
Li full force ant cRce p
FpIUy License Class •fl Lin.#, APPLIANCES-RESIDENTIAL ITION ❑PLUMBING RPPIPE
Dam Can III��_
ARCH Its,cada,pu DECLARATION EI MULTI-UNIT ❑STRUCNRAL
PANELS
Z O N Z 1 understand my plans shall he used us public records MODIFICATION
O W I UPT'0 2nd AMPS
O FI INTERIOR ❑CHIMNEY REPAIR
F�.F.,W Licensed Professional 201-((Ind AMPS PROVEMENT
OWNEN-BUILDER DECLARATION OVER IfgO AMPS HREMODEUREPAIR [I DEMOLITION
yy ooCC sW�a 1 hereby affirm that I am exempt from the Contractors License Low for the
hd 3 d U following reran.(gtttinn]031.5,Business untl Prufexvions Cale:Any city or county SIGNS ELECTRICAL OTHER
ttxD7I 0 which requims a permit to construct,alter.improve,demolish,or repair any strvcwre
s�F priarto its issuance,alsorequires the applicant for.vuch Permit o file o signet statement SPECIALCIRCUD/MISC.
{ y that he is licensed Pursuant to Ne previsions ofthe Contmemes License Lew(Chapter9
OG d� (commencing with Section 70k))of Division 3 oflhe Buddrassand Professions Cotle)or TEMP.METER OR POLE INST.
6y qo y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLD ION ❑DEMOLITION
pS�w
Section 7031.5 by any applicant for a perinno abjcix thtupplicanno o civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
F. not more than ftve hundred dollars($500). IMPROVEMENT
F� ❑ Las owner ofthe property,or my etvployees with wages as their.sole con,tanuuon, SWIMMING POOL ELECTRIC
p�Q will tlo the work,and the stmcmmisnm imm�dW ornffemlfor sale(Svc.]044.Business ❑OTHER
Yl
and ProRssione Code TM1e Connvnnr'e Littre Lnw dans nm apply to vn owner o1 OUTLETS-SWITCHES-FIXTURES
6 a ' pmperty who builds or improves thereon,and who dues such work himself or through _
his own employees,provided thin such improvuncnts so,not intended or fc.1 for NHW RHSIDHNTIA?.ELECIR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.f00RA LSQ.FT.
caner-hi ilder will have the burden of proving that he did not build or improve for par, ./
pose ofwlia) - TOTAL:
❑1,as owner of the pmpeny,am exclusively contracting with licensed commandsto p p�
construct the project(Sec.7044,Business and Professions Calc:)The Controcmra Li- JJ eI
cense Law does not apply to an owner of property who builds or improves thereon,and QTy.. PLUMBING PERMIT FEE {�/�
wan contracts for such projects with a contractors)licensed pursuant to the Cutnractorx IYI/'IR 19
El I.co U.
ntued PERMIT ISSUANCE 1996
❑I em exempt unJer Sec. ,B&P C for this reason {)
Owner ' Date ALTER-DRAIN&VENT-WATER(EA) `,"} Ur VALUATI�O�N
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTEGE DEVICE
I hereby affirm under penalty of perjury one of the following declarations: J
❑I have and will mvinlaino Cerificae of Comentto self-imme for Workers Co.,.. DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
satin.,as provided for by Section 37W of the tabu Cale,for the perfmmv.ce of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 hav trod will mninmin Workers Compensation Inmmnce,as required by Section
3100 of the labor Code.iW the performance of the work Por which this permit is issued. GAS-HA.SYSTEMS I INC.4 OUTLETS OCC,GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Canter: Policy N.: GAS-F.A.SYSTENUOVER 4(EA)
CERTI FICA'fE 017 EX EMPT'ION FROM WORKERS'
COM PF.NSXI ION INSURANCE GRRASFIINDUSTRL WASTE INTERCEPTOR.
BUILDING DIVISION Il?ES
(Thiaxctlon need ns)he completeAlithe permit is fmmne hundred Jnllwx($100) GREASE TRAP
nr.IcvsJ PLANCHECK FEP.
Loy any that in the any nanny nfthI work for which it lrenmit iLne,'coshell SEWER-SANITARY-STORM FB.3nd FT.
net employ any person in any manner w us to becmns cun�et_tyNe y(pr�rx Compen- ENERGY -ME
,z anon law Calif Dat S 7t.' �a1
O WATER HEATER WIVENT/ELELTR
70 NOT(Appli ,�T.If, GRADING FEE
NOTICETOAPDLCANT.IL Co making this Certificate of of Exemption,you should Wg1ER SYSTP.M/fREATING
a ; became subject m the Worker's Compensation provisions of the Labor Code,you man SOILS FEE
forthwith comply with such provisions or this pcmmit shall he Jeetned revoked. WATER SERVICE
LL 0
CONSTRUCTION LENDING AGENCY - NEW RESIDENTIALPLM13. SQ.PI'. PAID
=)z (hereby oflirm theuhcre is econstmnion 0 ......y fonhc pedormance of Data Receipt
the work for which this permit is issued(Sec.3097,Civ.C.) k
Name TOTAL:
U Ixnder's
U Lenders Address A,. 1-1
0. 1 certify that I have real this application and.mate that the above information is BUILDING IEE
r7n correct.leg me m comply with all city and county oNinanees and state lawsrelmir,to QTY, MECHANICAL P17RMIT FEE
V P7 building conswction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree to xave,indemnify and keep harmless the City of Cuperina against ELECTRIC FEE
Iiabilitics,judgmems,cons and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the grunting of this permit.
APPLICA T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,IXq CPM) MECHANICAL FEE
SOURCE s ULADONS.///�
X / AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCIONTAX
Signature ofA�n�nmc� Date EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MA'1 FRIALS DISCLOSURE
Wiltheapplicant or fraure building acetum store arhandle hicadmis postanal HEA'DNG UNIT ITO Indians)BTU)
as defined by the Cupertino Municipal Code,Output,9.12,and the Health and Safety
Calve,Section 25532(0)? HEATING UNTP(OVER Indpnd B"TUI
❑.lyes IgNa
VENTILATION PAN(SINGLE NPSIO) PAID Ilene Receipt
Will the applicant or future building occupant use equipment re devices which BOILER-COMP(3HP OR I(q,000 BTO)
emit h0rudous air contaminants as defined by the Bay Area Air Quality Management Tb
Ilistrict? BOILER-COMP(OVER IN,WO BTU)
❑Yes Pa. 1
1 have tend the harstJous ntetedals tequiremerns under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
foods Healg does&Safety tly have
e 8 recorons ,that,25533 esp 25534.1 ,,notifDody
th then if the NEW RESIDENTIAL MECH. SQ.FT.
building doth net c fety Core,
a tempt,that it is my responsibility m notify the that
if the
of the requirements which must IN,met pnnr to issuance of a Certificate of Occupunay.
Ownermatuhorieed agent Data A : \ ISSUED BY:
OFFICE