29104 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BWLDING-ELECTRICAL PERMITNO9. 29104 0 4
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BUILDING DIVISION APPLICATIONIPERMIT PLUMB -MECHANICAL
L YJ 1
BUILDING PRO.IECT IDKNTU,jcATION
ILDINGADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
/ 33 9 P. w4 �; Pjxa 12'2 0 9 S
jaWLk �NER'SNAMI!: PHONE: O ACTOR'S NAME: // LIC NO:
n'P V W 7'PMoar07/3c CONTROLa
ARCHITECT/1?NGINEER: - LIC NO: RISS:
30 nala �w C 9 �
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M'CH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Chapter
QTY. IiLECTRIC PERMIT FEE
' I hereby ufNw that 1 acn licensed under provisions of Chapter o)(commencing JOB DESCRIPTION '
RIZ with Section 7000)of Division 3 of the Business and professions Cade.and my license is
�UO y PERMIT ISSUANCE RESIDENTIAL:
in full force vnd effect.
IY� 07/3 ❑SFDWL ❑KRCHENREMODEL
.IQ..V License Cla_s—���Lia"
N<� Dam �1� w9� Convenor s � APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
4i ARCHITECTS DECLARATIO ❑MULTI-UNIT ❑STRUCTURAL
Z O >y> J�
q /as y 'sholl he used as public remN, PANELS MODIFICATION
OZ 6�� UP TO 200 AMPS
r� ty LrCensed Profesxionel ❑INTERIOR El CHIMNEY REPAIR
201-ItYJ0 AM1'.S IMPROVEMENT
OWNIiRAU1LDER DECLARATION OVER IIIIXIAMPS
yyx W 6 I hereby affiw that 1 am exempt fmm the Contractors License law for one ❑BATH REMODEL/REPAIR DEMOLITION
W 3 L V following mown.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
4l O which requires a permit m constmct,ober,improve.demolish,or repair any swan n
yy�a Prior m its isxuunce.ms.o,uire,lbeapplicantfor such permit to Nle.signed aluminum SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant o the provisions of the Conoactoes License Law(Chapter 9
GOq (commencing with Section._,.fDivixhm3cftha Rmaxeeand PmfessionsCMe)or TEMP.METER OR POLE INST, COMMERCIAL:
6 a c LL that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4• Section 103 L5 by any epplicarm hir a permit subjects the applicant 0 a civil penalty of POWER DF.VICI'S
�Y ❑TENANT ❑FOODSERVICE.
ZZ not more than five thundreddollarsyempl IMPROVEMENT
C7Q ❑ Lotheas work,nom
Property,nt MyemployeesWith wages avhei(cele 044,Bu mien, SWIMMING POOL ELECTRIC
CWCW will dothewons unde: he Conture iclora Licensoro(wdoestireapplyt an Business ❑OTHP.R
W add Professions Code:The C es them s License Law does not apply eo an owner of OUTLETS-SWITCHLS-FIXTURES
6 3' properly who build,or improves thereon, pr who ares such work deed or of through
his own employees,provided r m such mentis sold within ore not intended or pleend far NEW RESIDENTIAL ELHCTN SQ FT.
solar-howeventhebv theboden of pementis at heidoneildyear of
or i provetforthe SQ.PL FLOOR AREA LSQ.I•T.
caner-builder will have the burden of proving that he did not build or improve far par- '
pose of odd.).
1,as owner of the property,am exclusively contracting with licensed contractors to TOIAL:
construct the pmjmt(Sec.7044.Business rd Professions Code:j,�' omrcom's Li
cense law dues not applyto an awheraf pr `nywhobuildsar(rrlpmv Nereagmd QTY, PLUMBING PERMIT FEE
who conuans for such projects with3com Ss)Iiurtsed pars t Conwetola
License Law. 1 !! PERMIT ISSUANCE
I am exempt under Se d. I B&PCfor this reason
Owner Dam ALTER-BRAIN&VENT-WATER(EA) VALUATION
Tode, the
SWIPEN. IOpYD- LARATION BACK FLOW PROTECT.DEVICE
I hereby moraRyof do rte of the following declaration:
❑Ihaveandwilifieme�( toorf-insorefor Workers CorKa- DRAINS-FLOOR,RODE AREA,COND. STORIES TYPECONSTRUCTION
nation,as providan t]00 nrYye Latter Cale,for the penixmence of the
work fur which thisnmd. FIXTURES-PER TRAP
hove trod wiorker's Compensation Insurance,as required by Section
3700 ofihe Later oformucromfthe work for which lhislerrou is issued. GAS-EA.SYS'rSM ZINC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.: GAS-EA.SYS'T'EM-OVI;R 4(EA)
CERTIFICATE,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASFJINDUSTRL WASTE INTERCEPTOR
(Thissectlo meded he complaed due,pennot is Leon,hmolmddour,,($100) - BUILDING DIVISION FEES
GREASE TRAP
or less) PLANC111?CKiMOE T
I certify Nor in the perfntmenttnfNe work for which this permit is issued.Iahall SSWF.R-SANITARY-STORM EA.ZgI FT.
...I notemploy any personinany mann a���e�¢c uhjenlothe Workers Compcm BNER 'P.
A nation Laws M f tori D e ��"/�a i s
0 WATER HEATER W/VEXURLF.CTR
z 0 APPlicant-,}� GRADI P. O
NOTICE TO PLICANT:11',otter making this Certificate of Exemption,you should WATER SYSTEMITREATING
become subject to the Worker's Compensation provioons of the Labor Colo,you trust rS61LB F6Fj
.0. Q forthwith comply with such provisions Or his permit shall be the...drevnked. WATER SERVICEV/` - H,/^^�
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET PAID
C40
V 0 I hereby affirm that hem is a construction lendingagency for the prifommnce of Data Receipt
V. fz the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lander's Nome TOTAL:
V Lender's Address TOTAL:
y1 certify that I have read this.pplic.tion.nd statehet Ne above information is BUILDING FEE
fel correct l agree to comply with all city and county ordinancesand state lows muting to QTY. MECHANICAL PERMIT FEE
V cZ, building construction,and hereby amhodm representatives of his city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to n.ve,indemnify and keep harmless the City of Cupcnino against ELECTRIC FEE
Ii.bilities,judgmemx,costs and expenses which may in any way accrue against said City ALTER OR ADO TO MECH.in consequence ofthe granting of this permit PLUMBING PER
APPLICANT UNDERSTANDS AND WD.L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IgOW CFM)
MECHANICAL FEE
SOURCE GULATIO'S.
�A // � � AIR HANDLING UNIT(OVER 10.(XXICFM) CONSTRUCDONTAX
01,100 Situation of Appli...VCommcmr Dom EXHAUS'FHOOD(W/DUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantorfuture buildingoccupant store or handle hunallous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health amt Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,0110 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dole Receipt"
Will But nit vicunt nrfutum building by the Blase .Air Qr of Manawhichgement
BOILER-COMP(3HPOR 100,011(111M) I
emit harnrduus it cnnmminamn as defined by the Boy Areo Air Quality Menagemem
Disuict? TOTAL:
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
1 have read the horrendous materials requirements under Chapter 6.95 or the Cali- AIR CONDITIONER ISSUANCE DATE
fnnia Health&Safety Code,Serious 25505.25533 and 25534.1 understand that if the NEW RESIDI?NTIAL MSCI I. SQ.I'I'.
building does not currently have a tenant that it is my responsibility to notify the Occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or amhnimit agent Dam TOTAL: ISSUED BY:
OFFICE