29888 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPELRTINO BUILDING-ELECTRICAL. PERMITNO. 2 9 8 8 8
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L J o 0
BUILDING PROJECT IDFNTIFTCATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
n► n�. P 14 L Ari ,
ONER'S NAMB: PHONE: C 'TRACTOR' AMC: Sll O.�
NNi C4/J NIC CONTROL#
ARCHITECIENGINEM: LIC NO: ADD LSS: ❑
AF
lJe3N
CONTACT'. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) HIM ELECT PLUMB MECH
❑ (8( ❑ ❑
LICENSED CONTRACTOR'S S DECLARATION QTY. ELECTRIC PERMIT FEE
I herehy affirm that I ant licenud under provisions of Chapter 9(commencing JOB DESCRIPTION
C a1Z with Sation 7(g0)nfDivixinnlofthe Rosiness and Prnfcxxinns Cnde.enA my license is /
�O I ' PERMIT ISSUANCE 3J -' RESIDENTIAL:
n full force and effect.
C F ❑SFDWL ❑KITCHEN REMODEL
FG.U U License Class Lic.#
N<L Dam Contractor APPLIANCES-RESIDENTIAL .ADDITION ❑PLUMDING RF.-PIPE
ARCIII'1'EC S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F'Z 1understandm 1 PANELS
2 O r�� y P ons shall be used os public reroMs � MODIFICATION
O Z UPTO 2M AMPS
O ❑INTERIOR ❑CHIMNEY REPAIR
1-4 Licensed Professi...I 201.1000AMYS IMPROVEMENT
fey OWNER-exempt fr m the RATION
I hereby affirm that I am exempt from the Contractor's License Low for the OVER 1000AMP$ - AE]OTHFR
F1 BATH REMODEI/REPAIR �DEMOLITION
x30.F following rtamn.IStttinn](131.3,Business unit Professions Code:Any city or county SIGNS ELECTRICAL, ❑OTHER
{sed)0.O which reyuirts a permit to construct.alter,improve,demolish,or repair any structure
prior to its iswarec.also requires the applicant for such Permian file a signed statement SPECIAL CIRCUL'f/MISC.
that bets licensed pursuant to the p rvisions of the Comeactoes License Law(Chapter9
p0 (commencing with Section 7f)(Knof Divlsion3ofthe Humnemand Professions Cak)or TEMP.METER OR POLE INST. COMMERCIAL,
6 po m tY that he is exempt thercfmm and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
a� tc Section 7031.5 by any applicant for a permit subjects the applicant m a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
�. not more than five hundred dollars($500).
❑I,as owner of the yemp y pe IMPROVEMENT
property, In«s with compensation. SWIMMING POOL ELCLTRI
5a will on the work,and the awcwreis not immndedoroffered for sole(Sm.]1144,Business yl m and Professions Cock:The Grumnnr's License Law does not apply to an owner of OUTLETS-SWOCHES-PI R
6 a^ property who builds or improves thereon,vad who does such work himulf tui tlwugh
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR S -
mile.If.however,the building or improvement is old within one year ofcomplelion,the SQ.FP.F40OR AREA g✓ E/SQ.FT.
owncolmodder will have the huNcn of proving that he did not build or improve for pur-
pau of ma1eJ.-
❑ 1,us owner of the property,an exclusively connecting with licensed contractors to J TA MAY
(1 �(I(]Q
construct the project(Sec,7044,Business and Professions Codc:)The Convectors Li- MA l a7 AAII
cense Law does not apply in an owner afpropeny who builds or impmves thereon,vnd QTY, PLUMBING PERMIT dIn FEL'
who commets for such pe jece with s conracmrts)licenud punoanan the Comeaetor's
License law. I'CRMITISSUANCL' Ciii kit 1.urk:n k
I LfVl
0 lam exempt under Sec. ,B&PCforthismason
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION '
WORK ERS COMP17NSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby Arnim under pxmIIY of perjury one of the following declarations:
❑ l have and will maintain a Certificate ofConsenno self-insure for Workers Cemam- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
Sation,m provided for by Section 37M of the Lebo Code.for the perfonnanee of the
work for which this permit is issued. FIXTURES-PER TRAP
El I have and will maintain Workers Cm,crsmina las.....us required by Sectlom
3700ofine Lada Code,far the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker,Compensation Insurance cornu
corner ad Policy number m
Currier: Policy Na: GAS-EA.SYSTEM-OVER 4 EEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This action need not hemmplema ifne pemm is fortune hundred dollars IS IM) DUILDING DIVISION FTPS
or less.) OREASC'L'RAP
PLANCHECK EEB
Loy any parsntheip Performance
sm thework for famou,subjech tto the W rklas, ounce - SEWER-SANITARY-STORM EA.200 FT.
not employ any permn in any manner so m m haemo subject to the WnrkerS Compcn- �ENERGY IRE
,zmade.laws of California.Date
O WATER HGAfER WNENT/Fi1.F.CTR
2 Applicant GRADING FCL'
y NOTICE TO APPLICANT.If,after making this Cwd icam of Exemption,you shuuld WATER SYSTEMaREATING
h become eubjat m the Worlmex Compenwim. vimam,of the Lthnr Cole,yon must SOILS FEE
forthwith comply with such previsions or this Permit shall he Jremed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.14. PAID
U p I hereby uffimahatthere is a construction lending agency for the Performance of Date Receipt
{L H the work far which this permit is issued(Sec.3797,Civ.C.)
0 U LeMer's Name TOTAL:
Lenders Address TOTAL:
F0. I certify that L have read this application and sum that she above information is BUILDING FEE
IA cored.l agree in comply with all city and county ordinances and sate lawsrehan,to QTY. MECHANICAL PERMIT FEE
U o-zr building construction.and hereby autdrine representatives of this city to enter upon the SEISMIC FEE
above-memioned property for inspection purynus.
(We) PP.HMD'ISSUANCP, 0
agree to save,indemnify and keep hays mx the City of Cupertino id City ELECTRIC FEE
linbilitssione ce. the
and expenses which may in any way accrue again.raid City ALTER OR ADD TO M ECI I.
in cone ace of the granting of permit PLUMBING FEE
APP UNDERSTN NO WTI. MPLY WITH ALLN -POINT AIR HANDLING UNIT(TO 10,MO CFM)
S ,'R000LATIO MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUC1ON TAX
Si a lureof ApplicanVContrmaw Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS M LS DISCLOSURE
Wd"Em applicant or forum bu'di cecupant momorhvndle ha7allom materiel HEATING UNIT(TO 100,0100 BTU)
Cdefined by the 32(a)?nn Municipu ale,Chapter 9.12,and'Om Health wed Sufcty
Cale,Ration 23512(81 HEATING UNIT(OVIiR IM,000 BTU)
Yee ❑No VENTILATION PAN(SINGLE ILES ID) PAID
Date Receipt#
Will the applicant or(ewa b refined by
Bay Arm
equipmentterdevices which BOILER-COMP(3HP OR I W.000 BTU)
emit hnmrdons air comaminnms us refined by the Hay Arca Air Quality Management TOTAL:
Dinner)
❑Yc C3 No BOILER-COMP(OVER 100."BTU)
L have mad the hazardous materials p AIR CONDITIONER ISSUANCE DATE
r5,2553 encs under Cha ter 6.95 of the Cali- -
fonin building doesHealth&Safety Code,Sections 75505,25533 wit 3.5534.1 understand that if am NEW RESIDENTIAL MECH. SQ.FT.
of the
is 1,whicyhave vtenant that.ii my responsibility mnotify theoccupant
of the reyuirememr which must M met Prior w issuance of a Certificate of Occupancy.
Owner or uuthonzed agent Date TOTAL:
ISSUED BY:
OFFICE