29382 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PHRMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 29382
BUILDING PROJECT IDENTIFICATION
UILDINO AIIORP_SS: � I� �� SANITARY NO. APPLICATION SUBMITTAL DATE
Iq 9) I
i 'S PH R R'1a.5S NA LIC NO:
e a NIC CONTROL#
AR:HITRCTA NGINEER: LIC NO: ADDRESS: � n ❑
N G/7 ' , Y
C PHONE: BUILDING PERMIT INFO
1� � �� - 1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSI;DC RA R'S DECLARATION ❑ ❑ ❑
I herebyftimt that I am licensed under QTY. ELECTRIC PERMIT FEE
a provision%ofs Coo,
JOB DESCRIPTION
a$ with Section 7IXll1)nf Divlsinn3uRhe Puniness and Professions Crdu,anJ myllucnxa is
DO h PERMIT ISSUANCE RESIDENTIAL:
mfull force snA etfccl. `-f �^��
�UU�k� License I ss `? I.ia#—+J�- _ ❑SFDWL ❑PLUMBIKITCHENG
REMODEL.
rF0. DatcCmntmcmr APPLIANCES-RESIDF,NTIAI. ❑gDDITION ❑PLUMBING RE-PIPE
E,p A 1 C=F,CLARATION • PANELS ❑MULTI-UNIT []STRUCTURAL
ray I to used as public records MODIFICATION
OZ o U11102WAMPS [I INTERIOR ❑CHIMNEY REPAIR
�r gg L ns 201-1000AMPS IMPROVEMENT
Y OWNEmexemDER OE CLARATION OVER 1000 AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
Y I here y affirm that 1 am exempt from the Cessions o :Any c taw for the
4'�S V which following reuck a permit to 7031.3,Rosiness and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
3 LL which requires o permit re wires,cu,ahem improve,demolish.ar.pair any structure
pri.noits issuance,
also
requimsthe applicant for such Permit file a signed statement SPECIAL CIRCUTOMISC,
Wothat he is licidsed puromad tothepowisionsofthe Conrrunors License law(Chspter9
W CC (eommen6ngwith Smlion7Ng )of Division3 ofthe Business and Professions Code)or TE IR METER OR POLE INST COMMERCIAL:
6 q m a Net he is exempt.hemfrom and the htris for the alleged exemption.Any violmion of [3 NEW BLDG/ADDITION [I DEMOLITION
W tI. Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES ANT ❑FOODSERVICE
W-y+y notmmre than
fve bond it dollar(SSW).
O ❑ I,as owner nflhe property,lir my employe.wiAw,igecscthunimlecompenmurn. SWIMMING POOL ELECT RIC / IMPROVEMCNT
will dmhe work,and the structureN not intend rofferecilbrsal Sec.7(H4,Buainecy OTHER
�_ and Profession.Cmde:'I'he Cn Dant. Lice. La es mo apply lit ua owner of OUTLETS-SWITCHES-FIX'1'UR12S
- 4' property who hard,or impr s theieo d d sue ark himself ar through
his own cn"I"te"pnrvi that such npr e u of intended mr o0'cred for NEW RESIDENTIAL FLECI'R' SQ FT.
sale.lf,however,the bei l ng lir improve .t wi otaycarofcmnpletion,the t SQ.FI'.FLOOR AREAL $/SQ.FT.
owner-bridder will have he harden ro 'ng at a did not build or improve for pun �"' �Y
pose of esle,y -
❑1,as owner of the pro y. usively contracting with licensed contractors to TOTAL:
consumer the Project(See7 ,Business end Professions Code:)The Cnntmanr'e Li- MAR 7, 199,
c<nu law dues not upplyt pn caner of propcny who builds orimprovea thereon,and QTY. PLUMBING PERMIT FEE
who commas for such p maw amrdcmrtsl liccnsal Pursuant rumina Cmnwcmrs
License Law.
❑Iame,imniu oder Sec. ,B&PCforthismwma PERMITISSUANCE Clic CJI VUI"Cf1 L111..I
Owner Dam ALTER-DRAIN&VENT-WATER(PA) VALUATION
Isi WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of Kduq one of the following declarations:
I haveond will maintain uCeriftcamcf Comenuoself-insum for Workers Compcn- DRAINS-FLOOR,ROOP,AREA.COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 37W of the Labor Code,for Ne performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will mountain Workers Comisma don Insurance,as required by Section
37M of the Labor Code,for the perf srmance of Ne work for which this permit is issuN, GAS-EA.SYSTP.M-1 INC.4 OUTLETS �� OCC GROUP ANN
My Worker's Conmpercmian Insurance carrier and Policy number arc:
Carrier: I Policy No.: GAS-.EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF Fd(EMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This eemlnm ncod not becompleted if the permit is forone'hundred dollars(Sla(0 BUILDING DIVISION PEES
or I...) GREASE TRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM P.A.2W F.
son u
not employ any perin any manner so as to become subject the Workers Compen- ENERGY FEE
0Z %aria.laws of California.Date WATER HEATER W/VENT/ELECPRej to
z Q Applicant GRADINGFEE
.w rN-a NOTICE TO APPLICANT,If.after making this Certificate of Exemption,you should WATER SYSTEMIfRPATING
a 7 become subject o the Workers Compensation provisions of the Inbar Cade,you must SOILS FEE
forthwith comply with such provisions or Nis permit shill be deemed revoked. WATER SERVICE
is
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.PT, PAID
V O l hereby affirm that hem is a construction lending agency for the performance of Date Rei#
(Jr Hthe work for which this permit is issued(Sec.3097,Civ.C.)
o U IsndcrsName - TOTAL:
Lkl Lenders Addms%
1<cmfy that 1 have mad this applicmicn and state that he obese information is BUILDING FEE
N cunect.I.,me to comply withal)ch,md county ordi...cesenJnmelawxrelatingm QTY, MECHANICAL PERMIT FEE
U building cnnnmctinn,and hereby authndee representatives of this city to enter upon the SEISMIC FEE
.have-mentioneJ ,,,Perry for inspection purposes. PERMIT ISSUANCE
(We)agree to cava,indemnity and keep harmless the City of Cupertino against ELECTRIC FEE
liubobia,judgmcnts,costs and expenses win' ay n any weyaccme.,mnsted City ALTERORADDTOMECH.
PLUMBING PER
In consequence of the mg of 's peJ L
APPLICANTU ADW COMPLY WITH ALL NON-POINT AIR HANDLING UNIT [uphill CFM) MECHANICAL FEE
SOURCE RF ,.A'
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
I Sig reittractor ate EXHAUST FOOD(W/DUCD
H RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Il the plat or future building occupant store or handle hoommus material HEATING UNIT(TO I00,000 BTU)
Code,,Section deetin upertina Municipal Crude,Chapter 9.12,anJ Ne Health and Sefay
C255]2(¢)? I HEATING UNIT(OVER 100,000 BTU)
[J Yet (3 No VENTILATION FAN(SINGLE RESIDE PAID
Date Receipt#
WIIthe.1,ecsntnrfuture building occupantA .Air Quor deviceswhich
BOILER-COMP(3HP OR 100d"BTU)
emit iel? s air conmminsms as defined by the Be,y Area Air Quality Management TOT ,
nisain?
Q Yes ❑No BOILER-COMP(OVER IW,O(IOIITU)
I have read the husmMus.tatedds requirements under Chapter 693 of the Cull. AIR CONDITIONER ISSUANCE DATF,
fonds Health&Safety Gide,Sections 25505,25533 and 25534,1 understand Not if line NEW RESIDENTIAL.MECH SQ,FT.
building doe not currently have u tenant,that it is my rexrymsibility to ratify theocaupam -
of the mquirenrents which must be met prior to issuance of u Certificate of Occupancy,
Owner or mala rixed agent Bate TOTAL: ISSUED BY:
OFFICE