29495 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL FERMI'1'NO
BUILDING DIMS APPLICATIONIPERMIT PLUMBING-MECDANICAL 29495
BUILDING PROJFCTIDENTIFICATION
BUIL BROAD 7N{H. SANITARY NO. APPLICATION SUBMITTAL.DNI
W R'S M E' t TORS ` MI?: LIC NO:
N/C CONTROLa
• HITECT/FNGI .R: 1 N : A D ESS: ❑
ONTA T. P11 E: _ BUILDING PF,RMIT INFO
77_ O ❑ Consultant Fees Paid by Applicant(Initial) BLDG P.ECT PLUMB F.CH
OV ❑
LICENSED CONTRACTOR'S DECLA ATION QTY ELECTRIC PERMIT FIiE
ereby nffinn that 1 am licensed under provision.of ChaPt 9(commencing JOB DESCR PTION
Z vahS ianl"WDiv'sio se Businessan nfe cion' imdmyhsenveis
X00 �i _ PERMIT lSSuprvcr: RF-SIDENTIAL '
F� full foreeandertect' ❑SFDWL ❑KITCHEN REMODEL.
P"!d.U I� Licele nse Cl Lic,p Canvamnr APPLIANCES-RESIDENTIAL ❑ADDITION - El PLUMBING RE-PIPE
F Da _ -
tn HIT 'S DECI TIONPANELS ❑MULTI-UNIT E3S'FRUCTURAL
zOt2Z Iunderstandyplans mshall beusedms piblienecords MODIFICATION
OZ-m UPT02NAMP5 C1 INTERIOR El CHIMNEY REPAIR
Licensed Professional 2014(KKIAMPS IMPROVEMENT
�y OWNER-BUILDER DECLARATION
C 1 hereby affirm that 1 am exempt Irani the Contractor's IIXID AMPSs License Law for the E)BATH REMODF. EPAIR DEMOLITION
a6 U fallowing remain.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
W rF�r� which requires a permit to comuud,eller,improve,demolish,or repair any nmemro
gin 1.imis.vuance,alw,requires theapplicam lln.vuch permiuo f?leasignedswternme SPECIAL CIRCUIT/MISC.' —
�p.•ii that he is licensed pursuant to the provisions of the Contractor's Licersc Lave(Chapter 9
�ty0p (cununencing with Section AMID)of Division 3of the Bouressand Professions Code)or TEMP.METER OR POLE MST. COMMERCIAL: l
C,y o K that he is exempt dumfound and Ne basis for the alleged exemption.Any violation of ❑NEW BI.DG/ADDITT N I).:OIOLITION
aX1 M 4• Section]031.5 by any thaPhi am for n permit subjects Napplicant e applicano a civil penalty of POWER DEVICES
N ❑TENANT ❑FOODSERVICE
not mare
than five hundred dollars y em). IMPROVEMENT
60 Lasownork,theand property,or myemployeeswith wages for
ee70m,Busirass SWIMMING I'001,ELECTRIC
will Aa the work,and the sammre is notLicense Law sed fon sole(Seal o44,Rosiness QOTHER
and Professions Code:The Contractor',distend.
License Law does not apply m an owner of OUTLETS-SWI'1'CI{ES-PIXTURLiS
a' .. property who bonds or improves Nerconmrwho does suchworkhimself orthrough
his own employees,provided that such mentis old ware not intended or offered for NEW RESIDI?N'I'IAI.ELECTS SQ FT.
Role.ILhoweveathevethe burden
it mlhedid none yeaafmmpletfonshe SQ.14.FLOOR AREA S1SQ.fn'.
owner-builder will have the burd<no(pmving that he did not build or improve for par- -
❑ 1,as owner of act See.proparty.,am Bexclusively contracting with licensed mmoncmm i-
construct the pnt,ju�t(See.]044,Bunirievs and Professions Code:)The Cnnaocmr's Li- L
ase Law does not apply to an owner of property who bonds or improves thon
ere ,and Q1 Y. PLUMBING PERMIT FEE 1�
whocontm.tsforsuch projesswlthacontradons)Bcensedpursumil lothe Contractor's JUS 1 { 1996 ^
License Law. PERMIT ISSUANCE❑lameaemptunder Sec. ,B&PCfoon
rthisreas
Owner Dae ALTER-DRAIN&VENT-WATER(EA) YALLUA'DON-
WORKER:SCOMPENSAI'ION DECLARATION BACK FLOW PROTECT.DEVICE C�1Y VY V'L
1 hereby affirm under penalty of perjury one of the following dwlumtim'..
•� Ihmeand will tnuinnnin oCenifcac nl Cnn.Renun self-Insure for Workers Compen- DRAINS-F1.0011,ROOF,ARE ,CON - STORIES TYPE CONSTRUCTION
tion,as provideal for by Section 311%1 of the Lubar Cude,for the,........... of the
wonfor which this permit is issued. - FIXTURES-P in"Al
have and will maintain Wnsker's Compensation Insurance,as required by Section
3]011afthe eburCoda,for the perrrm ceofthe work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wo Co. Ratio [mumu er and Polio nu lzzoay
GAS-EA.SYSTEM-OVER Carrico Policy No.!RTI ATEOFEXFSHpBM FROM W(IRKI?RS' GRP.ASFJINDI15TIt1.WASTE INTERCEPTOR
COMPENSATION INSURANCP.
(Thisseciest need not be completed il'the permit is for one hundred dollars(Stan) BUILDINO DIVISION FI?ES
o.lese) GREASE I RAP ,
PLANCNIfCK FEE
I.comfy the ' any effor
aro mrsefor whichthio the W rkers'Compct- SEWER-SANITARY-STORM EA. 14.
not employ any any mannerp�tphecome subjem to the Workers'Compact- INERGYI'L'L'
Oz cation Lawsof rsa Dat�R Off13 WATER HEATER WNENUELECTR
Q Applicant JYII • GRADING FEE
y NOTICE TO APPLICT:It.after making ing this Ccnifih a of Exemption,you should WATER SYSTEMO BEATING
abecome subjut nt ate uloes Compensation Provisions of the Lubar Code,you must SOILS FCB
W forb ith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O Ihereb,.M.that there is a construction lending agency frame pshfntmance of Data Receipt#
IL s the work for which this permit is issued(Sec.3097,Cie C)
0 F' Lender's Name TOTAL:
WLxadcis Address )T
0. I certify Nm I have rend Nis a,hendoo and Rude Nut the above information is BUILDING ITH
W cormet.I imply with all eityond county insfin.uses and swat laws relating to QTY. MECHANICAL PERMIT FHI3 -
V z huildi onswnior and hereby authorize rcPresenmtives of this city di is,upnn the SEISMIC PER
ab mentioned pm -my Tori spectra purposes. PERMIT ISSUANCE ELECTRIC IEE
tWe)agree us av n mnify and keep hamless the City of Cupertino mast
iahilides,judgmem mnsr a Res whic may,in any way eccmea inns ad City ALTER ORADD'TO MCCH.
in onsequence of egra gof Nis pe PLUMBING FEF. -
APLIC D ANDSAND L COMPLY WIT}tA ,N jjj'''40 T AIR HANDLING UNIT 10,11X1 CFM)
S U G lr/-_J /`/ MECHANICA'PEE
71/0 AIR HANDLING UNIT(OVER 10,IIX)CFM) CONSTRUCHONTAX
Signa en Commctorof Date - F:%HAUST FOOD(WNUCT) HOUSING MITIGATION FEE
is HA9ARDOUS MAI ER1A DISCLOS Rli
Will the applicant or future building occupant store or handle bervNous material HEATING UNIT(TO 100.1100 BTU)
efined by the Cupenino Municipal Calc,Chapter 9.12,and the Health and Safety
Cods,Seddon 25532(.)'1 HEATING UNIT(OVER 100,000 BTU)
E]Yes ❑No PAID
VENTILATION PAN(SINGLE RES]D) Date Receipt#
Will the it licant or contaminants
aure building ythe Buseequipmento.deviceswhich BOILER-COMP(3HP OR 100,000 BTU)
emit hazvdous air cnnmminanns as Defined by the Nay Area Air Quality Management TOTAL:
District"
❑Yes ❑No BOILER-COMP(OVER 1110,1300 BTU)
I have read the haanrdous materials requirements under Chapter 695o the Cali. AIR CONDITIONER ISSUANCE DATE
month Health&Safety Chile,Sections 255115,25533 and 255311 understand that if the NEW RF,SIDEN'1'IAL MECH. SQ.FT
holding does nm currently have a tenant,thin it Is my responsibility to notify the occupant
of Ne requirements which must Is,met priorto issuance ofd Cenificom of Occupancy.
Owner or mentioned agent Date TOTAL: ISSUED BY: Gr
OFFICE