29430 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
. CM14F CUPC'RTINO BUILDING-ELECTRICAL PERMITNO. /�/"t ^43^O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. t. `9.
IIDILDING PROJECT IDENTIFICA'1'H1N
BUILDINGADDRESS: r SANITARVNO. APPLICATIONSUBMICTALDAI
ADT '113'113 s)rlow M . q- � t6
OWNER'SNAME: PHONE: CONTRACfOOR'SNAME: LIC NO:
CQ Z-A iv E (Y VST/AU( D g Q I O ( 17 N/C CONTROL#
1RCHITEC'fIENGINEER; LIC NO: ADDRESS: ❑
b C �K . W/r 4Wfi CUV4
CONTACT - PHONE: BUILDING PERMIT INFO
--at (44) 7 2 C -X 15 ; ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
DEW - 80 —S6 ❑ ❑ ❑ _
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEI7
1 hereby affirm mat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OL'Z with Section 7")of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL,
WOO PERMITISSUANCE
Fed full force and effect. ❑SFDWL. El KITCHEN REMODEL.
MLicense Class Lica APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
I ARCIII'fECT'S DECLARATION ❑MULTIANIT ❑STRUC'IVRAL
F0'n PANIiLS'
Z004 py 7J I understand my plans shall he used es public records MODIFICATION
p Z:J, UP TO 201 AMPSEl INTERIOR ❑CHIMNEY REPAIR
[.M Licensed Professional - 0 IMPROVEMENT
f6Y OWNER-BUILDER DECLARATION 201-IqAMPS
1 hereby affirm that 1 um exempt Gm athe Contractors License Law for the OVER!(AMPSS ❑BATH RFMODEUREPi DEMOLITION
k O L U following reason.(Seetimn 7031.0.Business and P,ofessiom Code:Any city.1 ,,only SIGNS ELECTRICAL ❑OTHER
4Wl iilO which requires n permit m cmuvucl,alter,improve,demolish,or repair any suuemru g �a
prior m its issuance,also requires the applicant or such Permit file u signed statement SPECIAL CIRCUIT/MISC.
�� that he is licensed randm to the provislonsof the Contractor's License Ww(Chapter 9 �
CaOC (commencing with Section7g0)of Division 3 of the nosiness and Professions Code)or TEh1P.METER OR POLE INST. COMMERCIAL'
L y�y e z
that he is exempt therefrom and me basis for the alleged exemption.Any viulmion of
C1 NEW BLDG/AUDITION ❑DEMOLITION
XON
Section 71031.5 by any applicant iia a permit s.hjc,,,,ha applicant,,,.civil penalty of POWER DEVICES ❑TENANT . ❑FOOD SERVICE
YY17 t more thin rive hundrul doll:us($500). '
F Qi] Las owner ofine property.or my employees with wages as their sole comparison, SWIMMING POOL ELECT RIC IMPROVEMENT,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
W and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
6 3^ property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improsemenis are not intended or offered for NEW RESIDENTIAL F.LECTR SQ Fn
and IL however,the building or mprovement issold withinone yearofenmpletion,the SQ.FT.FLOOR AREA $/SQ.PT.
awn
er-builder will have the burden of proving that he did not build or improve for par-
Case of soled,
I,as owner of the property,am exclusively emmmtins with licensed commcmm m q(
Ouse La the project apply
7044,llusiness and Professions Codi The Contractors V-
censeWwdwsnot applytoanowner of property who milds..improves thereon,and QTY. PLUMBING PERMIT FEE
who convects far such projects wish acomtmctbgs)licensed pureuanuothe Conwemr'n � ,
_ License Law. PERMITISSUANCE —
❑IamexemplunderSee ,B&PC for this mason .1 -
Owner - Date ALTER—DRAIN&VENT—WATER EA) / VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of me following declarations:
0.1 have and will maintain a Certificate ofConseano self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND., STORI. '1'YYE CONSTRUCTION
smion,as prnvidcd for by Section 3700 of the Labor Code,drum pamor..ance of the
work for which this pemtL is Issue. FIXTURES—PER TRAP
❑I have send will man m W', lka's Compensation Insurance,m required by Seetion
37M ofine Lnbnr Cod rot rhe performance of the wmkfor whichthis permit is issued. GAS—EA.SYSTEM-]INC.4 OUTLETS OCCGROUP APN
My ,kers Co. n nhsumnce canieranl Policy numbers.:Policy No.; GAS—I?A.SVSTEM-OVIiR 4(EA)
CERTIFICATE OF EXEMPTION!BOM WORKERS'
COMPENSATION INSURANCE GREAMWNDUSTRL WASTE INTERCEPTOR
BUILDING DIVfS10N R?LS
('Ihisaation need notMrnmplefed if the permit is forone hnvdreddo11ars($110) GREASE TRAP
or less.) PLANCNECK FEE
I certify that in he performance ofine work for which this permit is issued,I shall SEWER—SANITARY—STORM EA.20011'.
not employ any person in any mann,,so as to become subject w the Workers'Compen ENERGY FEE
Z
muton Low,of California Dole Q WA'1'fiR HEATER WIVEN'f11i1,1iC'D'R Applicant GRADING PEE
ZI NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WAI'BE SYSTEM/BEATING
a ; become subject to the Worker's Compensation prnvisiom of me Labor Code,you must SOILS FEE
fcMwithcomply withmeh provisions or mit permit a hall be deemed revoked. WATER SERVICE ,
ow
Q
CONSTRUCTION LENUINGAGFNCY NEW RESIDENTIAL PINE. SQ.FT. PAID
Ua Ibemby affirm Pan(here iso construction lemmngageney far the perfonnmmof Date Iieceiptia
LLI r the work for which this permit is issued(Seo.3097.Clv.C)
OU Ieideis Name TOTAL:
C.l Landers Address TOTAL:
1 certify that 1 have read this application and shoe that the abuse information is BUILDING FEE
h correct.I agate to comply with al)cityand conntyurdinances and aide laws relmlogm QTY. MECHANICAL PERMIT FEE - -
UZ building construction,and hereby authorize mjxvscnmtivesofmisciIy to morupon the SEISMIC FEE
atnownrenlin and property for inspection purpose, PERMIT ISSUANCE
(We),gra tosave,index mify send keep harmless the City of Cupertino against ELECTRIC PEE
habilioies,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in consequence of the gaming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE RF.GUTATI NS MECHANICAL FEE
aj L ` Alit HANDLING UNI'I'(OVER 10,000CFM) CONSTRUCTION TAX
Sign ApplicanVContmct D to EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Jl the applicant or future building occupant store or handle hszmdous material HEATING UNIT GO 100,000 BTU)
as der cd by the Cupertino Municipal Code,Chapter 9.12,acid me Health and Safely
Code,Ss tion 25532(a)T HE UNIT(OVER 11X1,W)BTU)
E]Yet; F1 No VEWHA9'ION FAN(S INGLE RES ID) PAID
Date Receipts
mit haz
Will ms applicant or(marc building use equipment or devices which BOILER—COMP QHP OR 10i BTU)
hazardous it conhminams ss darby the Bned by the Bay Area Air Quality Alanagemem
District?
E]Vca 0 No BOILER—COMP(OVER 100,000 BTU)
I have read the hazardous amounts requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
tonin Health&Safety Code,Sections 8505,25533 and 25534.1 mukrsmnd mm if the NEW RESIDENTIAL MECH. SQ.Fp
building does not currently have a do am.mat it is my responsibility to ramify me eecmpant
of the requirements which must be mel prior to issuance of a Certificate of Occupancy.
Owner a,man...ized agent Date 'TO'T'AL: ISSDED BY:
OFFICE