29732 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, w w
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL L Ju
BUILDING PROJECT IDEbV FICAT[ON
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
&I / 8 Pr e w Sl -
OWNER'S NAME: ONE: CO COORF.:
S AM 'L CNO
hi P, k U NIC CONTROL#
RCHITECTIGNGINEI;It� LIC NO'. ADDR iSS: O et _ t ❑
CONTACT: PHONE: BUILDING PERMIT INFO
1 (Y ❑ Consultant Fees Paid by Applicant(Initial) _ _ BLDG ELECT PLUMB MIEECH
W '11 ❑ ❑ ❑ X
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hnchy.M.Nm I am ween rd chapter 9¢mmmenam, JOB DESCRIPTION
�0p
with Sedion](X10)mf Dlvision]of NC Business anJ Professinnx Gale, rid laylicemcis ❑
PERMIT ISSUANCE RESIDENTIAL,
full farce and of t
�OF m SFDWL ❑KITCHEN REMODEL
UO License a Lic.# APPLIANCES—RESIDENTIAL
�'Ta� Date Contractor []ADDITION ❑PLUMBING RH-PIPE
AF&I ECT'SDECI RATIO PANELS ❑MULTI-UNIT El STRUCTURAL
Z p 1 understand my recur s MODIFICATION
O Z UPTO 2W AMPS
F z Licensed PnRessional - ❑INTERIOR ❑CHIMNEY REPAIR
201-1000AMP5 IMPROVEMENT
Q OW am
T DECLARATION Contractors
OVER 1000AMPS ❑BATH RE ODEUREPAIR El DEMOLITION
o J
Q I hereby.(Sinn that 1 am exempt Business an the Contractor's License Law for the IM
�4U
which
Permit
to con LS, t,alter,
Code:Any city or county SIGNS ELECTRICAL ❑O�yER
F�O E" which requires a permit m constrict,,Iter,improve,demolish,or repair any structurestatement
that hoslcensem,alsonpflesthc,pplicamrorsuchmnt innliensele a Law(Chpters SPECIAL CIIICUI'TIMISC
} that heislicensed pursuant tothe provisionsofof t Contractor's Licenselaw(ChapterY
(commencing with Section]tX10)of OivisionJol the Business and PmfessionsCNe)nr TEMP.MEIER OR .E INST. '
4 M 4 ,ba,he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
Beclion 7031.3 by any applicant for upermit suhjems the applicant it)ucivil penalty of POWER DIiVIC El BNANT 11 FOOD SERVIC17
FZ
t mom than live hundred dollars(5500).¢ I,as owner ofthe IMPROVEMENT
❑ property, with wages 0,14,Bsiness SWIMMIN LEI:CCTRIC
will dotfiewofk,gnat: noncom,mamnnif Licendnmffereds.,it (See.]044,Business C1 OTHER
"t
and Prnfessluns Cnde:'Ihc Contractor's Llcensc haw does not,#ply In nn owner of Ol1TLE .—SWITCfIH9—FI%TDRES
property who builds or improves therm,arta who does such work himself or through
his own employees,provided that such improvements are not imendeJ nr,01cb for N I ESIDEN'TIAL ELECIR T.
sale.If,however,the building or improvement issold within one yearofcompletian.the SQ.FT.FLOOR AREA SISQ.Pr.
owurr lbmldur will have the hunlen of proving that he did not build or improve for pur-
pose of snle.l.
❑1,as owner of the ro,ny,am exclusively command,with licensed mntmnnrs to TOTAL: le
ona nueube#.feet(Sec.7044,Business and Professions C...,.he Cnntm<mrs I.i-
ecrrsc Lawdnes not apply loan owner of property who bulldv or improves thereon,and QTY. PLUMBING PERMIT FBEges
who contracts for such projects wit ac wIrl licensed purs..attothe Cantmctnr's
License Law. PERMIT ISSUANCE / e^
F11 am exempt under! ,B&P C for this reason
Owner DateAUITR—DRAIN&V HNT—Wp'1'I7R IEA) VALUATIO�N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations. x0 r
❑I have and will maintain a Certificate of Ccmmnt to self-insure for Workers Compo. DRAINS—FLOOR,ROOF,ARF. ,GOND.
smion,es provided for by Section 371X1 of the Labor Code,for the performance of the STORIES TYI'1?CONSTRUCTION
week for which this Pe.oil is issued. FI%TURRS—PER TRAP -
❑I have and will maintain Worker's Compensation Infamous,as required by Section
3700 of the labor Code,far the Performance ofthe work for which this Kind,is issued. GAS—PA.SYSTEM-I INC.4 OUTLETS OCC,GROUP pl'N
My Wotyejj�ppy. tp ry,7psarayfya I'll Policy u h r OCC
f`[+KTTiY Policy No GAS—FA.SYSTEM OVER 4 HAI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIWNDUSTRL WASTE I RCEPTOR
Inds section need not be completed if the permit is for one hundred dollars(Slg) BUILDING DIV]SION FEES
less) GREASE'I'RAP PLANCt{ECK FEE Cq
Loy any that in Performancanfth hick this he Worker,iss'
Cm Ninsma. SEWER—SANITARY— RM P.A.200 FT.
.'itemployperson nnnymanner se as n Wuhjcct to he Worker.<Cnmpem ENERGY FEF.
satinn Laws of California.Dale
Q A licant WATER HEATER W GNT/EhI[CTR
z PP _ GRADING FEF. MAR
NOTICE TOAPPLICANT Wo,k If,after making this ,istn of of Exemption,you should WATER SYST' /TREATING
f•y � heeome suomp y the Workers Cmnpcns this permit
bel of the Labor Cade,you must SOILS FEH
s>•l fonhwiN comply with soah provisions or permit shall he JeemeJ rcvnkeJ. .WATER Sp ICE r Y i I 'II IPE
-H
.U. z CONSTRUCT I0PNI.ENDING AGENCY NE SIDLNTIAI.PCMB. SQ.Ff. PAID
V P .khereby whicloimuhntthere is e, union len ding agency forthe performance of Date Receipt#
F the work far whleM1 this permit ix ie •d 97,Civ.C.)
Lenders TOTAL:
LUkI LendeeAddress tvip
I x T
Or certify that 1 have rend this utiplicmimn and state that the above infomlminn is � BUILDING FEE
h correct.I agent,to comply with all city and county ordinances and mom laws relating m QTY. MECHANICAL PERMIT FEE
U(P^e building construction,and hereby authorize manconiatfves ofthis city to enter upon the SEISMIC FEE
ahove-mentioned property for inspection puryosee. PERMIT ISSUANCE
(We)agree to nave,indemnify and keep h,mlless the City of Cupertino against ELECTRIC FEE
Iinbilities,judgmens,costs and expenses which only in any wnyacerml,ma,,said City ANTER ON AUD'I'O MECH.
inempax mceofthe grain,ofthispermit. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO/KK)CFM)
SOUR2C-RF. LATI S. • p MECHANICAL FF.E
I `___ J-11-?,ri AIR HANDLING UNIT(OVER'I,1,0(N)CPM)
J L CONSTRUCTION TAX
Signature of ApplicanVControcmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building recupon ,ame or handle Ina...does anac6al HEATING UNIT(10 I IIB,BIIO RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
C]Yes X'Jn VENTILATION FAN(SINGLE REBID) PAID
Will the applicant or future building occupant use ca,ti,michit Qu or devices Management
Date Receipt#
JlNt hazalloux air conwminantx as defined by Ne Bay Arra Air Quality Management BOILER—COMP(3HP OR IW.t]W BTU)
District? BOILER—COMP(OVER IW,OIXIBTU) TOTAL.
LOwhori�d'agcht
aJ the heL dour ma'Xumdals rt is under Cha ter fi 95 of the CWi- AIR CONDITIONER 1��{,•
quiremcn p —" ISSUANCE DATE
Safety Code,Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECIL SQ. I
- ,currently have a tenant,that it lx my responsibility to notify the creation,
nts which mus,be met#dor to ismource of a Certificate of Occupancy C
mda,cut Dateq p J ISSUIiD BY:
OFFICE