29170 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINO, BUILDING-ELECTRICAL PERMIT NO, /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MICHANICAL 2x.1 1 70
BUILDING PROJECT IDEMrINICATION L s�JJ y 1
BUILDING ADDRESS: SANITARY AT
APPLICATION SUBMITTAL DE
1Qodr1' coos S
OWNER'. MH: A/�O PE NE: _ CONTRACTOR': ?' �OLICNO:
SMI N/C CONTROL p
g1rdARCH E GINF.ER:. L O: ADDRESS:
CONTACT.
N14: ���NEO� BUILDING PERMIT INFO
SlEN kA-# 3 �� ❑,COnSullgnt FeCs Paid by AppHcgnt(Initigl) RL1 ELECT' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION of ION QTY. ELECTRIC PERMIT IBE
I hereby affirm that I a3 licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
,O„�Z with Section lOMp of Division Business Rofessiore Code,and myliccnse is - RESIDENTIAL:
�O cote PERMIT ISSUANCE
i Tune ee and effect. D ILZ ❑SFDWf. ❑KITQHEN RF.MODEI.
P7MLicense Clms_8—Lica T ppPL1ANCE5—RESIDEN'f1A1.
y�ul Dote _ Cnntructor DADDITION ❑PLUMBING RE.PIPE
F,Orra ARCHITECT'S DECLARATION PANEL: El MULTI-UNIT El STRUM URAL -
Z 0!2'� 1 understand any plans shall be used as public recoNs
0z UP TO 209 AMPS MODIFICATION
Fy�W Licensed Pmfessinnal _ ❑INTERIOR ❑CHIMNEY REPAIR
�X ')i OWNER-BUILDER DECLARATION 201-IOW AMPS IMPROVEMENT
0.%' a 1 hereby affirm that 1 um exempt from the Contractor's License Law for the OVER 1000 AMPS []BATH R TA DEMOLITION
iWS E,,V following reason.(Section 9031.5,Business and Professions Cndm Any city or county SIGNS ELECTRICAL ❑OTHF.�..I
su a IL F which oNmeos a penait ,,wnawn,oiler,improve,demolish,nr repair any structure I�r�^
prior to its issvnnce,also requires the applicant for such permit nfile nxigned statement SPECIAL CIRCUIT/MISC. s
p. that he is licensed pursuant to the provisions of the Convectors License Law(Chapter 9
� p0 (commencing with Section 7000)of Division 3 of the Business and Prafessions Code)or TEMP.METER OR POLE INS'I'. COMMERCIAL
a a c eC)but he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 707 LS by any applicant for uPermit subjects the applicant oacivil penalty of POWER DEVICES
>} notmarerhanrivc hundred dcaeo($501p. ❑TENANT FOOD SERVICE
G ❑Lea owner of the prnpeny,ormy employees with wages us their sole compensation, SWIMMING INOLELECI'RIC IMPROVEMENT
wdldotheworkand le ureemee is nm intended or offered forsole(Sec.704,Business El 0`111 ER,
d3 and professions Cedt:'I he Contractor's License Law does not apply in an owner of OUTLETS—SWI TCHES—FIXTU R NS'
pfopeny who builds or improves human.and who does such work himself of through
his own employees,provided that such improvements oro not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
art .If,howeventhe building or improvement is sold within one year ofeompleion,the SQ.IT.FLOOR AREA $/SQ.PT
owner-builder will have the burden of proving that he did not build or improve for pur-
ofseleJ
WE
os owner or the property,am exclusively contracting with licensed contractors to T L: 'r Fy
A B
[onstei the project(Sec.7044,Business.,,it Professions Co&)The Contractor's U-
anseLawdoesnotapplytomownerofpropertywhoI ills or Improves thereon,unit QTY, PLUMBING PERMIT FEE
whoconlmets forsuch projects wibacontmemr(s)licensed pursuant to the Contractors JAN 1996
License Law.
CII am exempt under Sec. ,B& re
P C for this ason PERMIT ISSUANCE
Owner
ALTER—DRAIN&VENr—WATER(EA)
he Ur (g Ul"CVALUATION
p WORKGR'SCOMPI AT]ON DECLARATION BACK FLOW PROTECT.DEVICE
' I hereby affirm underpenaltyof penury one.(,he following decimation:
❑I have and will maintain a Cenificam of Consent to self-inmre lin Worker's Comps. DRAINS—FLUOR.ROOF.AREA,COND.40, :TORIES TYPE CONSTRUCTIONcation,as provided for by Section 3700 of the Labor Cade,for the perfmmence of the
work foe which this permit is issued. FIXTURES—PER TRAP.
❑I have and will maintain Workers Compensation Insurance,us required by Section
37Mof,ha Lady Gale.for the performance of the work for which this pemut is issued. GAS—FA.SYSTEM-I INC.4 OUTLETS OCC.GROUP qPN
My Worker's Compensation Insurance carrier and Policy number one
Confer: Policy No.: GAS—EA.SYSTEM-OVER 4 BA)
C17KI'IFICATE 01'EXIim[MON NROk1 W ORKli]ts'
COMPENSATION INSURANCE GREASEYINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FENS '
or less)(This section need not lx completed if the permit is for one hundred dollars($(W) GREAMi TRAP
PLANCIIIfCK FEE
Toy any Person
train peffornecanymanneeo ass work foe which this the W rkers'Compact-
SEWER—SANITARY—STORM EA.209 FT.
not employ any person in any m�nnerwusmbecome subject the Workers'Compen- - ENERGY FEE
GO srpneLaisof� Da WATER HEATER WNENTULECI'N GRADING PGE
NOTICE A PLICANT:I,oRermuking this Certificate of Exemption,you should WATER SYS'T1?M/TREATING
Irate �^ become sohject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W (y forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ,FL PAID
V O (hereby action that there is a construction lending agency((it he performance of Date Receipt#
LL P he work for which this permit is issued(Sec.3097,Civ.C.)
O Lender's Name TOTAL:
[[[O}]]] Lender's Address - 'TOTAL:
I cenify thin 1 have reed this application unit stem that the above information is BUILDING FEE
UJ Correct.)agree to Comply with all city and county mdimmocsond stale). .s relmingm QTY. MECI IANICAL PERMIT FEE
V z building emea Bion.and hereby malem a representatives ofthia city to enter upon the SEISMIC FEE
#have-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save;indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,Costs and expenses which may in any way areme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the groming of this pernat.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOPLPOINT AIR HANDLING UNIT(TO 10.00(i
SOURCE REGULATIONS. MHCHANICALFEE
AIR HANDLING UNIT{OVER 10,00 CFM) CONSTRUCTION TAX
Signature o(Applicivt/Contmctor Data EXHAUST HOOD(WMUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecipmn store or handle harurdous material HEATING UNIT(TO 100t BTU)
as defined by the Cuperllue Municipal Coda,Chapter 9.12,and the Health and Safety'
Code,Sectum 25532(u)7 HEATING UNI'('(OVER 1 W j)[30 HE
El yes ❑Na VENTILATION PAN(SINGLE RESIDE PAID
Will the applicant or future building occupant use equipment oDoe Receipt a
r Devices which BOILER—COMP(JHP OR I W,IXO flTU
•emit l assrdous air ammminan¢as defined by the Bay Area Air Quality Management )
De
istrict? BOILER 100,17 0It'FU) TOTAL:
i ❑Yes F7 No O
I have read the foramens materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER
ISSUANCE DAT
forma Health&Safety Cole,Sections 25505,25533 and 25534.1 undta
ersndus if ththe NEW RESIDENTIAL MECHSQ.FT.
building does not currently have a moans,that it is my responsibility In notify the oecupant . -
of the requier nems which must be at End m issuance ofa Cenificam of Occupancy.
Owner or amhoneed agent Dam TOTAL: ISSUHU BY:
OFFICE