29745 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDINGI IVISION APPI,ICATION/PERMIT - PLUMBING.MECHANICAL 297,45
YI BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - _ t. SANITARY NO. APPLICATION SUBMITTAL DATE
8 1 5�[ �ldr Etc . �_ �i�9G
O 'S AME: s •� -i PHONE: } CO RACTOR'$NnAMG �� LIC NO:
re-C 2,3 JV t ,J r 1 ern) NIC .CONTROL N
A CHITECT/ENGINE R:. LIC NO: ADDS S: d `-I ❑ -
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION ❑ •❑ � ❑
1 hereby that I ant licensed under f Chapter 9 QTY. ELECTRIC PERMIT FEE
y Provisions. p (anrumenseis JOB DESCRIPTION
,0„pZ with Section 7UW)of DivisionJofthe Business and Professions Code,and any license is ^ RESIDENTIAL: '
�Wy,�p in full farce and effect. PERMIT ISSUANCE
UV License Class Lictt ❑SFDWI, El KITCHEN REMODEL
NZW Date-Contractor APPLIANCES-RESIDENTIAL []ADDITIONZ?LUM,BING RE-PIPE
h,Oh ARCHI'I'EC'I'S DECLARATION ❑'MULTI-UNIT []STRUCTURAL
>
PANELS
ZO-q .l understand my plans shall be used as public records MODIFICATION
UPT0200 AMPS
r VIE'+hOW Licensed Professional El INTERIOR 11 CHIMNEY REPAIR
sy y OWNEIUBUILDER DECLARATION 201-IOUOAMPS IMPROVEMENT
{ CNls a a 1 hereby affirm that i um exempt from the Conuuctor's License Law for the OVER 1000 AMPS. ❑BATH REMODEUREPAIR El DEMOLITION
{TiLLS5 O y U following Mason.(Semion 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL - ❑OTHHR
which requires a permit to construct,almr,improve,demolish;or repair any structure At '
p,lot e it,in..lice,also netuiMstheapplicant ka,.chpemmitto file sm,ned,aement SPECIAL CIRCUIT/M C.
�NNIM1m M1e is licensed pursumn.theprovislmns of the C.mmcrore Lieense Law(Chnpter9
(commro0ing with Scctien7fX1U)u[Division 3.fihc Btieincse and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL:
that he is exempt therefrom and the basis for Lha alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
X 4. Section 7031.5 by any applicant for a permit subjects the applium,to a civil penalty of POWER DEVICES TENANT ❑FOODSERVICE
mol more than five hundred dollars 01500).
F� ❑ m
1,as owner ofthe ppeny,or my employers with wages as their sale compensation, SWIMMING POOL ELEC7dRVi IMPROVEMENTu
will do@ewmk,amd dialummu,smm intendedorolfened fim,cle(Sne.9044,Brio.,,, DOTTER _
a and Professions Code:The Comlmcmis License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE
pmpeny who Fullds or improves therwn,and who does wcM1 work hi meelF or lin his own employees,provided that such improvements art not intendedm offered lo. NEW RESIDENTIAL ELECTR S
,site.If.however the building or improvement is sold within one yearofc.mpleti.n,the SQ.Fr.FLOORAREA $/SQ.F.
owner-builder will have the burden ofproviag that he did not butld or improve for par- FEE� A
❑ 1,as owner of the property,run exclusively contracting with licensed contract...to TOTAL: I '
nslruct the project(Sec.7044,Business and Professions Code:)The Contmetods Li- �
cense Law does not apply to an owner of pmpeny who builds or improves Iherwq RAR
and QTY, PLUMBING PERMIT BEE pIN, p 11
' ,wineotrma,fo.urer projectswifB.,mumatoron licenxedpnrsuantaotse Gmnactor's II t
License Law. I JV PERMITISSUANCE N� 199 _
T7I am exempt underSec, ,B&P C fat ruts mason z 1 utt, i
Owner Date ALTER-DRAIN&VENT-WATER(EA) �CEVAjyATION
WORKER'S COMPENSATION DECLARATION BACK IlOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations
D l have and will maintain a Certificate of Consent to self-insure for Worker's Comput- DRAINS-FLOOR,RODE AR FM,CONED. STORIES TYPE CONSTRUCTION
union,as provided herby Section 3'100 of the Labor Code,for the performance of the
t; work for which this permit is issued. FIXTURES-PERI'RAP -
)61 have and will maintain Worker's Compensation Insurance,as retained by Section
37W ofthe Labor Code,for the performance oflhe work for which this permit is issued. GAS-EA.SYSTEM_-1 INC.40UTLEfS OCCGROUP APN
My Wark Cdna Imurunee rnnicr acid Palley nu byy[c,�- O
Cartier. '7]efe �wr� _ Policy No.:��'F�J7- /S GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' (
COMPENSATION INSURANCE GREASUINDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION PEES
(This section need not be completed if the permit is for one hundred dollars($IW) - GREASETRAP
nr less.) PLANCHECK FEE
Cottager-
wpmm
rtify isatin the forance.f dha work fur Whichthis permit is iesuCLtSEWER-SANITARY-STORM EA.200 FT. -
not employ any person in any'mannet so as to became subject m the Workers' _ F ENERGY FEE
0 ,7, sation Laws of California.Dale WATER IIEATER W/VENTIELECTR
Q Applicant - GRADING FEE
NOTICE TO APPLICANT:If,after making this Cedilicate of Exemption,you should WATER 5YSTEMfIREArING
.� become subject to the Worker's Compensation provisions of the],shot Code,you must SOILS FEE
frnhwithcomply Withnuch provisions.,,his pcar,,hnd be deemed revoked. WATER SERVICE
Q
CONS'fRUCI'10N LENDING AGENCY NEW RESIDENTIAL PLMN. SQ.FT. PAID Dac R
U O l hereby affirm that them is a corwrunina lending agency funds,performance of
Els r+ the work for which this permit is issued(Sea.3097,Civ.C.) '
p ULeader's Name TOTAL:
Lender's Address - L'
1 certify that 1 have read this application and stain that the above information is BUILDING FP,
tom/) correct,I agree m ommply with all city and county ordinances and state laws relaing to QTY MECHANICAL PERMIT FEE
UZ building construction.and hereby andamer,manoatwes of this may t.cntaru,smthe SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE-' (We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Ilabilaux,jud,orman,cons and expanses which n ey In any way amerce againstaaid City. ALTERORADDTOMECL PLUMBING PE
at mnse,mr.or the gmming of Isis
APPLICANT UNDE TANDS LI COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCERE .LAT NS. MECHANIC F,E
-3=�� Q AIR HANDLING UNIT(OVER IU,000 CFM) MECHACONSTRUCTIONTA
Signal. ppl artAfmo i - Dae EXHAUST HOOD(W/DUCT) h10USIN0 MI'PIGATIONF '
HAZARDOUS MAA ER1ALS DISCLOSURE
Will the applicant or future building occupant save(it handle hazardous notarial HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cafe,Section 25532(0)9 HEATING UNIT(OVER 100,000 BTU)
❑Yes E]No PAID
- VENTILATION FAN(SINGLE RE SID) Dam ' ReeeiplN
Will the applicant or future Fri lding occupant use equipment or deviw.which BOILER' COMP(3HP OR 10D,000 BTU)
emit hazardouse
air contaminants as defined by the Be,Bey A .Air Quality Mi mgem -
ent TOTAL:
Districl7 BOILER-COMP(OVER 100.0001BTU) -
❑Yes ❑No •
I have read the hazardous materials requirements under Chapter 6,95 of the Cali- AIRCONDHIONER - ISSUANCE
funis livelth&Safety Code,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. 5Q.fT.
building does not normally have a tenant,that it k my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy. t
Owner or aumarimd agent Date TOTAL: ISSUED BY:
OFFICE