29436 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO. /N/N aN/N
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING-MECIIANICAL L`1..J1 `{1 y6
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
L/30
f �/ ��a�
OWNER'SNAMB: PHONE: M'RACTOIJl�N/aME: IC O'
�� 91[l(��., �S
NIC CONTROL#
-•ARCHITECT/ENGINEER: LIC NO: ADDRE..: ��'� ❑
2_67clYuwr /P
CONTACT: •PHONE: 8I1ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB . MICA
❑ ❑ ❑
Mm that IDCONTEd underTOSSDeOons of CON QTY ELECTRIC PERMIT FEE? -
1 hereby affirm that 1 ran licensee i nes provision orehode, 9(commencing JOB DESCRIPTION
�0Z with tIfrom]l,f Division 3ofthe Bminess and Professions Code,and mylicense is RESIDENTIAL:
OO i PERMIT ISSUANCE
{c� I,Pat
force aW of c
�VV LiccnscC as
a Lick GSFT)WL ID KITCHEN REM01]F:I.
F�W Omc Co. APPLIANCES-RESIDIiNT1AL ❑ADDITION F1 PLUMBING RE-PIPIT
[y[.,,Oy ARCHITECTS DECLAR TION PANELS MULTI-UNIT ❑STRUCTURAL
Z O v�Z .1 undersmad my plans shall be used as public¢mord. DIFICATION
oz—, UPTO200AMPS
C~R Licensed Professional C1 INTERIOR MNIiY REPAIR
OWNER.BUILDER DECLARATION 201-IOW AMPS BATHRMPROMODE
Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
3 U following mason,(Section?031.5.Business and Professions Code:Any city or county []OTHEReq
F which requires it permit m coroumi,nine,improve,demolish,m repair any sumre SIGNS ELECTRICAL
uu
�R10 prior to its issuance,also requires the applicant for such enmit to file a slgneJmatmuom SPECIAL.CIRCUIT/MISC.
�} Bad he is licensed pursumuo the prevision.of the Convectors License Law(Chapter 9
n1�00 (commencing with Section 7000)ofDivision 3 ofthe Businessand Professions Csde)or TEMP.METES OR POLE INST. COMMERCIAL:
4 n Ihal he is'cxempt therefrom and the basis folio alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
.ry Sedinn 7031.5 by any applicunl lit a permit xulims lhcapplicint ran civil penaltyol POWER DEVICES
F Z>. not mnre than five hundred dollars 1$500). 0 TENANT -El FOOD SERVICES
=C O 1,as owner of the pmpcny,or my employswith wogesndleir sole mmpenetion. SWIMMING POOL ELECTRIC IMPROVEMENT
will du the work,and the structure is oat intended or offered formic(Sec.7044.Business D OTHER
and Professions Code:The Contractor's License Law docs not apply to an owner of OVI'LETS-SWITCHES-FIXTURES
A' property who builds or improves thereon,and who does such work hlnssolf or through '
his own employees,provided that such improvements ore not intended or offered for NEW RESIDI?NI'IAL ELECTS SQ FT. - -
mIe.ILhnwesm the building or improvement is sold within one year ofcompletion.the SQ.FT.FLOORAREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for pur-
[11.asowne TOTAL: MAR 14
1,a owner of the Sm.70,1 ,B exclusively cnmradins with licensed Contractor
Id. 1996
orimmm dm project(Sm.]1H4,Business and Professions Code:)The Comracmr's Li- I
cense Use does not apply to an owner of property is fin builds or improves Lemon,and QTY, PLUM GPERMIT FEE
whocontmcu for such projects with a cnmrm,m(s)licensed pursuant to the Contractor's CNY UI-
License Law. (aUr'CfY I INN
D I um exempt under Sec. B is P C for dds rens.. PERMIT ISS CE
Own
ALTER- N -WATER IFA) VALUATION
Date
WORKER'S COMPENSATION DF.CIARATION HACK FLOW PROTECT, EV CE
Owner I heichy affirm under penalty of perjury one of the following declarations:
•D l have and will maintain a Certificate ofComentto selbinsure for Worker's Compm- DRAINS-FLOOR,ROOF.AR COND.
scion,as provided for by Sectio 3700 of the Labor Cade,for the perf Somme of the STORIES TYPE CONSTRUCTION
wads for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as regnired by Section
370E ofthe Lobar Cade,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-II 'LETS OCC.GROUP ANN
My Wort/ yCryper�W Inter c camoomal Policy p�jy gn
Carrier:a]1YNG 1'on Policy Na.:�T'e'J/�� GAS-EA.SYSTEM-OVER 4(EA /
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASFJINUUSTRL WASTE .#CETT
COMPENSATION INSURANCE BUILDING DIVISION FEES
sectionneedret hccomdided ifthe permit is Intone hundreddallars l$EXB GREASETRAP ur less.) PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued l shall SEWER-SANITARY-STORM EA.2M FT.
not employ city person In any nwnne,sit as it heoome suhiccuo the Workers'Compcn- [?HI?RGY FEE
OZ satin,Laws of Colifomin.Did. WATER HEATER WNI?N'T/1?LF.CfR
Z, 0 Applicant GRADING FEE
In NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING
became subject to the Worker's Compensation provisions of the Labor Cade,you Inuit SOILS FEE
forthwith comply with such provisions or t his permit shall he deemed revoker, WATERSERVICE
Q
CONSTRUCTION LENDING NEW RESIDENTIALPLMB. SQ.FT. PAID
UO
thereby affirm lhanbere isuconstmction lending agency fonhe performantt of Dam Rtteipip
W
Under a far which this permit is issued(See.JIY9],Civ.CJ
Q Lender's Name TOTAL:
U Lender's Address TOTAL:
t� y 1 certify that I have mad this application and Stam that the above information is BUILDING FEE
�^ (a) correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF.
U �y bulldingconsmetion,and hereby aatbonm representatives ofihis city memerupontho SEISMIC FEE.
above-mentioned property fur impcatien purples.
(WO agneas save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,cuss and expenses which may in my way accme against said City
in mma,mon,of Ne granting of thi,permil, ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO IE,DX)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCIONTAX
Signature of ApplimnVComnmmr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Willtheopplicmt or future building escapism same or hurdle bazardom material HEATING UNIT(TO 1(1(1,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9,12,and the Health and Safety
Cale,Section 25532(x)] HEATING UNIT(OVER 100,00()BTU)
El Yes FlNn
VENTILATION FAN(SINGLE REMD) PAID
Will the applicmt or forum building..part use ryuipmcm Date Receipt N or devices which BOILER-COMP(3HP OR 100,000 BIM)
emit hazardous air Contaminants as defined by the Bay Area Air Quality Management
UimrictP
❑Yes ❑Na WBOILER-COMP(OVER IEB, t ETU)
I have mad the hamrdms materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DAT
(amia Health&Solely Cade,Sections 25505,25533 and 25534.1 undersand that lithe NEW RESIDENTIAL MECH. SQ,PI'.
looddin nes nal cormntly have,leant,lh,I iIis my rnpons,di1i1,mnmify the axcupunh
offlm hems which mus met rho ilii. ecl u Cenifc is f0«u 'ncy.
or
n mrized eat, am TOTAL: ISSUED BY:
OFFICE