29159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAL
BUILDING PROJECT IDENTIFICATION 29159
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
t i 9 sr�a Dip— CuPr�/jo -a-�
OWNER'S NAh1E; VHONE: CFI
NTRAQ'OR$NAg1E LIC NO:
4 o AM��&(Z .ZS7 232 I� CCd�1Si�• 4 g3o NIC CONTROL It
ARCHITECT/ENGINEER: LIC NO. ADDRESS ❑
�2I 67 N4.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
'I hereby affirm shot 1.m licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DMZ with Section]Clyd)of Doislon 3 ofthe Business and Professions Cole,and my license is
in full force and off (- 7 PERMIT ISSUANCE RESIDENTIAL
�UU License Clan —' Liana II��JD �a-� ❑SPOWL ❑KITCHEN REMODEL
yQW Done Canvuctor pplF �67Alsg APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION'" /��( ❑MULTI UNIT ❑STRUCTURAL.
Z O n Z 1 undcramnd my plans shall be used as public records PANELS _T\
MODIFICATION
O Z UPT02fgIAMPS
FBF-w Licensed Professional ❑IM1TERIOR El CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT
�ct:0: OWNER-exempt m in Ce Contractors
OVER 1000 AMPS KRAili•REMODEIJREPAIR DEMOLITION
yy Q I hereby affirm shot I am exempt from the Convannr's License Law for the
5<3 a U following reason.(Section 7031.5,Business and Profexaions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Yu11 LL.y which rtquirts a permit m conswe6 aBa improve,demnlisR nr rvpar any slrvcmrc
prinno its issuance.also requires the applicant for such permit o rile a signed statement SPECIAL CIRCUIT/MISC.
Qthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 a
%
HC (commencing with Section]BlgB of Division 3 of the Business and Pmfessiens Code)or TEMP.METER OR POLE INST COMMERCIAL
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a potion mbjects theapplicam to a civil penalty of POWER DEVICES so ❑TEN NT
FZ} not more than five hundred dollars(S500). ❑FOODSERVICE
r2¢ I,as owner of the OVEMFNT
2 ❑ the somy,uf try cremated
ate l stall( ea compensation, SWIMMING POOL ELECTRIC
M-2 will Jn the work.and lM1e structure is not intended ondfered lbr vk(Ses.]OW,Business
3 m and Professions Cndc:The Contractor's License Law dues not apply to an owner of OUTLET'S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work hi tmelf or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Ff.
sale.If,however.the building or improvement is sold within one year ofcomplelion,the SQ.FT.FLOOR AREA $/SQ.PT.
serer,lumicer will have the burden of proving that he did not build or improve for pur-
prse rf.ala).
C]I,as ow..rrof the proper},ant exclusively cumoteling with licensed comments nm TOTAL: J\
construct the project(Scar,]OW,Business and Professions Code:)no Convamnts Li-
renew Law does not apply it)an owner of posterity who bacilds or improves thereon,and QTY. PLUMBING PERMIT FEE
who wntracts for such projects with a coneranorts)licensed pursuant m Ne Contractors
Lacomw Law.
❑ Iamexcon,im Jcr Sec. ,B&PCfur this reason PERMIT ISSUANCE,
ALTER IN&VENT-WATER(EA)
Owner Dam J� VALUATION
WORKER'S COMPENSATION DECLARATION BAC O 1 v �Af �Iqa
1 hereby of firm under penalty of perjury one of the following dmlamtic m: VV
❑Ihaveand will mxinminaCenifica¢of Consent to sell'-insure fur Worker's Compcn- DR A.
onion,as provided for by Section 37N)of the Labor Cute for the perfontwnce of the STORIES TYPE GQN$TRGGTIQI
o
work for which Nis permit ix issued. FIXTURES-VER Tiff
❑1 have and will maintain Workers Compensation Insurance,as requirel by Section
3700.1'be WborCade.for the performaneeofthe work fur which this permit is issued, GAS-PA.SYSTEM-I INCA S OCC.GROUp qp,N
My Worker' Compenamion�m eg and Policy formation:
Caries—.l,L{J�i_L•Y/f !la !Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASFJINDUSI'RL WASTE INTERCEPTOR It
(This section need not becompleted ifthe permit is forene hundred doll./S luld BUILDING DIVISION FEES
nr jr—) GREASE TRAP PLANCHECK FEE
1 certify Per in the any man nee dlhe work for which It to peel is issued,I plat's
net aremploy Lows.any persnnin any manner sit avmbecome subject the Wnrkcrs'Compen- SEWER-SANITARY-STORM EA.200 FT.
ENERGY FEE
Z vthon lows of Califrnnia.Dam WATER HEATER W/VENT/BLECTR
z ^O
Applicant GRADING FEE
NOTICE TO APPLICAN'p:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING
I" heannc subject¢m the Worker's Compensation provisions of the La
lwr Cade,you most
ti forthwith comply with such provisions or this permit shall Na deemed revokest. WATER SERVICE SOILS FEF.
CONSTRUCTION LENDING AGENCY
z NEW RESIDENTIAL PLMB. SQ,FL PAID
VQ I for
which thi that thereisacd(Ser.on len ding agency fonheperfnrmvnee of Dvm Recuptp
W N the Lenders
for which thispermit it issued(Ss.309].Civ,CJ
ULenders NamAddress Uj Isndcrs AJJrexv TOTAL:
F0. 1 certify that I have read this application and.state that the above information is TOTAL: BUILDING IEE
V) cotrcm.l agree to comply with all city and county ordinances and some laws relating it, QTY. MECHANICAL PERMIT FEE
C„)Z building conamction.and hereby andante representatives ofthis city am enter upmnlhe SEISMIC FEE
above-nmntioned property for inspection pupmxes. PERMI f ISSUANCE
(Wo)agree to save,Indemnify anti keep harmless the City of Cupertino against - ELECTRIC FEE
liabilities,judgments,costs and expenses which on,,in any way nectar against said City gLTGR OR ADD TO MECII.
I.consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0110 CFM)
SOURCE'REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.0011 CFM) CONSTRUCfION'1'AX
Stgncomeof AOplicanVCmdraror Date EXHAUST HOOD(W/DUCT)
HA-IARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION IMF.
Will thevpplicant ortumre buildingoccupant Immo"handl.haemdous material HEATING UNIT(TO I00.000 BTU)
.s dcOned by the Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety
Code,Section 25532(.)9 HEATING UNIT(OVER I(p,IXp BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RMID) PAID
will the applicant of future building occupant use equipment or devices which Date Receipt p C
iIIIIIIIIIIIIIIIIIIenal hasco mus air conmminana a,defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,0011 BTU) ✓
Dir..", TOTAL:
❑Yea f_1 No BOILER-COMP(OVER 100,000 BTU)
I have rand the haezNuus materials reyuirementa under Chapter 6.95 of the Cali- AIRCONDITIONER
humin Health&Safety Cede.Sessions 25505.25533 and 25534.1 understand that if the ISSUANCE DATE
buildingdees asurtmently basearenml,that it is mymsWnsibilitymnotifyiheoccupanl NEW RESIDENTIAL MECH. SQ.FT.
of do,mquiremcros which most be met prior to comov a of a Ccnificote efoccupanry.
Owner or awhnnecd agent Date TOTAL:
ISSUED BY:
OFFICE