29700 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^/1 O O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING L`J•
B
NG-MECHANICAL
BUILDING PROIF.0 T IDENTIFICATION
RUILDI^AU)[y3'35:��� �� SANITARY NO. APPLICATION SUBMIT-IAL DAT
ro
OWNFriN E' �. HONF,:�/ O. R' NA tri LI N
�Z 3l7 L �r O NIC CONTROL p
�ARCHITECT/IiNGINEER: LIC NO: 1) S ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consuitanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S add, DECLARATION Of CON QTY. ELECTRIC PERMIT FEE IV
1 hereby affirm that 1 am licensed under provisions of Chapter Y(commencing JOB DESCRIPTION
{p{y�Z with Sarce mo00))ofDivision Sof the Business and Professions Code,and mylieensc is
FOO in(all force anJ efte� PliRhtl'f ISSUANCE RESIDENTIAL-
1- Z-O 30M72- ❑SFDWL ❑KITCHEN REMODEL
V V License Class - Lie k
hZi Dam - Cmmmcmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
1„py ARCIf11ECT'S DECLARAT )N PANELS ❑MULTI-UNIT El STRUCTURAL
Z O in Z 1 understand my plans shall he used as public records MODIFICATION
O Z UP TO 200 AMPS
[[-"cl Licensed Professional ❑INTERIOR ❑CHLMNEY REPAIR
Q OWNER-BUILDER IIECLARAT'[ON 2111-1000AMPS IMPROVEMENT
C C Q 1 hereby affirm that 1 an Csampr form the CmnLmmms Lianas Law for the OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
k3 L F following reason,(Section 7031.5.Business and Professions Cede:Any city or countySIGNS ELECTRICAL ❑OTHER
41 LL O y which requires a pennir m Construct.alter,imprmr,demolish,or repair any somemre -
�•'sn� prior or its issuance,also requires Ne applicant for such permit to file a signed stmemcm SPECIAL CIRCUITMISC.
S;!(} that he is licensed purauam to the provisions of the Contractor's License Law(Chapmr9
ad 0O (commencing with Section 7")of Division 3 oohs Business and Professions Code)or TEMP.METER OR POLE INST. OMMFR IA
tY cy that he is exempt therefrom and the laid,for the alleged exemption.Any violision of ❑NEW BLDG/ADDITION
NSection 0(131.5 by any applicant fora permit subjects Ne applicant to a civil penally of POWER DEVICES ❑DEMOLITION
not more than rive hundred dollars($500). []TENANT ❑FOOD SERVICE
❑Lres owner oftheproperty,or my employees with wages auheir sole compensation, SWIMMING POOL ELECTRIC `,l IMPROVEMENT
will do the work,and the wrocture is nor intended ondftted for.sule(Sec.7034.Business ❑OTHER
43 m and Professions Code:The Conrmnor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employces,provided that,such improvemems Co.nm intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however,the building or improvement is sold within oneyearofcomplerion.dre SQ.E..FLOORAREA $/SQ.FT
owner-budder will have the burden of proving that he did not build or improve for pur-
pose of salt.}
C h as owner.of rhe property,am exclusively contracting with IicenseJ centracmrs 1. TOTAL
Constrict the project(Sec.]OMI.Rmineau and Professions Code:)The Conrmcmr's Li- ��
cerise Law does norapply us an owner ofproperty who builds or improves thereon,and QTY. PLUMBING PERMIT FEE Ll 0
who corsets for such projects with a cmntmcauts)licensed pursuant to the Contractor's
C3m
I a Low. n0
❑I oto exempt under Sea. ,B&P C fonM1is rcasePERMIT ISSUANCE n A
Door ALTER-DRAIN&VENT-WATER(HAI
Owner WORKER —
'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE rr�r - 79,gjLUATION
• I hereby aRvn under penalty ofperjury one of the following declumn.on.0 VL'L yJ {U(►�
❑I have and will maintain a Certificate of Consenttoself-insure for Worker's Corepen- DRAINS-FLOOR,ROOF,AREA,COND,
station,as provided for by Sectio 3701 of the L-bur Coda,for the performance of the STORIES9�� 'TYPE CONSTRUCTIO!
work for which this .It is issued. FIXTURES-PER TRAP
❑1 have and will maimmn Worker's Cmnpenm'ion to-o ace,as required by Section
3700mf Ne LaborCaR.for'beperforrnance ofine weak forwhichdr,,non is issued. GAS-FA.SYSTEh1-1 INC.4 OUTLETS OCC.GROUP ANN
My Workur'�.Cprnpcnxm�m 4 carry and Policy m thr
Camiee l'Jh1._ �i `Policy No.:� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FRO WORKERS'
COMPENSATION INSURANCE. GRHASFANUUSTRLWASTE INTERCEPTOR
IT cation need nal wenmpleted if Ne permit is Toros hundred dollars EP W) BUILDING DIVISION FEES
or last.) GREASE TRAP PLANCHECK FEE
Toy anythatim in peradromanymanosce nerof rhewvok for wComcwhichthio psoitisissuCompall SEWER-SANITARY-STORM EA.2001 FT.
not employ any person in any manner so as m bcmme suhjum to[he Wnrkc's'Cmmpcn" ENERGY FEE
Oz Applicant
Laws of California.Dam WATER HEATER WNENT/ELECTR
z NOTICE
GRADING FEE
.N. NOTICE TO APPLICANT:If,efmr making this Crnificate of Exemption,you should WATER SYSTEM/('BEATING
> become svbjual to the Workers Compcnsaion pnwilam,of the Labor Code,you most SOILS MEW forthwith comply with such provisions or this permit shall he deemed revoked Wq'I'[R SERVICE
d 0
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ FT. PAID
V 0 I hereby affirm that them is a construction leading agency for the Performance of Date Raeip'N
4. N the work for which'his permit is issued(Sec.3097.Civ.C)
finder's Name
V Lender's Address TOTAL: 'TOTAL:
y 1 certify that 1 have read this application and aam that the aMve information is
iF+ A Cortef I-gree ro comply with all cit and BUILDING FEE
UZ buildingCorporation.and hereby yon yoMinunccf and sato lawter upon
QTY. MECHANICAL PERMIT FEE
cons y-uthmnzercpresenmives Of this ntymemtt ulxm the SEISMIC PEIi
shove-mentioned propene for emnif an keep ha. PERMIT ISSUANCE
WC)agnea m save.indemnify and keep hay a r handless the City ofc dimno against ELECTRIC FEE
incon equnce of the granting
of this pe which may in any way accrue agains'saiJ City ALTERORADDTOMECH.
in consequence of the UNDERSTANDS
of thispermit.WIL. PLUMBING FfiE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT TO 10,000 CFM)
SOURCE RGGULATIONS, ( MECHANICAL FEE
AIR HANDLING UNIT(UVEB 10.000 CPM)
�i CONSTRUCTION TAX
Signamrt of AppbcanZ.ronwcmr Dam EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIA . DISCLOSURE HOUSING MITIGATION FEE
Willtheappliodum or fummbuildingac pant state orhandlehazardmusmarcrial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cock,Chapter 9.12,and the Health and Safety
Cale,Section 25532(x)7 HEATING UNIT(OVER 100.001 BTU)
❑Yes 0 N
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which=CONDITIONER
Date Rae,d
emit hazardous air cmn'aminams as defined by the Bay Arca An Quality ManugememHP OR 100,f1W BTU)
DiorwO
❑Yes E]No VER I(0,000B'1'U) ,,T'OTAL:
1 have read the hatordous mmcnals requirements under Chapter 6.95 of the Cali- R Kforma Health&Safety Code.Sections 25505,25533 and 25534.1 undersand that if theISSUANCE DATE
oftWingdoes uiremntscurrentlywhich hast amnet pthato ism biliry'onrifthtoccu tLMECH. SQ.FT.y resprmsi y panof Ne tequlrerlenrs which must be met pnnno issuance mfe Cenific:ne ofOccupancy. ''�7��j�t Dal, TOTAL ISSUED BY:
OFFICE