31223 APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OPICUoPryHm31223
ERTINO BUILDING4U,ECTRICAL .PERMITNO.
BUILDING ISION APPLICATIONMIERMIT PLUM
G-MI±CIIANICAL
BUILDING PROJECTIIIENT'IFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT[
S
OWNRT tTAME.
A
PHONE , OO PACT NIC r CO_N�TROrLp 29;� OS7 C9U
(.. tkllQ LIC NO: AD�NE� /j_ K2e. (/J a�'' `� ❑
NTA PHONE: C/ BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ (19:1 El COMI'RACTOR;S DECLARATION QTY ELECTRIC PERMIT FEC
1 hereby uflirm Ihm 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�OZ win Section]HHH)of Division Sof the Rosiness mid Professions Code,and my license is RESIDENTIAL
F- C 'n full fort and effect. PERMIT ISSUANCE
a�� h O KITCHEN REMODEL
UV License Class Lie, APPLIANCES-RESIDENTIAL OSFT)WL
Ina6 U.am Convector OADDITION PLUMBING RF.-PIPE -
ARCHITECTSDECLARATION ❑MULTI-UNIT ❑STRUCTURAL
[-. PANELS
z p Z I understand my plans shall be used or public records MODIFICATION
UPTO 20X)AMPS ❑IN'DiR10R El CHIMNEY REPAIR
F,41 W Licensed Poo ormil 201-1000AMPS IMERIOR [NT
� J
OWNER-BUILDER DECLARATION OVER)DOGAMPS ❑BATH REMODEURF.PAIR 0DEMOLITION
6 1 hereby affrm4hm 1 am exempt from the Contractors License Law for the
iq5 C d V follnwiug reason.(Section 9031.5,Ilusinen and Ihnfeasitns Cnde:Any ehy or countySIGNS ELECTRICAL ❑O'THER
F O rFjr which moires a I�cre it to convect,utter.improve,demolish,or resimulate pair any sulate
prior to its issuance.also requires perm
the applicant for such inoe a signedcutement
file TSPECIAL CIRCUIT/MISC.
W Num
at he is licensed Personal e provisions of the Commormes License Law(Chapter 9
CSO (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.ME'I'EROR POIE IMT COMMI:.R.IAL.•
0.p� ar Ihal he is exempt iherefinm and the basis for the alleged exemption Any vimlaion of ❑NEW BLDG/ADDITION ElDEMOLITION
i< Y.
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
ul m net mom than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
~p=Q ❑1,as owner ofthe pmpeny,or my enhPloyeeswishwages astheirstlennnpensation. SWIMMING POOL[LIiLTRIC IMPROVEMCNT
�jF+< will do the Werk.and the sbueure nlr t intended ooh wrigminr sale(Sec.]04Q H,sibs. ❑OTHER
I;T R and professions Cede:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
E property who builds or improves thereon,and who Aces such work himself or through
his own employees,provided that such Improvemems are not intended nr offered for NEW RESIDENTIAL.F.LECTR SQ IT.
sale.IL however,the building or improvement is sold within one year of completion,the SQ.FT.FLO(B1ysRyA' D $/SQ.FT.
- owner-builder will have the burden of proving that he did not build or improve for par. BB�� ff{{
pose of sale.). /I (j
❑1,as owner of the prupeny,am exclusively contracting with licensed contractors in TOTAL. MAY e 9
toteme,the ponect(Sea 7044,anoints,and Professions Code:)The Co....-1's Li.
ase Low does not apply to an owner of property who builds or improves lhemon,and QTY. PLUMBING PERMIT FEE
who mmracrs ler such pmjecus with a comructons)licensed pursuant m the Contractors CITY'
Liccme Lew.
Iran I'IiRMIT ISSUANCE Gh I,urt{�I'I O
octopi under Sec. ,B&PCfami,reu,un
ALTER-DRAIN&VENT-WAJ'RR(FA)
Owner Date ALTER
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I hereby affirm under penalty or perjury one of she following declarations:
[have and will maintain o Certificate of Comem to self-insure for Workers Compre- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by lection 3700 of mthma
e Labor Code,for e performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have end will mainmin Worker',Compemorme'Insumnce,as required by Section
3700ofinelyh rCodc.fonhe Pertor voce of the work for which this permit is issuW. GAS-EA.SYSTEM-I INC.4 DO'[LETS OCC.GROUP APN
My Wnr C tin c 'cr and Policy upbs( ts,�s yy��
Cmric s Policy No: �/1G� GAS-EA.SYSTEM-OVER 4IRA)
( iRTIFI A'I'L EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASC' DUSTRL WASTE INTERCEPTOR IIU)I.DING DIVISION III�S
(Thi,seetimnneednnl hecompleteE ifnhepcmut isforonehundreddidms($100) EASF.'I'RA
or kss.)
PLANCHECK FEE
Toy any Ihminthe any member
mberance of tee workletwhich this permitisissued,Lshnll SEWER-S ITARY-STORM PA.200 Ff.
not employ any person in any mannc�r so as m become subject m the Workeri Compen- ENERGY FEE
Z satin.Laws of Catifomia.Date
O Applicant W ER HEAT'[R WN 1:
PP GRADING FEE
V3 NOTICE TOct to the ANI:Work r Compensation
this viNln%of of Exemption,youshould WATER SY5'1'EM/fREATING
a ; become subject m the Workers visons.,his p.iit hal of the Luer Code,you must SOILS IEE
W fonhwiW comply with such provisions onhis permit shall be deemed revnkW. WATER SERVICE
Q
`U0 CatthemRUCTION LENDING AGENCY NIiW RESIDEMIALPLMB. SQ.IrC. PAID
U k for by which
that is issued
construction lending agency for Ne performance of Dae Receiptp
U. F the work for which this permit is issoeJ(Sec.3097,Civ.CJ
O U Lenders Name
ISI Lender's Address T
I certify that those read this applicaion and state that the above information is BUILDING FEE
V)7 correct.l agree to comply withal)city and county ordinances and state laws relufing It QTY. MECHANICAL PI7RMIT FEE
L7 s7- building construction,and hereby authoutc represe.mive,oftbix city to enlerupon the SEISMICFEE ,
above-montoned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,casts and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in c.ow,ran a of the gmmmil onhis permit PLUMBING PER
APPLICANT UNDERRCCmmAANDS AND CO V WITH ALL NON-POINT ALR HANDLING UNIT(TO 10�ic .000CFM)
SOURCE HCll0 5. Q p MECHANICALFEE h
AIR HANDLING UNIT(OVER 111,0110 CIM) CONSTRUCTION TAX -
Signau md/Crrioo for Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
ME hheapplicanwr furore building cecupantsmmor handle hazardous macml HEATING UNIT(RD](to,"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,audit Health and Safely
Code,Section 25532(a)] HEATING UNIT(OVER HalHIXt HI L
❑Yes ON. VENTILATION PAN(SINGLE RESIDp PAID
Data Receipt#
Will ms air comm or nts a building by the Bl use equipment m devices which
emit Ld�sn�
us air cnnuminnnts as defined by the limy Area Air Quality Management BOILER-CONI'(3HP OR 100,gX1 BTU)
1 61 BOILER-COMP(OVER 1 W.tN)0 BTU) TOTAL:
s ❑No
reel the hcoodoix materioN is under Chapterti.95of the Cali AIRCONDO'IONER
reyuimme" ISSUANCE DATE
&Safety Cale,Sections 255x5,25533 um125534.1 undersuth hot if me NEW RESIDENTIAL M[Cff. SQ.1-7.
nd curtenIf have a tenant,Nob iI is my resryntsibility Io nmify the cecupanhments which must la mm prior m issuance of a Cenificute of Occupancy.
rmized agent Orae TOTAL: ISSUED BY: -
OFFICE