29550 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
UILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTALDAIT
All 20'1fD PfT/���
' ti III PHON& CO fRACfORS NAME: LIC NO:
A NIC CONTROL as
AR P T INFER: LI .NO: AD .S g L
ONTACT: P �
/_ BUILDING PERMIT INFO
i�//�f•�yNJ/ �
EJ Consultant Fees Paid 6y Applicant(Initial) BLDG ELECT PLUMBMECN
'K ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT Ifi3F,
1 hereby nlErm that;ala licensee uncap provisions of Chapter 9(commencing JOB DESCRIPTION
�DOCZ with Switch 7000PofDi ition 3ofthe Bmanessand Pnsfwsioms Codgandmyliecoseis RESIDENTIAL,
O PERMIT ISSUANCE 1 NTIAL,
in full force and effect.
a VEj Lirense Class Lich ❑SFDWL ❑KITCHEN REMODEL
I-aw Date �Commctor APPLIANCES=RESIUfiNTIAL [)ADDITION ❑PLUMBINGRE-PIPE
NOy ARCHI'T'ECTS DECLARATION PANELS '' ❑MULTI UNIT C1 STRUCTURAL
Fv2
O Z�J l undersmnd my plant shall be used as public reasNs MODIFICATION
UPTt1200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATIONN
�r/r Licensed Professional 201-10g1AMPS IMPROVEMENT
i I
04 1 hereby affirm that 1 am exempt from the Compactors License Law for the OVER IIKKIAMPS ❑BATH REMODEUREPAIR DEMOLITION
aa Ufollowing reason.(Section]031.5,Business and Pod..old,Code:Any city or.,an,, SIGNS ELECTRICAL El OTHER
a which regain,,a pemou m conslowl,ulten improve,dentulish,m ncpair any structure
1q.�y priorwas issuance,alsorequirevhcapplicant formed porwitu,file a signed astemenl SPECIAL CIRCUIT/MISC.
fhmbeis licensedparsaanfto theppovisiensoffhe Comramur's License 1aw(Chapter9
wwa (commencing with Section 7")of Division 3ofthe Maintained Professions Cale)nr TEMP.METER OR POLE INST COMMERCIAL:
a a m y In.,he is exempt therefmm anthe d basis for the alleged exemption.Any violation of 11 NEW BLDG/ADDITION El DEMOLITION
WX a Section 711113 by any applicant far a permit subject the applicant to a civil penallyol POWIiR DEVICES []TENANT -1 TOO[)
thin live hnndpeddollars(5500). TENANTHMP
Iq6 ]I,as owncnsf the propeny,nr my employees with wage>as theirsnlc compensminn, SWIMMING POOL ELRCI'kIC - MpROV -
2211 Q will do the work,and the structure isnot int,awalm.1pered for sale(See,]ID4,Business HER V-Vnw•�-
W and Professions Code:The Contractors License Law does not apply toIse owner of GUTI.LetS-SWITCHES-FIXTURES It
Hh�
propeny who builds w improves themon,and who does such work himself or through
his own employees,provided that such improvement are not intended or offered for NEW RESIDENTIAL ELELTR SQ Ff.
sale.If.however,the building or improvement issold wilhinane,owafewupletion.the SQ.FT.FLOOR AREA VSQ.Cr.
owner-hander will have the burden of proving that he did not build or improve for pnry
poseof sale.).
FI Las owner of the propeny,um exclusively emnmcfing with licensed comroan to
<nnswn the p jam(Sec.]804,Business unJ Itofeuions Cade:?The Commnnrs Li-
censeLawdoesnotopplytoanownerofpro,city who builds or improves thereon,and QTY. PLOMHINGPERMIT FEE
who contracts for such projects with a contraction licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
E]I ant exempt under Sec. _ ,B&I'C for thisrwsan
ALTER-DRAIN&VENT-WATER(EA '
Owner Date ` VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECC DEVICE
I hereby affirm under penalty of perjury one of the following reductions: J7t W
❑Ihvve anJ will mainminu Ccnihcate of Conscm nssdf-insure lar Worker's Gsmpcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCfION
salion,as pow dial for by Section 31110 of the Lubar Cale,for the pwfimr ance of the
work far which Phis permit is is.sued, FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section - - ew
3700of Ne Labor Code,for performance of the work for which this permit is issued. GAS-HA.SYSTEM-L INC.4OTILETS C ROU qPN
My Work nsmlof ,bran, carrieranalPolim
cynuberare:
Carrier: Policy No.; GAS-EA.SYSTEM-OVER 4(EA) e
CERTIFIC TG OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRLWASTE INTERCEPTOR
(This section neW nm be completed if the,annul is frdeac hundred dollurs($100) Bull.I O DIVISION IME,S
or less.) GREASI?TRAP
PLANCHECK FEF.
1 cenify that in the any at..ur a es 1 work for which this,omit is issued.I shall'
notemploy any person in an nvnnerso asmbecnmc suM1'ecunthe Workers'Com SF.WF.R-SANITARY-STORM EA.2fNI Ff.
Yf J pen- ENERGY FEE IYs
Z AWliLaws of Cullfornis.Bate V
'OO Applcant - WATER HIiA'I'Ek'WIVI!N'I'/ELECTR GRADING PEE
Li NOTICE In APPLICANT,If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
hvewhe subject Ir the Worker's Compensation provisions of the tabor Cale,you must SOILS THIS
[[I
Parnassian comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RLSIDP.NTIALPLMB. SQ.FT. PAID
UO I for
whichrmfhauhero issued(Sect 30 len ding agency forlho paGrrmmfoeof Dela Receipt is
qtr+
the work far which this Perini(is issued(Sea 3119],Civ.C) -
O Lenders Name TOTAL:
I<ndera Address 'TOTAL:
0. 1 cenify that I have read flus applowion and state that the shove information is - BUILDING FEE OX �•
fA correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEISMICFEE
above-mentioned propeny for inspection pur,swo,' PERMITISSUANCE(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accme against said City pDl'ER OR ADD TO MECN.
in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS1AND yyXILL COMPLY WITH LL NONPOINTAIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOC: iULATI(7 & If //
AIR HANDLING ONE'I'IOVBR 10,000 CPM) CONSTRUCTION TAX
Signature of A,pIiOpmC7 mmvow Dam EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store whandle hazardous materiel HEATING UNIT On 100.000 BTU) ra 0 h1
as defmW by the Cupertino Municipal Cade,Chapter 9.12_,and the Health and Safety -
Code,Section 25532mr? HEATING UNIT(OVER 100,000 BTU)
❑lit C]No ' PAIDI.
IT
VENTILATION FAN(SINGLE BESIDE Will fibs applicant ip future building occupant use equipment or devices which (-Date R x
emitict? sex air comaminamsmdefined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100.t]W BTU) syr
District? S'/Tr; TOTAL:
❑Yes F7 No BOILER-COMP(OVER IgI,(IIp BTU) •V
I have rcud the hazardous nmtdals i AIR CONDITIONER
rcq 15533 an under .I and h to d t at drive
ISSUANCE DATE
Gonia gdoes&Safety Cale.Sections 8505,is my and 255341 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
.building goes nut company which have a mnznh that o is sea ce of a responsibility to e notify Ne,xanr ant
of the requirements which must he met prior to issuance of a Cenilicate of Occupancy. '
Owner or authorized agent Date - TCH'ALISSUED HY:
OFFICE