29507 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O
BUILDING DIVISION APPIACATION/PF,RMIT PLUMBING-MECHANICAL.
BUILDING PROJEC'C IDENTIFICATION
BUILDINGADDRESS: iW SANITARY NO. APPLICN SUBMITTAL DATE
RP O
y/
OWNER'S NAME.0 Iii.,� 1' NEi5—/ / NIRA ORF( ME: r 1-130: NIC CONIROI.M
TO
�ARCHITEC(ENGINEER: LIC 0: AD RESS: t/ ( j_ J/(' ❑
(T l(I J
coN'p'pC'c PHONE BUI,DING PERMIT INFO
❑ Consultant Fees Paid by Applimurt(Initial) BLDG ELECT PLUMB ECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC P13RMIT FEE
I hereby aR m that I an)licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with Section 7")ofDivision 3 ofthe Business And Processions Cods,and s 1
CO yianuis PERMIT ISSUANCE RESIDENTIAL`
�Fpyp mumll CleanJ,II'cm. O 0'f A, ❑SFDWL ❑KITCH17N REMODEL
UZ Licrnse Class Lic v T APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMB ING RE-PIPE
Q� Dale Comrvcmr
ARCHD'F.CPSDECLARATIO ❑MULTI-UNIT ❑STRUCTURAL.
F 7 m PANELS
Z p°a Z 1 undersmnJ my stuns obeli he used vs poetic records MODIFICATION
O Z E1UPTO 200AMPS
q - C3 INTERIOR El CHIMNEY REPAIR
��1W Licensed l'rofcsxinnAl - - 201-IB00AM1'S ,IMPROVEMENT •
raj Oat I am eUILDER DECLARATION ConTION OVER I"AMPS
y 1 hereby affirm Nm 1 am eacmlis from the Contractors License Law for she ❑BATH REMODEVREPAIR (]DEMOLITION
Sit 3 6 U following rcaaon.(Section 7031.5,Business unit foie xims Code:Any city or county SIGNS ELECTRICAL El OTHER
YI 0 which respires A permit to consimn,ager.improve,dem dish,or repair any swcmre
{On priorto its inuus...lm requires dom.,licant for such ycroomm file.signed dormem SPECIAL CIRCUIT/M1SC.
y�y,a+
that he is licensed pursuant m the provisions ofthe Contractors Licens,Law(Chapter 9
C00 (aosmmeneing with Stelion EXKb.f Division 3 ofshe Business and professions Cale)or TFiMR METER OR POLE INS'it COMMERCIAL:
C.ppx,,e y that he is exempt sbemfmm unit Ne basis far Ne ullcgul exemption.Any violation of NEW BLDG/ADDMON ❑DEMOLITION
W^t4 Section 7031.5 by any Applicant for a permit subjects the Applicants to a civil penalty of POWER DEVICES
W relA Z IFNANT ❑FOOD SERVICE
i+ not more than five hundred dollars($500).
�a I,As owner of the n IMPROVEMENT
❑ property,re is et mandea with Nn(Sm.cumpcnsiien, SWIMMING POOL ELECTRIC
will doshework,and the he Contractors
pots Licensor Law
dos not apply L14J, weer of ❑OTIIF.R
andertyProfessions bildso The Cmmtaeors L ndwlawsIncnmapplyroan lfowner of OU'ILLTS-SWITCHES-PI%TURPS
.. his o ny who builds or improves t such i and who does tush work himself or through
his own employeese provdeJ that such improvements are not intended ot offered for NEW RESIDENTIAL ELECIR SQ Pf.
ulnr-however,llhave the haran ofprovinsisat he
noncyemt improve for
SQ.FT.FLOORARP.A S/SQ.PI'.
owner-builder will have the hunlen of Proving that he did not build nr imMrve for ter- ,. '
you cf sd,J.
❑ 1,as owner of the property,am exclusively connecting with licensed mometars to TOTAL:
construct the project(Sec.7100,Business and Professions Code:)The Counselor's Li-
cease law doe not only to An owner of Property who builds or improves NA ems.and QIT. PLUMBING PERMIT FEE 1� 1 6 1996
whoempmms for such projects with a connotations)Ikensed pureuanno the Contructors
License Law. PERMIT ISSUANCE:
❑I am AAmFPtooler Sec. ,B&P C for this reason s Vs �ssri s
ALTER-DRAIN&YEW-WATER(EA) - VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under Penalty of perjury one of the following dalarations: -
❑I have and will maintain is Cerificme of Consenrto self-imme,for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
.tion,m provided for by Section 37M of Ne I<bnr Code,for Ne performance of the STORIES
TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compenution Insurance,As required by Section
370pafthe LaborCode,for the pchfomnanceofthe work for which this permit is issued. GAS-EA.SYS1'EM-1 INC.4 OUTLETS OCC.GROUP APN
My Wnr r aC 'osis m er.nd via my man �
n
/ Carricr.� /pL Policy No. � Ll {� GAS-EA.SYSTEM-OVER 4 BIG
CER17 ATP,OF EMPUON(ROM WORKERS' ❑RUSFJINDUSTRL WASTE COMPENSATION INSURANCE BUILDING DIVISION IFPS '
- (This section need not becompletedifum permit is foronehundreddollars($INH GRRASETRAP
or less) PLANCHF.CK ME
I certify that in she perfommnre ofthe work forwhich this permit is issued,i shall SCWhR-SANITARY-STORM PA. FT.
not employ any person in Any manner so As to become subject o the Workers.'Compen .
- ENERGY FEE -
Z section Lows of Califonateia.D
O WATER IIUTEH WNENTB3LECIR
O NOEIam GRADING FLP.
f�j3 NOTICE, bj ct to the
Workers
IL Cour making this Certificate dEvebor o d you should WATER SYSTEM/IREA'1'ING SOILS FEE
a ^�' femme sojas n the Workers G+m s FF tri n Permit
deal of the Labor Cnde,you sun
D.1c foN+wiN comply with such provisions nr Nisfcrmit shallhdumW revoked, WATER SERVICE
d Q
CONSTRUCTION LENDING AGENCY NEW RESIDI?MIAI.PCMB. SQ.PI'. PAID
U 0 Iherehy affirm thanhere isoemsuueinn lending agency for the peAorm.nce of Data Receipt
D. H the work for which this permit is issued(See.31H7,Cu,CJ
0 Lenders Name .TOTAL:
GLenders Address TOTAL:
I certify that I have read this application and state Ninformation at the above infoation ix BUILDING ME
N correct.I Agme to comply with all city and cosy ordinances and state laws miming to QTY. MECHANICAL PERMIT FEL?
V building comuctinn,and hereby autumns,repreunustim,of Nis city menter urymthe SEISMIC FEE -
above-mentioned property for inspection purposes. PI?RMIT ISSUANCE
(W,)Agrm move,indemnify std keep ham lcs the City of Cupertino against ELECTRIC LLE
Iiabilitias,judgments,costs and expenses which may in any way accme against said City ALTER OR ADDTO MECH.
I.consequence of the granting of this permit. PLUMBING FEL:
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT sift HANDLING UNIT(TO 10.0110CIM)
5 +RCE REGULATIONS. MECHANICALFEE
rb` AIR HANDLING UNIT(OVER IO,IgOCFM) CONSTRUCTION TAX
Signature ofppplicam/Cnmre Date EXHAUST GOOD(WIDUCf) HOUSING MITIGATION FEEHA9ARDOUSif GRIAL ISCLOSURC
Will thcapplicammmumehuildiall6m anssteromhandiehmadouxmmerial HEATING UNIT(TO RAL(sk(ITU)
as defined by she Cupertino Municipal Cade,Chapter 9.12,and We health and Safety
Code,Section 23532(4)? HEATING UNIT(OVER 100,I)CO D RJ)
E]Y. ❑No
VIiNTIU'1'ION FAN(SINGLE RPSIO) PAID
Will the applicant or future building occupam use equipment of devices which Data Receipt N
emit bitumens it,mnsminunts As defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
Own,? TOTAL:
Dyes [-I No BOILER-COMP(OVER I00,00011TID
I have rend the bamrdoms materialsresents under Chapter 6.95 of Ne Cath- AIR CONDITIONER
requi P ISSUANCE DATE.
Genie Hshh&Safety Code,Smions 23505,25577 unit 25534.I undnstand that if the NEW RFSIDENTIAL MECH. SQ.IT.
building does not currently have tenant that it is my responsibility In notify the occupant
of[lie amuimmi which must be met prior m issuance of a CcdiBcam of Occupancy.
Owner or a duo iud agent Date TOTAL: ISSUED BY:
OFFICE