29789 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 29789
BUILDING PROJECT IDEN'I'IEICAI'ION
BUILDINGADDRESS'. SANITARYNQ APPLICATION SUHM I'I'I'AL DAPI
/47 / T )/////Wl AeD. !fit-'lYfac'�.�o
WNEE�Sy NAM@(.�/ PHO NIi: CONT TTORS NAM{E: LIC NO:
31' /'/ / M•//G� 1540
xJC�/ �a[/.SIMGJ O NIC CONTROI.N
KCHHhCLaiNGINEER: LICNQ At )KESS: ❑
4) NAmoueLJ S, eic/l.Ca5'y�a
CONTACT: PHONE: 13UILUING PIiRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG. ELE PLUM
TRME
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE aGlpv
1 hereby affirm that 1 ser licensed under provisions of Chapter v Lonmtemang .JOB DESCRIPTION
Ong with Section 700nof Division 3nfthe Business it Profeasionn Code.and my license i. RESIDENTIAL:
PERMIT ISSUANCE
IyF in full I...nd effe e /_a�G I_O ❑SFDWL ❑BITCH EN REMODEL
�UU Luense Cl 'G Lic.p fY Y Q APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
NZ ➢IC Contactor
Q ARCHITECTS DECLARATION ❑MULTIUNIT ❑STRUCTURAL
1..,�on PANELS
Z O y Z I understand my piens shill be used as public records MODIFICATION
OZ— UP Z gV 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 30I-1000AMPS IMPROVEMENT
D IY IY y' Thereby affirm hoed em eulmhlFfRromENe Con wlOors License law for the OVER I"AMPS /- 1 ❑BATH REMODEUREPAIR ❑DEMOLITION
xst'O a U following re➢son.(Section 0031.5,Bre mv,s➢nit Proles➢iona Code:Any city nr mm�tY SIGNS CLEGTRICAL� c�1 ❑OTHER
W 3 LL St which tryuins.permit m etmsaaet,ober,improve,demolish,or rcpao eny swewm
prior toils issuance.also r aims.the applicant for such permitto file a signed statement SPECIALCIRCUI SC. j
f } that he is licensed pu munuo the provisions of the Contractors License Law(Chapter 9
tat (commencing with Section 7")ofDivision 3 ofthe Bmfdem➢nd Professions Ctdelor TEMP.M r OR Iro ST / COMMERCIAL
e.a eieg that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X
Section 903 t.5 by any applicam fora pewit subjaus the applicamm.civil pcnultyof v ER UEVC / ❑TENANT ❑FOOD SERVICE
n more than five hundred dollen($5001.
F Z} 0THERVEMENT
=Q ❑Lmowner af the progeny,document,isa.inoyces with engmanhei(Sec.cotepens➢tion. S 1 Lf:L[GTRIC
W G will dC lesions and,The Cis notintendedo Law
ds not apply o W. owner of ❑OTHIiR _�-.�".���
W
3 m and Professions Code:The Contractors License Low does not apply to on owner of OUD.E 5 4 W ITCHI?S-PI%TURFS
pmfRnY who builds or improves Nertnn,and who does such work himself or through
his own employees,Provided that such imroemare
pvents not intended or offered for NEW RF_SIDIiM'IAI.ELECTR SQ FT. \
sale If.however,the building ce improvement issald within one yeao(completion.the SU FE FLOOR AREA ') S/SQ.FT.
owner-builder will lime Nc burden of proving that he did not build or impmee for per- OR
1 sew '
pave of ale.). TOTAL: R 2e
❑1,as owner of the pmpenY,am exclusively cumacting with licensed cnmanoas to [
coronad the project(Sm.9uw.Resines and Professions Cmde:l The Contactors Li- is
96
c nse law does not apply a an owner of property who builds a improves Nerrnn,and QTY. PLUMBINGP tdjT FEE "'' (,
who conwca for such projects with a contractions)licensed pursuant to the Contractor's (rYC,�
Lic°me law. PERMIT ISSUANCE nJJ U
❑1 am exempt under See .B&PC for this reamn YZ
ALTER-DRAIN&V WATERA) VALUATION
Owner Dae
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE Dl 2 1 �' 060
I hereby affirm under penalty ,of ue jury one of N<following declarations:
I have and will maintain a Cerificau of ConeattosdGinsum forwurker's Compcn- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPE CONST RUCTION
cam n,as provided for by Section 37M of the Labm Cade,for Ne perfar ance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have add will maintain Workers Compensation Insurance.as required by Section
3700 of the Labs Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
Wrk and Policy
rtySitmdcy nye q pgccame comer.- Policy No:n
JT�f(IV YYN(l GAS-EA.SYSTEMOVERi(EA)
in
CERTIFICATE OF EXEMPTION FROM W RKERS GREASF/INDUSTRL WASTF.INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This union it not bemmpined ifthe permit is for..hundred dollars(SIM) GRFASCTRAY
or less.) PI.ANCHECK FEE
I certify that in the performance ofine work for which this permit is issued.I shalt SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner m m to become subject m the Workers'Compco- ENERGY FEE
O Z cation laws i fC.IiPomie.Dare WA'T'ER HEATER WNENT/ELECT'R GRADING FEE
.Za Q Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM)TREATING SOILS FEE
Fx ?
become subject o the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this Permit hall be deemed revoked WATER SERVICE
72
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.EL PAID Date Recciptp
U O I hereby aNrm In., is a conswction lending agency for the Mrformunce of
H Ne work for which his permit is issued(See.3097.Civ.C.)
U. Lender's Name TOTAL:
c,wLender's Address TOTAL:
Q. 1 certify that 1 have read this application and state that the above information is BUILDING IEE
.H. h correct.l agree to comply with all city and county ordinances and state laws reining to QTY. MECHANICAL PERMIT FEE
U Z building constriction,and hereby manrinninuscnutives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree an save,indemnify and keep harmless the Cityof Cepa tion against ELECTRIC PEE
Iiabililies,judgmemc costs and expedses which may in any way acerae against said City ALT17R OR ADD TOMECH.
in consequence of the granting of this pert. PLUMBING FEE
mi
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UND(TO 10.000 CPM)
MECHANICAL PEE.
SOUR REG'fAT10NS.
AIR HANDLING UNIT(OVER 10.(XX)CFM) CONSTRUCfIONTAX
of
Signaureo Applicam/Comucmr —� Date EXHAUST 11001)(WIUUCT) HOUSING MH'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or Loan building occupant store or handle himadots material HUNTING UNIT(TO 100.000 It TO)
as defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety
Code,Section 25532(x19 HENT INC.UNIT(OVER 100.001 It'IU)
I
0 �Yes No
VENTILATION PAN(SINGLE RL'SIU) PAID Dam Rcceipl M
Will the applicant or future building occupant use equipment or devices which
te
unit hnvnrdous r onldmments us defined by the Buy Are.Air Quality Management BOILER-COMP011P OR 100.000 HTU) 'TOTAL.
Disvicr!❑Yes 0 N BOII.IR-COME(OVER 10,0X)it'I'U)
(have mad the m,ardouamamw
erms re,ireenunder Chapter R 95ot the Cali. AIR CONDI'I'IONCR ISSUANCE DATE
fomla Heahh&Safety Gds Seetions 255(1.5,25533 and 25534.1 undeomnd that if the NEW RESIDENT IN.MP.CH. SQ.FL
building does not cumendy liave a tenant,that it Is my neponsibiloy e)nntilY the occap;mt
of the requirements which must be met prior m Issuance of a Cer ilicute A Occupadcy.
Owner or awhmivcd agent- Date 9t)1'AL: ISSUED BY:
OFFICE