29770 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q 7 7
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 2 9 1 1 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDENFIFICA ION
BUILDING ADDRESS: , 1. IC R� Cuis-fier-hr,30
t (�a SANITARYNO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: 1 s�1 p __ PHONE: CONTRACfOR'SN ME: LIC NO:
ail `-11}A aIL _ C jj ^/ N/C CONTROL#
(�ARCHI'1'EC'1'/ENGINEER: LIC NO: AUL I:SS:41QbO 6(!t ve ❑
CONTACT f PHONE: �i BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLLD�DDGyG ELECT PLUMB MECH
yiV ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEP.
izz I hereby affirm that I an 11CeeBJ under provisions of Chapter n(commencing 70B DESCRIPTION
�-W— in fall ion]cllll)of Division of The Business errs Pro(euions Cak,end my license is PERMIT ISSUANCE RESIDENTIAL:
f Iy in full force wd eBegct.
�UyLPU1 License Cl � —L ❑SPDWL - El KITCHEN REMODEL.
6a Dale Conouetnr APPLIANCES-RESIDENTIAL. ❑ADDI'TION ❑PLUMBINGREPIPH
ARCHITECT'SDECLARATI N ❑MULTI-0NIT ❑STRULTURAI.
f n
PANELS
Z O�? 1 understand my Plans shell homed m public rttnNu MODIFICATION
OZ�g. UP TO 200 AMPS ❑INTERIOR CHIMNEY REPAIR
❑C6 R w Licensed Professional 201-I0OOAMPS IMPROVEMENT
.�4J OWNER-BUILDER m DECLARATION OVER IOMAMPS ❑BATH REMO t l IiPA R ❑DEMOLITION
1 hereby af0rtn mm 1 um exempt from the Contractor's License how for the
?p5,31 VV following reams.(Section]831.5,Business and Professinm Ctxle:Any city or county SIGNS ELECIRI L ❑OTHER
F^p yQj which reyuirea a permit m cnmwn.ahee improve,demolish,or rtpeir any swaure cs" a6I .I I l-i
h.] prior to its issuance,also requires the applicant for such Permit to Too a signed statement SPECIAL CIRCUI =
sus 9. that he is licensed pursuant to the pmAkions of the Contracmr's License Law(Chapmr9
�0 (commencing with Section 7000)of Division 3of the Businessnnd Professions Code)nr 9'IiMP.MEfF.R(IRP .1 COMMERCIAL:
ta"p, Y that he is exempt thefel'mnt and the basis far the alleged eaetno,on.Any violmion of
m [I NEW BLDG/ADDI9'ION ❑DEMOLI'T'ION
i< 0. Section]11315 by any applicanl fora permit subjects the applicunn et civil penalty of POWER DEVICP
ul Z>- not mom than five hundred dollars($5IX). ❑TENANT ❑FOOD SERVICE
< Los ownerof Nero norm IMPROVEMENT
f,❑i$ 0 ❑ t pe y my with seed far
cont,Business SWIh1MINCK Kill,
andwilBothe work,and the he Co eisoati LiverJn Law does
solepply TO1 an Rosiness []OTHER
and Property
whlotCs Co de:The Cnneaereca L nd w Law saes not apply s if owner of OUTLETS-S T S-I7XTURES
property who builds or improves thereon,and who saes e n work himself 11 through
his own employeese pmlding Ihm such impms sold within
art not intended or pllBmJ for NGW RESIDG AL ECTR SQ FT.
owner-howeverill have
bunor ks of proving
is at he lid n one build
or i provetior the n NSU.FL FLOOR AREA LSQ.FT.
owner-builder tc.),will have the buNcn of proving ohm he did not build or improve far Pur- '
you of sakJ.
L as Owner of the ru n
❑ p pe y,nm Business
and Pratax mc.w,le:)m e Cmnmrucmrs i-
nswa theproject(Sec.oan owner
endrty wh i builds
Cale:)Thees thereon, ni-
cermelewdoesnotapply�oaswithaombatanywhosedparimprovesComittees QTY. PLUMBING PIiRMIT PLC; `
who contracts for such pryers wiNacnmrncmr(s]Iicenscd pursuant to Me Cnmmctoh b ty)tl�
License Law. PERMIT ISSUANCE V(A
' ❑Iamexempt under Sec, ,B&IsCfor this Mason aIV. kaU�
ALTER-DRAIN&VENT-WATER(EA (s,11 VALUATION
Owner Dam `
OO
WORKER'S COMPENSATION DECIARA'I'ION BACK ROW PROTECT.DEVICE
• I hereby affirm under Penalty of perjury one of the following declarations: ) yYJ YJ
❑I have and will mutation a Certificate Consent of Conseno self.insu,for Worker's Camper. DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPCCONSTRUCTION
cation,as provided for by Section 3400 of the Labor Code.fnr the perfarnmuce of the
work fnr which this Permit is issued. FIXTURES-FER TR
IR I have unJ will maintain Worker's Compenamion Immune.,os required by Section
3700af the LeMrCadefonto performance of the work for which this permit is issued. GAS-EA.$ TH IN 4 UTLETS OCC.GROUP APN
Aly Wtakee peyunion In u.:ga rand Policy number�ry5 /
Carrier. p •}e .'....,!'ro`policy Nn; IM1'72 - Q/. GAS-EASY, ' O R (EA)
CERTIFICA'I'EOFEXIMPTION FROM WORKERS' ❑REASPlINU115' 'Ii TNT%RCEPTDIi
COMPENSATION INSURANCE NSI h7 BUILDING DIVISION Milli
becompfoub! he permitisfanmehunJreJ dollars(51!10) GkIrASETR
or less.)
' PLANCHECK FEE
IceNfy pehatrson
m Perany wancedithe work for subject
bjech tto the Wikern'Componl SEWER .ANTPARY-STORM EA.200 FEE
oat employ any person in any manner so as to I+ttame subjecua the Warkeri Compen- ENERGY FEE
Qz smion Laws of California.Date WATER BEAT W/VEN DfiLECTR
7 C) Applicant - - GRADING FEE
fl NOTICE TO APPLICANT.If,da,making this Ccnificote of Exemption,you should WATER SYST 13MUTREATING
Fal 7 become subject to the Worker's Compound..provisions of the Labor Cade,you most SOILS FEE
IFa forthwall comply with such provisions or this permit shall be deemed revoked. WATER SERVICE -
Q
z
CONS]RUCTION AGENCY NEW RF.51013N'1'IAI.P[.MB. SQ.IT. PAID
IJ0 k for
rat that thereisaronswm on leading agency far the peH'nnnance of Date Receiptp
� rs on work for which this pemut is issued(See.3119],Civ.CJ
04L) L.eniket Name TOTAL:
[,.does Addreu TOTAL:
a1 comfy are I have read this application and sate that the idm o informal ion is BUILDING FEE .dc)
tti Vl mrrcet.I agree mcomply wish all city end county ordinances unJ state laws rcl:ning to QTY. MECHANICAL VFRMIT' Flip
U builsing nmsvuction,and hcrehy authorize represenm[ivu of this city to enter alum the SEISMIC FEE r
above mentioned Property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep haveleas the City of Cupertino against ELECTRIC FEE
liabilioca,judgments,costs and expenses which may in any way seem,against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AUR HANDLING UNIT(TO Io CFM)
SOURCE REGULATIONS, MECHANICAL.FEE
AIR HANDI.I U ER 140010 CFM) CONSTRUCTIONTAX
Signmureof ApplicanUComractor Date EXHAUST D 13 (7f)
HAZARDOUS MATERIALS DISCLOSURii
HOUSING MITIGATION FEF.
Will The
Contemn.
ogle.Chaptr9A2,handle Health
Safety HEATING UNI IOD,WfI❑T11) -
Cs de.Sed by the Cupertino Municipal Cnde,Chapter 9.12,unJ the Health and Safety
Cade.Section 25532(e)7 It1iATIN NIT(OVER I00,00(1 BTU)
❑Yes PN. PAID
VENTILATION FAN(SINGLE R&SID) Date Receipt It
Will the applicant or future building occupant use equipment or devices which BOILER cGMP(3HP OR 100,M)RTU)
emit haeonlons air conmmioanfs ax defined by the Bay Arco"Air Quality Managcn -
tent TOTAL: �J
District]
❑Yes RNo [TOILER-COMP(OVER I DLW BTU)
I have read the havarhas materials mquiremenm under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
Mon.Health&Safety Code Stolons 255115,25533 and 8534.1 modoem nd thm if the NEW RESIDENTIAL MUCH. SQ.n'.
building does not currently have a tenant,that It is my responsibility in notify the occupant
of the nsiuim Orts w'ch must be rn non 'asuantt of a Cedifeme of Ota
Owner onmtboriae a ate TOTAL: ISSUED BY:
OFFICE