29908 (2) APPLICANTTO FILL ININFORMATION WITHIN HED LINES•USE BALL POINT PEN ONLY " -
CITYOFCUPEHTINO BUILDING-ELECTRICAL 'PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2.990,8
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO: APPLICATION SUBMITTAL DATE
XOMO alwG �C `rj QVC
OWN R'S ME: PH NE: C NTRNIC CONTROL N ACTOR' AME: LIC NO.
'
RCHITECTMNG EER: IC NO: ADDRESS: - ❑
CONTACT: PHONE: BUILDING PERMIT INFO
-5'1&
G� ❑ CoaSu1[aat Fees Pali]by Applicant(Initial) BLDG ELECT PLUMB MECH
\Q1:W�.i 1 liECVf/ al per' '�
LICENSED CONDwerOR'$DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby.)flim that f am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{OyI W'Z with ilforcn]0W)mf Division3oFlhe Business anJ Rofessions Cotle,andm licenwis
F+Op in Poll force and effect. y PERMIT ISSUANCE RESIDENTIAL'
F`
ULicense Class ElSFDWL [I KITCHEN REMODEL
UU Con#
rF•7�-tD Dete Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z8-4 1 understand my plugs shall he axed as puhfr records MODIFICATION
024 UP T02BB AMPS
Eee�e.�Iqq"GOrf Licensed Professional [_1 INTERIOR ❑CHIMNEY REPAIR
�pGZaj OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
yp�g�66''4Cl 1 hereby affirm that 1 am exempt from the Contractors License Law or the OVER 1000AMPS ❑BATH REMODELREPAIR D DEMOLITION
W 3 0.F following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
{zl O which requires a permit an construct,alter,improve,demolish,or repair any stmeture - ,, I -
priortoitsissuance,also requires the applicant for such Permit o rile a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
GO (commencing with Scditm7W1)of Division 3 ofthe Business and Professions Code)or TEMP.METE R NST. COMMERCIAL: v
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^w Section7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWERD - ❑TENANT FOOD SERVICE
y not more than Eve hundred dollars(5500).
❑1.asowner ofthe property,or my employees with wages as their anle compensation, SWI 1 C LBLEC C• IMPROVEMENT
`- will do the work,and the structure is not intended oroffered for sale(Sce.J044,Bromess ❑OTHER
ti] m and Professions Code:The Contractor's License Law does not apply to an owner of O LET WITCHES-FI RES
L r property who builds or impmbes thereon,and who does such work himself or through
hisow employees,provided tact such imeme
provnts are not intended or offered for NE RESIDE EL R SQ FT.
sale.If.however the building or improvement is sold within one yearofcompletiomthe SQ.FT FLODRAREA $/SQ.IT
toner-builder will have the burden of proving that he did not build art improve for pur-
poseofsal
1,as owner,of are properly,am exclusively contracting with licensed cnntraclnrs to TOTAL: - q
et the project(Sce.]044,Business and Profession.Cade)The Commences Li-
cerise
i-
e use Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBI PER FEE
who'contracts for such projects with a contractor(&)licensed purseant to the Contractor's u' 4Q --
LicenseLaw. - PERMIT ISSUANCE J
❑I an exempt under Sea ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Date 1 _ r�A TIQN'1Q
W S COM S TION DECLARATION" BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty perjury one ofthe following declarations:Worker's
C C11 V I sn
❑ion.as and will for
n a Se Certificate of the ent to Labor
Corrie,for the performance
of the
DRAINS-FLOOR,ROOF AREA,GOND. STORIES ��"••t ITYPECONSTRUCTION
&.[sort,as provided far mi Season 37W of the Labor Coda for the performance of the
work forwhichthis maintain
Worera Fl%TURES-PER TRAP
" ❑ 1 have end will maintain Worker's Compensation Insurance,as required by Section '
37W of the Ube,Code,for the performamce of the work for which this permit i&issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Insurance cattier and Policy number arc: -
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
., CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Dissectors need nor be completed if the Permit is for one hundred dollars($1 W) BUILDING DIVISI P
or le..) GREA56 TRAP '
PLANCHECK FEE
I Certify that in the any mmosec 1.the became which this pee Woo er,'Counter-
ndtemployanypersoninanymannersoastnb¢come subject tothe Workers'Cnmpen- SEWER-SANITARY-STORM EA.2W FT. ENERGY FEE
sating Laws of Cali forma.Date
O z WATER HEATER WNENT/ELECTR
O Applicant - GRADING FF.B
N NOTICE TObj APPLICANT:the Work If,ager making this Certificate of Exemption,you should WATER SYSTEMnIREATfNG
a �^ become subject y the Workers Compensation provisions of the Labra Code,you most SOILS FEE u
LiI ry
forthwith comply with such provisions or this permit ehali be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY
UO Ihereb affirm that there is a construction lending agent for the NEW RESIUENTIALPLMB. SQ.FT. PAID
y i y performance of Date . Receipt#
V.0 U the work for which this pemnt is issued(Sec.3097,Civ.Cr) TOTAL:
Q U Lender's Name
Lender's Address f TOTAL:
a - I cenify that I have read this application end state that the above information is BUILDING FEE
In cancer I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V G building construction,and hereby amhodze representatives of this city to enter uponthe SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree to save,indemnity and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way mance against said City ALTER ORADD TO MECH. PLUMBING FEE "
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. _ MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SignamremfAMlicanVConuactor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant store or handle hazardous material HEATING UNIT fTO 100,0021 BTU)
as defined by the Cupertino Mutational Code,Chapter 9.12,and the Health and Safety
Cole,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU) j
ED Yes ❑No VENTILATION FAN(SINGLE RES[D) 'PAID- -
- Dam. Receipt#
Wmmusl the aircordntorfntare bullring by the nt useBay A .Aiequipmentorde.nagees ant BOILER-COMP(3HP OR I BLOW BTU)
emit hazardous air contaminants os defined by the Bay Area Air Quality Management TOTAL:
DisWnY t' BOILER-COMP I01i BTU)
F1 Yes,� � �Nn -
formahave read the hazardous m 9 P otorial,requirements under Chapter 6.95 of the Cali- AIR CONDITIONER'
Health&Safety Code,Sections 25505,25533 and 25534 ISSUANCE DAT
Whom,
understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a naop Not 1[Is my responsibility m notify the"thereon '-
mfNerequirementswhiehmostbemetprinnoissuanceofeCenificapeofOecup�ncy. -
Owner or authorized agent Dote TOTAL: ISSUED BY:
OFFICE