29089 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO, O
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL.
^ BUILDING PROJECT IDENTIFICATION
BUILDING AD RESS:- O�jf - SANITARY NO.. A 89
PLICATION SUBMITTAL DATI
powk&
OW11i NAME: t l' j�tU)IF' '�y II CO OR'S N ^
a 77 OV N/C CONTROLtl
AR ITECT/E (NEER: LIC NO: AD ❑
CONT PHONE:
- BUILDING PERMIT INFO
//� /f ❑ Consultant Fee9 Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
/ ,!/f),t ❑ ❑ ❑
LIC SED CONTRACTOR'S DECLARATION
Qyaz QTY, ELECTRIC PERMIT
1 hereby affirm at 1 tem licensed under provisions of Chapter 9(commencing 'JOB DESCRIPTION
{ with section'IUW)of vision3 o1fleBusiness and Professions Codu nd 'ansa is
Ir afullf.e. .'al, .PERMIT ISSUANCE RESIDENTIAL
F+ O'
U V L¢ense Cla s myl
-Lic.# - ElElSFDWL. KITCHEN REMODEL
' rF�a Date "Cmmmmpr APPLIANCES-RESIDENTIAL - ❑ADDITION [I PLUMBING RE-PIPE
Fpm ARCHITECTS DELLA ❑MULTI-UNIT ❑STRUCTURAL
yy I understand m 1 hall be used us public records PANELS
O Z Fi Y.plans s MODIFICATION
UPT02M AMPS
A El INTERIOR ❑CHIMNEY REPAIR
jLicensed Professional 201-I000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
Q 1 hereby affirm that 1 ami exempt from.the ContractorOVER IOW AMPS's License Law for the 11D VR
BATH REMOEPAIR DEM LI IO
{ii5 O as U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
FWO to which requires a pemut rte construe,aline improve,demolish,or repair any stricture - ) I lots,
QQ prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/Ni e' _
Ithat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
I �M (commencing with Section 9000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST - COMMERCIAL:' `
dq c that he is exempt therefrom and the basis for the alleged cxarraui n:Any violation of
i5 u• .5 by any applicant fora pp [ITEWBLDGIADDITION ❑OEMOLIRVICE
Scene.7031
Worry permit subjects the applicant penalty of POWER DEVICES El ❑FOODSEVICE
pz not mom than Bve hundred dpllam($500). IMPROVEMENT
; G ❑Lo the work,
Ne property,r intended
with agefor
rsale(Sole 0FEBu anis SWIMMING POOL ELECTRIC
WWR will doth¢work,Craand t:The Cure istors License Law does rot apply Loan Business ❑OTHER
L and Professions Cade:The Contractors License dodoesnesapply himself
of ` OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through -
own employees,buire lding that such improvements anot hoarded or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.
owns L however the have fee bur improvement issoldhe within one build
or improve
the SQ.FB FlpO AREA ASQ:FT.
ewner-builder will have the hunks of proving that he did not build ur improve for Pur- 0
pose of sale J. ,
t ❑L as owner of the property,am exclusively contracting with licensed contractors to TOTAL: ,
consumer the project(Sec.7044,Business and Professions Code:)The Contractors Li-, 190VJAN ry 190L
cense Low doesnot apply to on owner of property who builds or improves thereon,and Q Try, PLU IN PERMIT FEE `, J '
who counncu for such projects with a amilecmr(s)licensed pcame n [.,he Contractor's
License Law. PERMIT ISSU CITY Uf UUPL l V
❑,I am exempt under Sec ,B&P C for this reason. LIN
Owner - Date ALTER-DRAIN .NT R A)
VALUATION
0
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. VI Y �-�/`p�/
1 hereby afftrm under penalty of perjury one of the following declarations:
❑Ihave and will maintain a Certificate ofCe Labor Code,for the
Workersce of the DRAINS-FLOOR,ROO REA, ON STORIES TYPECONSTRUCTION
moron,as provided for by Section 37W of the Labor Code,for the performancebf the
work for which this permit is issued. p1XTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,h required by Section °
' 3]W of Ne Lab Co afar eperfonnnnce of lM1e work fo which this pe d. GAS-EA.SYSTEM-I INC.40D TS ` DEC.GROUP APN
My War kat'sC no drier and Pollc, IifY
Cartier: Policy No. -� a GAS-EA.SYSTEM-OVER4(EA) - -
CERTIFIC EOE XEMPTIONFROMWORKERS'
COMPE SATION INSURANCE GREASEANDUSTRLWASTE INTERCEPT
(This section need caths completed ifthe permit is foronehundred dollars($I W) BUILDING DIVISION FEES
or less.) - GREASETRAP
PLANCHECK FEE
(certify thatinthe any
awtobecomewhichthis the Workers
SEWER-SANITARY-STORM EA.2W FT.
shall
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE '
O z intim,Laws of California.Date WATER HEATER WNENT/ELECTR -
z O Applicant - GRADING FEE
rte NOTICE TO APPLICANT.If, outranking this Cenificate of Exemption,you should WATER SYSTEM)TREATING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must _ SOILS FEE
W forthwith comply with such previsions or this permit shall he deemed revoked. WATER SERVICE
sci 'Q
UO _ !, CONSTRUCTIONLENDINGAGENCY NEW RESIDENTIAL PLAID. SQ.FT. PAID -
Iherebyaffirmthatthere is a construction lending agency for theperl'ormanceof Data - Receipt#
(L H the work for which this permit is issued(Sec.3119],Or.C.)
O U Lender's Name - TOTAL:
w Lender's Address - TOTAL: -
1 certify that 1 have rated this application and state that the above internist on is BUILDING ME
Tap correct.I agree to comply with all city and county ordinances and state laws relating to QT MECHANICAL PERMIT FEE
U 7 building construction,and hereby authonre representatives ofthis city to emeropon the SEISMIC FEE
above-mentions roperty for inspection purposes. PERMIT ISSUANCE
(We)a e o save,indemnify and keep harmless the City of CUFlenim against ELECTRIC FEE
Iiididities.jad a casuandexpensesw), hmay in nn wry accrue guinst said City -ALTER OR ADO Ib MECH.
Inconsequem of a n'ngofdaspermit. PLUMBINGFEE
AT LICANI UN t NDS AND ILL C PLY WITH ,1.1110 V JN-POINT AIR HANDLING UNIT(TO 10,0(X)CFM)' rte^
SOURCERE UL 10 - 1 MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTION TAX
Signature ofA cony o actor
U DaEXHAUST HOOD(W/DUCT) - HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOS
Well the applicant or future building occupant stere or ban I -e hamNous material HEATING UNIT GO I W."BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532001 HEATING UNIT(OVER 1 W."BTU) -
❑Yw C]No - VENTILATION FAN(SINGLE RESHy' PAID -
Will Neu applicant or future building t use equipment or devices,which Date fi Receipt#
PFl gby the
quipr Qu BOILER_COMP(3HP OR IW,WO BTU)
emit homrdous air contaminants as definetl by the BayArea Air Quality Management
District19 BLER-COMP(OVER 100,000 BT(1)
TOTAL:
❑Yes tL]No OI
.1 have read the harerdeus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCEDA
forme Healg data ar Safety Code,Sections.that i 25533 and 25534.1 understand out file NEW RESIDENTIAL MECH. SQ.FT.
building drcs not cutren0y hav<h tenanWhnt it is my responsibility mortify the eceupon
of the requirements which most he met prior m issuance of a Certificate of Occupancy.
Owner or authoured a send - Date TOTAL: ISSUED BY:
OFFICE