29352 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO - - BUILDING•ELECTRICAL PERMIT NO. ^(� n n
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL L 9 s L
_ BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS: ..I_, SANITARY NO. APPLICATION SUBMITTAL DATE
�0� Q
as I C 4 1 O C 0, Y-27—f�
OWNER'S NAME: 1 HON CTOR'S N.Tpala��rY LIC NO'. s
E, K 1/ICED ))1A.5oney _ NIG CONTROL»
RCHITECT/EN ER: LIC NO: ADDRESS: ( ❑
a o I f' ) /�r f�sem,61
CONTACT, PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSEDCONTRACTOR'SDECLARATION, QTY ELECTRIC PERMIT FEE
I hereby arum than I am Eemaed ander Pmddom rd chapter 9(commemem, JOB DESCRIPTION
DZ with Section]00(hrd Division Sof the Business and Professions Code,and my license is
00in fullfRESIDENTIAL
arcc and if ss��,, t PERMIT ISSUANCE
U Licen Clan Lie. "O 6 SFDWL ❑KITCHEN REMODEL
Date'Ty�t�p�-C'd Cmuac APPLIANCES-RESIDENTIAL ❑ADDITION 0PLUMBING RE-PIPE '
b.z. ARCHITECT'S DECL ON PANELS ❑MULTI-UNIT []STRUCTURAL
Z O�vJ 7^. I understand my plans.h ll be used as public records ODIFICATION
O Z:J UP TO 200 AMPS ❑INTERIOR RJCHIMNEY REPAIR
F F{i Licensed Pmfeesional 201.1000AMPS IMPROVEMENT
soup,
OWNER-BUILDER UILDEfr DE Ce cmie ON OVER 1000AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
p❑y,K:CC,''6 1 hereby.(fent on 11. exempt from the Cssions o License Law for the
a(36 V following reason(Section]Or'LS,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
Du1] fa,� which requirca a permit to construct,alter,improve,demolish,or repair any structure
Z�m prior w its issuance,also requires the applicant fprsuch permit ro flea signed sutomem SPECIAL CIRCUIT/MIS..
fY(y that he is licensed poemarttothe previsions ofthe CommctorsLicense Law(Chapter 9
(commencing with Sadon7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POI. 1 COMMERCIAL:
6 y� that he is exempt therefrom and the basis barite alleged exemption.Any violation pf ❑NEW BLDG/ADDITION C DEMOLITION
yx^�la• Section 7031.6 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEV ICES
41^rn ❑TENANT ❑FOOD SERVICE
FZ} not more than five thundredty.or my(Ssemployees
IMPROVEMENT
6 Lo work.the pesurac,pr myemntended or offered
as their m.compensation, SWIMMING POOL ELECTRIC
�O well do Be,the work,and thertmcture is not intended proffered for sale(SttJ(W4,Business ❑OTHER
3 and Professions Cc&:The Commcmr's License Law does not apply to an owner of OUTLETS-SWfTCHFS TUR
property,who builds or improves Elverson.and who Jas such work himself or through
his own employees,Provided that such improvements are not intended or offered for
NEW RESIDENTIAL[L'
sale.If.however the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AR EA $/SQ.FE
owner4oilder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1,us sweetof theproperty, Bexclusively contracting withlicensed Contractors
I- OTAL:
construct the project(Sec.]I1W,Business and Profession Code.)The Comrumr's Li-
censeLawdaanotapplyfoanownerofpropertywhobuildsorlmprovdsthcreon,and QTY PLUMBING PERMIT FEE
who centime;for such pmjecss with a conuanor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ 1 can exempt under Sec. ,B&P C far this..,in
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALJyAT10N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE VA
1 Mreby.meta areae pewlry pf perjury one of the following dcdamtion:
Iheve unJ will mainuina Cenific.m ofCunsemmselGinsure for Worker's Compen- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
nation,as provided for by Section 3810 of the Labor Code.for Ne performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of lee Labor Code,for the performance of the work for which this permit is issued.. GAS-EA.SYSTEM-]INC.4 OUTLETS OCCGROUP APN
mywork Cpmpensatioh Insuranm eerier and Policy nyym_be.rare: �
Canicr.u N1= �[-'LIIZ_Policy No.:�j�y� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFlCATE OF EXEMPTION FROM WORKJ RS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES(This secn need nm be completed if the permit is for one hundred dollars(S 10/1 -
or last tioGREASfiTRAP PLANCHECK PEE
I certify that in the perforrunce of the work for which this permit in issued,i shall SEWER-SANITARY-STORM EA.200 FT.
ma employ any person in any manner so as to become subject w dee Workers Compete- ENERGY ME
OZ salon Laws of California.Date WATER HEATER W/VENT/ELECTR
O Applicata GRADING FEE
r~N•a NOTICE TO APPLICANT:If,eMr making this CeniRcam of Exemption,you shoulJ
omWATER SYSTEM/1'REAfING
W(~ become subject to the Worker's Compensation provisions of the Labor Code.you must SOILS Flip forthwith empty with such Provisions or this permit shall be deemed revoked, WATER SERVICE
Q
CONSTRUCTION
performance ONLENDINGAGENCY NEW RESIDENTPLMB. ,SQ.FT. PAID
L)0Ihercby affirm that themem is isaconstruction lending agency forthe perfoance oP IAL Data Receipt p.'
the work for which this permit is issued(Sec:3097,Civ.C.)
Qf'+ Lenders Name TOTAL:
{U 1-ender',Address TOTAL: �a
I certify that I have mad this application and some that the above information is BUILDING FEE
F V) correct.l agree ns comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE c
Ll4 building construction,and hereby amhorixe representatives of this city to enter upon the SEISMIC FEE •SO
above-mentioned Property for inspection purposes. PERMIT ISSUANCE
(We)aura m (Lp
save,indemnify and keep halo less the City of er ino against ELECTRIC FF-E
liabilities,judgments,costs and expenses which may in any way accem against said City ALTER OR ADD TO MECH. PLUMBING FEE
arimmse,amosofthegramimg Inferred. -
APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM)
SOURC GULATI MECHANICAL FEE
.r AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCIONTAX
SiEntoti-Of JfpWaddConcra� Dm EXHAUST HOOD(W/DUCT) HOUSING_MMGA11ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the.pplicanmr furore building em.pantsmninhatdle Incursions material HEATING UNIT CM 100,000 BTU)
res defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 2 532(a)t HEATING UNIT(OVER 100.010 BTI)
ED Yes [3 No VENTILATION PAN(SINGLE RESID)
Will thea applicant or(ream building cu t use t pr devices which lar Receipt M
pp ga pan cgai it Qu BOILER-COMP(3HP OR 100,000 BTU)
emit hamrdous air contaminants as defined by the Bey Arca Air Qualify Management S..
I IJC GYfI11VU TOTAL
❑Vas []No :
District? BOILER-COMP(OVER I WPW BTU) V u�
1 have read the hamNous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Code,Sections 25505,25533 and 25534.1 understood that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not cwmmly base a tenant,that it is my responsibility w oatily the account
of the courtrooms,which must M met prior to issuance of a Certificam of Occep toy.
Owner or unformed asset Date T0TAL.1 ISSUED BY: til
OFFICE