29080 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. /tO QO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -/Q
BUILDING PROJECT IDENTLIFICATION 9 V
BUILDING ADDRESS: � ` ' SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAM f 'g9 PHON': '��/✓%/,C/!ONTRACfO SB1 NI✓p.F:p ,J/ /LIrN NIC CONTR Ltl
CHITECUENGINEER: LIC NO: - ADDRESS /l�Lar!//rl1�f�� lf+(a,G ❑ ,
CONTACT PHONE: - BUILDING PERMIT INFO
'�fp/�l��j Ays`� /� ❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUMB MECH
S ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OaZ thSection7")of Division 3 of the Business and�rofessionaCale,and my license is RESIDENTIAL
yy1E00 w't PERMITISSUANCE
F+d 1-lee force end effect
U� Licene ClLic.p �� ❑SFDWL ❑KITCHEN REMODEL.
((]] APPLIANCES—RESIDENTIAL ❑ADDITION 13 PLUMBING RE-PIPE
Z)a Dam�_Con 7m AR CHITECTS DECLARATION
DECLARATION PAN[LS ❑MULTI-UNIT ❑STRUCTURAL
z8PJZ 1 understoodmy plans shall Inroad ss public records MODIFICATION
OZ UPT02MAMPS ❑INTERIOR 0CHIMNEY REPAIR
Licensed Professional 2014000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITI
Og t 1 hereby of nee that I am exempt from the Con etwons License Law for the
30.0 following reason.Saloon Business and Professions Cale:Any city oramody MGNSELECTRICAI, ❑OTHER
Cwhich requires a permit to construct.alter improve,demolish,or repair any structure
prion,its issuance,also requires theapplicam for such penman,fileasigned nmemrnn SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to thc provisions of the Contractor's License Law(Chapter 9
<0 (commencing with Section 7")ofDivixion 3 offlue Business and Professiorocale)or TEMP.METER OR POLE INST. OMCOM(' fMERCIAL<
la.y G that he is exempt therefrom and the basis for the alleged excmplion.Any violation of - - ❑NEW BLDG/ADDITION ❑DEMOLITION
X
Section?031.56,any applicantfor.permit subjects the it,licamrou civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
,Z N twt more Nen five hundred dollars(5500). IMPROVEMENT
^�< ❑I,as owner of the properly.or my employees with wages as then'ttic compenn.dnn, SWIMMING POOL ELECTRIC a
p0 wJl d,Ne work,and Neswcture is not imm�JW or uffemd for sole(Sec.]Bi4,Buitoni OTHER
6C6C6C6C and Professi,ns Cole:The Conwetnra License Law docs not apply m an owner of OUTLETS-SWITCHES-FI%TURES
p' .+ Properly who builds or improves thereon,and who dues such work himself or through
his own employees,provided that such improvements arc not intended or offered far NEW RESIDENTIAL ELECTR SQ IT,
sale.If,however the building or improvement is sold within one year ofcompletion,the S(LPT.FLOOR AREA $ISQ.FT.
owner builder will have the burden of proving that he did am build or improve for par-
pose of sale.). t J'
❑ I.as owner,fthe propcnX am exclusively c,mmaiag with licensed contractors to TOTAC
I
construct fbe project(Sec.]094,Business and Profen...CoJcO The Conwcmr's U. J�V/1 (I
c u law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT T E ` 17 996
who contracts for such projects wit a comracturo)licensed Fmsuanno the Contractor's
License Law. PERMIT ISSUANCE r V/•
I am exempt under Sec. ,B&P C for this reason WJI-44 Jff'fl
Owner Dam ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKERw 'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �'JImo'
1 hereby uRunder penalty of perjury one of the following dmlamtfom. V I
j I have and will maintain aCenificateofConsenuo self-insure for-Worker's Creeper. DRAINS—FLOOR.ROOF,AREA,COND. 'STORII3 TYPE CONSTRUCTION
s union,as provided for by Section 37W of the labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1N 1 inverted will nuinuin Workers Compensation Insurance,as required by Section 11
'c)ofthe labor Code,for Ne performance of the work for which
this PeerrfmitJissiissued. GAS-EA.SYSTEM;!INC.4 OUTLETS OCC.GROUP APN
CWfrkeA'q Cp nasi, nmrence corierand Polcy Noy EVAPDIVIL.Os+ GAS-EA.SYSTEM-OVER 4(EA)
L 4./CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FE,E9
(Thin sermon need oat be completed if the Pamir in ionone hondrcd J,Ilaa 15100) GREASETRAP
or less.) - - PLANCHECK FEE
I sanity Nat in Ne perforoarea.fhe work for which Nis permit is isaued.I shall SEWER-SANITARY-STORM FA.200 IT.
not employ any person in any manner so as to beme cosubject m the Wnrkerx C.rr,r- ENERGY FEE
OZ Applicant WATER of California;Date
Z Applilicaant WATER HEATER WIVENTMLECTR GRADING FEE
N NOTICE TO APPLICANT:If,after making Nis Ccnificem of Exemption,you should WATER SYSTEMRREATING
a became subject to the Wmrkers Compensation provisions of Ne Labor Code,you must SOUS FEE
forthwith comply with such powisions or this pertni[shall he deemed revoked. WATER SERVICE
2.'
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. 'SQ.FT. PAID
- Data Receiptp
.f,Q Ihereby which thi that issed(Sec.30 larding agency for the performance of
{T+ Pdm work for which this permit is issued(Sec:3119],Civ.C.)
Lenders Name TOTAL:
U Lcadcr's Address - TOTAL:
o - BUILDING FEE+ 1 certify Net I have read Nis application and into that the above infomution is
yc rest I agree to comply with all city add county ordinances and state laws relating to QTY. MECHANICAL PERMIT PEE
U7 building construction.nadhemhy authormoapreurnatives orthis city toenterupcn Ne SEISMIC HE
shove-mentioned prapcny for impdotion Fantasias. PERMITISSUANCE
(We)agree to save,indemnify and Ice,bmmless the City of Cupertino...bad ELECTRIC FEE
Iiabilities,judgmenis,cousend expenses which may in any wayacemeageinn said City ALTER ORADDTO MECH.
in aonxequcnce of the flooding of this permit PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,0110 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER Milan CFM) CONSTRUCTIONTA%
Sigvmreol'Applicano Convector Data EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,future building occupant smm,r handle hazadous material HEATING UNIT TO 100,0041 BTU)
as defined by the Cupenin,Municipal Code,Chapter 9.12,and the Health and Sudety
Code,Section 255320011 _/ HEATING UNIT(OVER 100.000B TO)
C]Yet NNo PAID
///--- VENTILATION FAN(SINGLE RESID) Dale Receipt if
Will the applicant or future building occupant use equipment to devices which
thximilous air conum...1,as defined by the Bay Area Air Quality Maaagemeat BOILER-COMP(3HP OR IW.000 BTU) TOTAL
Distin^ - r BOILER-COMP(OVER 100,0(10 BTU)
E)Yes //r`'''o
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
ford.Health&Safety Cole,Sections 25505,25533 and 25534.1 undersuad Nat if the NEW RESIDENTIAL MECH. SQ.ET.
building does nm cuwmdy have a tenant that it is my responsihility to amitythe occupant
of Ne whichmust be,met prim m issuance of a Cenificv of(k cy.
er.ra.....sdagem Dam TOTAL ISSUED BY:
OFFICE