29063 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO ,. BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICAT9O6 3
ION J V v
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
t n a- 0 C�lb w �..tg
OW 'SNA E'. I E' C 'SN .h
I '((/ NIC CONTROLp
RC MW LIC NO: A D S ❑
r�A PHONE: BUILDING PERMIT INFO
.a ���b/� ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB
LIC ENS D CONTRACTOR'S DECLARATION- o QTY. ELECTRIC PERMIT FEE
1 hereby uRrm thin am licensed under provl0lnns of Chtptu 9[commencing JOB DESCRIPTION
Opwife Seelm.7000)m 3 the Businessand fssion C de and rylicenseis RESIDENTIAL,
PERMIT ISSUANCE
�p m full farce and eRtt sion 0 SFUWL '❑KITCHEN REMODEL
�UU License Class Lic.p 11LIANCE.S-RESIDENTIAL ❑ADDITION [-]PLUMBING RE-PIPE.
F zj a Dele Commclor
fF.Om ARCHITELTS DECLAR, 1 PANELS
[I MULTI-UNIT []STRUCTURALZ Om 7hMODIFICATION
OZDO UP1O20OAMPS
[I INTERIOR ❑CHIMNEY REPAIR
F'Ili Licensed Professional 201-I0NAMPS IMPROVEMENT
S Sd JJ� mm I am exempt b rn DECLARATION OVER IOW AMPS El PTE REMODEL/REPAIR 0 DEMOLITION
yy S' 1 hereby affirm Nm I am exempt from the RATImnr's License Law fur the
following reason(Sound 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
YY17 3 O which cuisines a permit at convect,alter,improve,demolish,or repair any x a✓
prior to its issoance,also requires the applicant for such penniro file asig .atement SPECIAL CIRCUPUMISC. M
?J. ,a•
not he is licensed pursuantto Ne provisions offee Contractor's License ,w(Chiplert) - -
'"�� (commencing with Section 7000)of Division 3 ofthe Business Said crohnsCode)or P.METER OR POLE INST. COMMERCIAL'
Q, a Nat he is exempt therefrom and the basis for the alleged exempt .Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant fur a permit subjects the applic t to a civil penult,of POWL DEVICES
u1..y []TENANT ❑FOOD SERVICE
a.7,} not main then rive fthundred dollars(SSW). IMPROVEMENT
p�xx6 will
Lo the work,and pro perly,r myemployees dwith wag as their compensation, SWIMh11 F'001,ELECTRIC
FO will dathework,ands: heCoeactornt icensyr tiff does
apply to
Business ❑OTHER
63 and Professions Cade:The Convectors License does not apply m an owner of OUTLETS-gWITCHE.S-FIXTURES
progeny who employees,
or improve thereon,and o docs such ri k hied., fi throng
his own employeese provided that such in vements aT- in ed or offereJ To RESIDENTIAL LLECTN SQ FT.
sale.IL however,the building orimpro ant is sold wi ti e o kf�rye SQ.Fr.FLOOR ARCA
caner-builder will have the horde proving that he did ori pre for
pose of sale.).
❑1,as owner of the properly exclusively conga t as q�a noun t' TOTAL:
connote,me project(Sec.7 .Business nd Pm ' o C Lxantrubi n-
causes Law does not apply to nownerofp y hadorY,ves thmen ,aad QTPLUMBING PERMIT FEE
whoconuacisfmsuchpmje ewithacont d
censedpuu ronuomeCo actor's
License Law. PERMIT ISSUANCE
❑ I am exemptunder Sec. ,B&PC this..,an
Owner Doe ALTER-DRAIN&VENT-WATER EA) VALUATIO
WORKER'S\0MPENSAM)N D[CLARATI BACK FLOW PROTECT.DEVICE �T hereby alarm under pefpejury ane of the folio ng deefinumns:❑I haveand will mainfainaCreofConsemmself-ins •for Worker'sCompen- DRAINS-FLOOR,ROOF.AREA,CONO. STORIES TYPECONSTRUCTION
radn,asprovidedforbySecti00oftheLabor Cade ortheperfortttattceofNe
work fnr which this permit is isFIXTURES-PER TRAP
I hove Std will mainlein Wompensetion 1 urance,as required by Sution
3]
).final theperfom mature rkforwhicleNis permitisissual. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker' C cec olic)'taaA 'a/i GAS-EA,SYSTEM-OVER 4(EA)
Carer: ser n P,diey NO.� SCC LL .
CERTIFICATE OI ' EMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissecfion neednot tc completed i rhe permit is hone hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FELE
I certify that in the Performance of Ne work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in tiny manner so us to become subject to the Workers
OZ satin oLucas of CWifomia.Date WATER HGTER WNE- MLECTR
0 Applicant DING FF.
rpt NOTICE TO APPLICANT If,after making this Certificate of Exemption,yen should WATER SYSTENITREATING
a become subject to the Workers Compensation provisions of the Lahr Code,you must SOLI ELUM,
forthwith comply wife such Provisions or this permit shall be deemed revoked. WATER SERVICE 1/
(1, � I s CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
,7 Z Date Receipt It
L)0 Ifar which
his erat there issue (See 3 97,Cing agency for the performance of
Ne work for which this permit is issued(ga.J119],Civ.CJ
OF Lender's Name - TOTAL:
led( Lender's Address TOTAL:
y, I
codify that I have Head this application and nate not we Shove information is BUILDING FEE
s.t0 correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U7a.'
building construction. SEISMIC FEL
w
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(WNW517ZI19
emnify and keep harmless the City of Cupertino against us
ELECTRIC FEE
liabilides. expenses which may in any way Sccme against said Ciry ALTER OR ADD TO MECH.
in comx, of Nispermil. PLUMBING PEE
APPLICAS N COMPLY ITH AL NON.POINT AIR HANDLING UNITOD 10.000 CFM)
MECHANICAL FEE
SOURCE I
AIR HANDLING UNIT(OVER IO,t]W CFM) CONSTRUCTION TAX
Si,n.t.m.fA,l7 icanVCanitmenr c EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will fee applicant or lomre building Occupant store our handle hmardous material HEATING UNIT OU 100,0BTU)
as defined by the Cupertino Municipal Code,Chapter 913,and Ne Health and Safety 110-
Code,Section 25532(0)7 1 HEATING UNIT(OVER INQUOD BTU)
O Yes No PAID
VENTILATION FAN(SINGLE RESID) Date Rmeiptis
Will the applicant or future building occupant use equipment or devices which
emit hazardous air confirmation as defined by Ne Bay Arm Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TCTAL.
District? BOILER-COMP(OVER 100.000 BTU)
❑Yes Fl No
the hazzrdom materials"itimmenu under Chapter 6.95 of Ne-Cali- AIR CONDITIONER ISSUANCE DATE
Safety Code,Sections 25505,25533 and 25534,I understand that if the i NEW RESIDENTIAL.MECH. SQ.FT.
u g n ..tiny have a tenant,that it is my responsibility to notify the occupant
iswhichmust4sectpriormissuanceofa CcniLcateoft upancy.
rizcd agent Date TOTAL ISSUED BY:
OFFICE