29098 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIffsk ^ O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. y
BUILDING PROJECT IDENTIFICATIONNO.
98
BUILDING ADD : SANITARY APPLICATIO`N�g1113 SUBMITTAL DATE
2rESS
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0 IS RS E. PHONE: CONIACTOR'S NAMfi: a LIC NO:
N/C CONTROL
Ap
v S . ❑
.ARCHITGCT/ENGINEER: LIC N'O'. I ADDRESS. x
CONTACT. - PHONE. /�// BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL IMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMI'P FEC
1 Section
norm leis lain bcanm ander n nvidom of Chimer 9 my
is JOB DESCRIPTION
O�Z with Saaion And
DiviaionJofthe Oscines and Profcsionn Code,anJm license is
F-00 in full forte slid cRm •� y Ice PERMIT ISSUANCE RESIDENTIAL-
0
NIWDF_N_TIAL.
aUV Liccmc Class 45 Lic.N v ❑SPDWI. ❑KITCHIiN REMODEL
�<L Dec zl Cummaor APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE
Ern ARCHITECTS DECLARATION OMULTI-UNIT ❑STRUCTURAL
F PANELS
Z 01`x? IunJrnmnd my plana.hall sensed u,public rcnlNa MODIFICATION
O Z UP TO 2IX1 AMPS
W Licensed PtefeWmard INTERIOR ❑CHIMNEY REPAIR
101-1000AMPS IMPROVEMENT -
���;
OWNER-BUILDER Di heARATION_ OVER IOWAMPS ❑PATH REMODFUREPAIR ❑DEMOLI'T'ION
G Q 1 hereby xfl ism Ihw 1 am exempt from the Convxcmr'e license how for the
x3aF following teawm(Section 7031.5.Business and Professions Cath:Any city or county SIGNS ELECTRICAL ❑OTHER
LLl u,or which requites a permit m ennxtmct...her improve,demolish,or rtpvtr.ny structureof ofI prior m its issuance,also requires the applicant for such permit to File asigncd stamncill SPECIAL CIRCUIT/MISC.
ce the he is licensed pu,uam in the provisions of be Chirac License Law(Chap...9
ID°ECO (vommencmg with Scan.7000)of Division 3ofthe Bminos and l'mfcssianx Crde)ur TFAIP.METER OR POLE INST. COMMERCIAL:
a 6x e C In.he is exempt Imorfmm and the huix for the alleged exemption.Any vinlioi ni of ❑NEW BLDG/ADDITION ❑DEMOLITION
W m Section 903 IS by any applicant for a penin mbjca,the xpplicum Io,civil penally of POWER DEVICES
m mart than five numbed Jolla(S500). ❑TENANT ❑FOOD SERVICE
~=O ❑Las owner of Ne ptepeny,or my cmployccx with wagesulM1cir cote almpcnxaiioq SWIMMING POOL ELIiCfRIC IMPROVEMENT
F willdolhewor ,and the_%tivclaten not intended oroffered for-_%ale(Scc.70D4,business [JOTHER
W and Pmficewom Code:The Chainor'x Liunac low does not apply m vn owner of OUTLETS-SWITCHES-FIXTURES
proxnr who builds"rten,dawho does tech with himself nr through
his own employees,p J h impreconcets are not intended or offered for NEW RESIDEST]AL ELELTR 'SQETsole If,hwevenlhe bui ncmcmThione year of completion.the SQ.FT.%IIR(IOR AREA 95Q.nes-builder will a f Orovin J not build o,r improve for per, o
❑ 1.a. ,1 �ly a1Mlraain6 with licensed canirudorx to 'TOTAL: 01,9
-
[onx pm)ea C oK dna Pfnfexsionx Coda:)The Cmurecmrx Li- �f
whseln can lv`ry_ an owner of property who builds or improves diction,and QTY. PLUMBING PERMIT FEE
o conlr aforsuch mlects with"mntracmro)licensed pursuant o the Conlruaoex
Licen¢law. PERMIT ISSUANCE Ur`•/ n�
0 l am exemP ran pt under See ,B& C arhi,re ��•Y
Owner Date ALTER-DRAINA,VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of Isilmye one of the folDowing declurnions: -
❑ I have end will maintain a Cerificme of Consent o xelf-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,CONO STORIES TYPE CONSTRUCTION
cation.as provided for by Section 3700 of But labor Code,for the performance of the
work for which this permit is issued, FIXTURES-PER TRAP '
1 have unit will maintain Worker'..%Comperism on Insarunce,ux required by Section of the Labor Code.for the performance ofthe work felt which this permit is issuAd. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC,GROUP APN
m
My Worlue mpensatio In ace c d Policy namberam: ,
Camicr: Policy No, GAS-HA.SYSTEM-OVER 4(EA)
'I'IFICAT:OF 17 EMPI'ION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRI,WASTE INTERCEPTOR
(Thi,vection need not he templet W if the permit in formic hundred della,is 1(KI) BUI DING DIVISION FEF_
nr Icsx) GREASE PLANCHL'CK FEE
1oyany the int he anymmerce of the work for whichthis the Workers'issued.
pen-shall SEWER-SANITARY-STORM EA.200 FT.
Aid employ any perste in any manner w as m become subject ro the Workeri Compcn- ENERGY PF.F.
- O ,Z 'ansa laws of CAfnmiu.Dam WATER HEATER W/VENI'/ELECTR '
Z 2 Applicant GRADING FEE
NOTICE TO APPLICANT:If,afar making this Cenificvm of Exemption,you should WATER SYSTEM?REATING
a , become subject m the Worker's Conlpemation provisions of the Labor Cod",you muss SOILS FI!H -
forthwith comply with such poGumexor this peri he deemed revoked. WATER SERVICE
a �
7Z CONSTRUCTION LENDING
ending NCY NEW RIiSIUENTIALPLMB SQ.Pr. PAID
V O for
rte lhvuvem iso issued(Sec.
ugcney for the peri nnunce of Dam - RecaplM
Ll.0F-' due work(or which this permit is issued(Sec.3092,Civ.CJ
O Lcmlerne,x Name _ TOl'N,:
w Lcndcr'I Address
yt
(•' Z) 1 certify Nu.T have read ll city and coup y u sum that the sMvc iwso Whoa ix BUILDING FEE
rA n,rraLlagree mcomply winsallcity'and cnumyomlinvn[cs and.teerowsminting Ine QTY. MECHANICAL PERMIT FEE
L) Z ,xis i-menmwairopert forcbyeuthori'rcrnpmacnmtiven of this city mcnmr u0^n the SEISMIC PEE
shave-mee)Agre In-esfariamily a seenea. PERMIT ISSUANCE
(We)agreemamx,irtcmpcndnakccpbemn An way
of Cupertinoagamic ELECTRIC IRE
liabilitica,ju ma.alasi ndcfpliv IN which may in any way uv'nm again..paid City ALTER OR ADD TO MECH.
in e the graining of this permit' PLUMBING FEE
APPLIe T JNDERST .' S AND WIL PLY WITH AL1.NON-POINTAIR HANDLING UNIT ff010.OW CFM)
SOU 'U.A O' _ MECHANICAL FEE
NR HANDLING UNIT(OVF,R 10.000 CFM) CONSTRUCTION TAX
rtofSe / plic VContncm a c EXHAUST HOOD(W/DUC) HOUSING MITIGA'T'ION FEE
a IIAPARDOUS MATERIALS DISCLOSURE
Will the applicant r future building Occupant%lure or handle haesNoin material HEATING UNIT GO 100.000 BTU)
m defined by the Cupertino Municipal Cade.CTvpto 9.12,and the Health and Safety
Code,Section 25532m)f HEATING UNIT(OVER 100,000 BTU)
C]Yes ❑No
VENTILATION FAN(SINGLE RF_ID) PAID
mit huWaNII utmhe pplicvnubuilding recupord cm,equipment or devices which
Dec• Receipt#
uranmam.imons us cfumdby Ill,anyAre.Air Qulity Mungcmwi BOILER-COMP(BIT OR 100.W)01,U)
Dixmin? TAN:
❑Ycx ON. BOILER-COMP(OVER 100.000 BTU)
I have read the hazmdons materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE ATE
forma Health&Safety Code.Sections 25505.25531 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT
building Jags A.evu cn.ly have a icia.m.that it my nc,,m,miIit,to notify oc,opard
of the requiremen.a which most be me,pnio n,iwom.of v Cet ife"m"f Occupancy.
Owner nr man iral agent Dula Tt) AT. ISSUED BY:
OFFICE