29071 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F,LEC'PRICAL PERMIT NO. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BIJII,IIING PROJECT IDENTIFICATION
71
BUILDING ADDRESS:' (. V xx l { �/���7� /� SANITARY NO. APPLICATION SUBMITTAL DATE
OWN' E: OmAwPHONE: CONT O 'S NAME: 1 O. NIC CONTROLk
RCHIT[Cr/13 GINIi[R: LIC NO. ADDRESS: ❑
GONTA PHONE,
) BUILDING PERMIT INFO
�1I/n ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ylEC�1
LICE ';DCONT,admak 'SIIECLARA9WN .
1 hereby arum mm lain ban•ca nndcr provi-nm.or Chapter v(commend°" QTYELECTRIC PERMIT FEE JOB DESCRIPTION
WO. with Secrion]WO)of i lot cBusincae anJPd I y cnsciv PERMIT ISSUANCE R SIIDENTIAL,
Fw. to full fore-al lel _L'onscsin m
�UI_j Liccnsc hick �I//u ❑SFDWL ❑KITCHEN REMODEL.
FZW are Comrecar APPLIANCES-RESIDEMMAL ❑ADDITION ❑PLUMBING RE-PIPE
f�H ARCHITECTS IIECLA ATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O'n Z I midenwnd my plan -hall hs used as tru die nctords MODIFICATION
OZ—q UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
l=4F"41 Licensed Pmfessi...I 201-100JAMPS IMPROVEMENT
9yEj OWNER-BUILDER DECLARATION OVER IIHDAMPS ❑BATH REMODF.IIREPAIR ODEMOLITION
C C Q 1 hereby affirm that 1 um exempt from the Contramor•License Law for the
k 3 a U following reason.(Section 70315.Buiines•and Prom,icri Code:Any city or countySIGNS ELECTRICAL ❑OTHER
u1 u. which requires a permit to c uxurim,alter,improve,demolish,or repair any amemrc
F'y0 prior no its issuance,also requires the applicant for such Permit to file a signed statement - SPECI AL Cl RCUIT/MISC.
} thin he is luamed punuunfto,the pmotems mfum Conto oh License Law(Chapter 9
y' 0 (commencing with Section 70NE of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
a E pe C that he i-exempt thcrefmm and rhe hair for the alleged exemption Any violminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
^LL Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES
—tn ❑TENANT ❑FOOD SERVICE
F=< not mom than five hundred A,Ilua 155(X1).
0Lo the work.the pmpeny,or myemployres withwadfiershei(See.nm,peosiness SWIMMING POOL ELIiCI'N[C IMPROVEMENT
.t:2 will Pr f e work.and e. nmcmre is not intended Livens or Law does not
apply o an Rosiness ❑OTHER
ty m and ere@sciono Cole:The Contractor theeco License Low Jots our apply to an owner of OUTLETS-SWITCHES-FIXTURES
�-3— Progeny who builds or improves the i and who doe-such wnrk deed o f or through
his own employees,the provided g mat.men improvements are not intended or,(fired rte NEW RESIDEN]'Igl.ELECTR SQ IT.
ole.ILhoweventhhave thin handers l proving
he ithinoneildori provetfar,mc SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the bonen el proving thin he did not build or improve for pur- //��ss n
'we of sale.). 5-' 'J
O I,us owner of the property,am exclusivity contracting with licensed....,noun m TOTAL: / e
construct the project(Sec.7(Wi,Business and Professions Code)The Coorano'%Li-
contact Law does not apply m min,net of moprny who build,or improves memo..and QTY, PLUMBING PERMIT FEE rvfN ] ^
wnocontraca forsuch projects with acontracmgat licensed punaant to the Conuvetods - a g`f
License Law. PERMIT ISSUANCE V�}' 199
❑ I um exempt under See, ,B&PCfororismaon LQ-Lr
ALTER-DRAW&VENT-WATER( t /�FALUATION
Owner Date r// V
WORKERS COMPENSATION DECLARATION BACK FLOW PROTF,CT.DEVICE
1 hereby of inn under penalty of perjury one of me following decla ri i,m:
l have and will maintain a Cenificam ofConsnot n,all'-msure for Worker's Counter- DRAINS-FLOOR.ROOE,AREA,CO STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the Performance of be
wnrk for which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
CA'
SYSTEM'
Myy Workc ann Cs�Ie,fI cAtce canierandePolic Iiav xyrld•p'R�I,s• GAS-LA.SYSTEM-OVER
OCC.GROUP ANN
Currier: Policy Nu.: �J�JI l U-I
CERTIFICATE FEXEMPI'ION FROM WORKERS'
COMPENSNPION INSURANCE GREASFIINDUSTRLWASTE INTERCEPTOR
(This section need net hecompleted ifthe t is forsme bond"dollars S IPPB BUILDING DIVISION[LES
Permit GREASETRAP
or la".) PLANCHECK PEE
I certify that in the perfomnaccofihe work for which this permit is i-sued.[shall SEWER-SANITARY-STORM EA.200 FT.
nm employ any petmn to any manner on as to become subject m the W orkcrs'Compcn- ENERGY IEE
0 Z sait..Laws of California.Date WATER HEATER W/VENT/ELECTR
Z 2 Applicant GRADING FE-H
t,O NOTICE TO APPLICANT.If,aper making this Cenificnte of Exemption,you ammid WATER SYSTEMNREATING
have tc subject to the Worker.Compereminn provisions of the Labor Code,you must SOILS FEE
{IJ fxonwith romply rith.meb provision.ser this Nmi te,deemed revoked. WATER SERVICE
Uz CONSTRUCTION LF.NDINGAGENCY NEW RISIUENTIALPLMB. SQ.FT. PAID
U I for
rwhich rte mat nnertio,cred taa.097,C.,agencyformepeAormance of Data Receipt of
r. the work for which this permit is issued(Sce.709],Civ.C.)
O U. F-' Lenders Name T01'AI,:
f..J I<tNerx Address TOTAL:
Fy 1 ecnify that 1 have read this application and state that the above information is BUILDING FEL?
w coned,I agree to comply with all city and county entrances=it state laws renting to QTY. MECHANICAL PERMIT FEE
L) Z building construction,and hereby unthoriae representatives ofthis city memerupom the SEISMIC FEE
`+ above-mentioned property for inspection purfoses. PERMIT ISSUANCE
(We) me to save,indemnify and keep hornless the City of Camor in r against ELECTRIC FEE
liabilities,j grants,costs and expenses which may in anyway acerae against said City ALTFRORADDTOMECII. PLUMBING FEE
in nsequ rte f the granting of this permit.
APPLIC T I RSTANDS AND WILL COMPLY WITH ALI NON- )INT AIR HANDLING UNIT(TO 10.00)CFM) MECHANICALPTE
SOURCE tE( A,
_pII AIR HANDLING UNIT(OVER Ip,11Ip CFM) CONSTRUCTION TAX
Signumreo'ApplicvnfiCantramnr Date EXHAUSTIIOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huildingowcupant store orhandlehaeanous material HEATING UNIT(TO 100,0(10 BTU)
as defined by the Cupertino Municipal Coda Chapter 9.12,and the Health unit Safety
Code,Section 25532(a)7 HEATING UNIT(OVER I00.Oq)BTU)
Yes C]No VENTILATION I AN(SINGLE RES ID) PAID
Dam Receipt k
1 Will ms air comm nr future defined occupant use equipment or devices as Management
BOILER-COMP CHP OR IW.W)BTU)
r.'...,n aux air commitments as defined by the Hay Area Air Quality Nanagcmcm TOTA.:
iJ]
❑Yes E]No
BOILP.R-COMP(OVER 100(Nb UTU)
1 have rod the hmardous materials nu f iremenu onG-,Chapter 6.95 of me Cali- AIR CONUI'1'IONER ' ,
ISSUANCE DA E
foto Health&Safety Code,Sections 25505.25533 and 25570.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a tenant,that it is my resissohility,to notify the occupant
of the requirements which mum he met prior to issuance of a Cenificate of Occupancy. ��'����J
_50(lwmnar umhuriaed agent Dann TOTAL: t ISSUED BY: r '�
OFFICE /'