29086 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29086
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHA.N'ICAL
BUILDING PRO F=IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICA ION SUBMITTAL DA'
ZI 7 �i
OWNER', NA E: �1 HONE:— CO SHAME: Cs NIC CONTROL#
•ARCH (ENGIN ❑R: LSSC It A) RESX ❑
CO T. PHONE: BUILDING PERMIT INFO
`�/7 pj) �Q'\,1�11 ❑ Consultant Fm Paid by Applicant(Intoe) .@LUG APLUMB ECH
LICENS:D CONTRACTOR'S DECLARATION J b QTY. ELECTRIC PERMIT FEE SLfs
I hereby affirm On 1 mm ficamro
ed ander Fvl.in d
,of Chapter 9lcomrncnng JOB DESCRIPTION
Fw5A with5eclinn7n f si. .' aHas csand Pr fc of #cense i.
es- in full force and eff t. /n 1'ERMIi'ISSUANCE RESIDENTIAL:
QFUSj Liccnu Class Lic.p �/� -55 CSFDWL y' I1 El KITCHEN REMODEL
NQL Uam Carol It., APPLIANCES-RESIDENTIAL XDDITION"f� 11 PLUMBING RE-PIPE
F.Dm ARCHITF.CI"S UECLARA ❑
PANELS MULTI-UNIT OSTRUCTURAL
Z OinZ 1understand my pl.,hall IN asedaspublic record` -
CZ— MODIFICATION
UPT0 2M AMPS
W Licensed Professional OINTERIOR [D CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT
x x: OWNER BUILDexempt Fir DECLARATION
S��U I hereby affirm that I um exempt fiat the Contractor's License Law for the OVER IfXIB AMPS [I BATH REM( EI/REPAIR ❑UEMOLITIO.
¢3 w F following reason.(Section]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL 11 OTHER
a O Ha which requires a permit to construct,alter,improve,demolish,or repair any structure ,^ /
y.]] prior m its issuance.also terraces the applicant for such permit File a signedetaenni SPECIAL CIRCUVDMISC. (�
E p. Nat he is licensed pursuant m the provisions of the Contractor's License taw(Chapter 9
al ,QOO (commencing with Section 7000)af Dismar,3ofthe Hentmessane Praftwalns Ccdc).r 'TEMP.METER OR POLE LIST COMMERCIAL
Q. *C that he is exempt therefrom and the basis lir Ne alleged exemption.Any viol.iun of
,LLl^q Section 7031.56 ice ti Imam for a pe man subjects the sppheannn:t civil / CHEW BLDGIADDITION CDEMQLITIQN
Y Y PP J penany of POWER DEVICES / ❑TENANT OFOOD SERVICE
not mare than five hundred dollars(caps.
=QQL.thevoowner of Nepmpimeom myorimenceswith wages astheir,me compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
F-' wad Bothe Bene,and rhe he Cl n is l.,"License Law ed does
to an ovare r of BOTHER
W and 1aly who h Code:The over nclea License law docs not apply fin owner of OUTLETS-SWITCEIFS-FIXTUR
d 3 his o ny who build.or improves Hereon,and vete docs men work ded ohimself m NmngM1
his own employees,providcJ Nat such improvements arc not intended or oRBmd for NEW RESIDENTIAL ELECTR SQ Ff.
tale.If,however,the building or improvement is sold within one year efcomplentn,me SQ.FT.FLOOR AREA VSQ.Fn
her-builder will have the burden of proving that he did not build or improve 1'or po
pow of so
0 1,a,owner of the propene,am exclusively contracting wc.
ith licensed naamrom ro AL:Ito
construct the project(Ser.7044.Business and Pmfes,iona Cme:)The Commemor'n Li-
QTY PLUMBING PERMIT FEE
who contracts for such projects with a umtracmrisl licemW pummnt to Na Contractor's
License law. 11,15
PERMIT ISSUANCE
lam e.ari under Sea ,B&P C for Nisreason
ALTER-DRAIN&VENT-WATER(EA)
Owner Dae VALUATION �
affirm notice
COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /_ �
• l hereby arm under parmlyofperjmD ane.tone following declarations: �J r V
O l have and will maintain a Certificate of Consonuoself-insure or-Worker a Compen- DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Sce 3700al'the IaMr Cafor.r Ne performance of the STORIES TYPE CONS'TRUCfIO;
work(nr which this part ssued. FIXTURES-PER'TRAP
0 1 have a oil n nsWorker',Compensation Insurance,as rrymmil by Section
3700.fih Nor odcf he perfomrance of the war fou', is I ', rtuihµsy yrQ. GAS-FA.SYSTEM-1 INC 40UTLETS OCC GROUP APN
My Work 's ns ti 1 carrier an Pnoc rV�( U �(/)rA1/l\
Cartier, m 1'nlicy N I. GAS-EA.SYSTEM-AVER 41EA)
CERTIFICATE l i.XEMPTION FROM WORKERS'
COM SATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need nm be complewd Hare permit is forone hundred calla..(SI W) BUILDING DI VISION FEES
or less.) GREASETRAP PLANCHECK FEE
1certify Naia in any manner
ofNcwork for which dais permit:.issued,lshall
not employ any#erten in any manner,na,it)heconm subject to are Worker:Camper. SEWEk-SANITARY-STORM EA.29)FT
ENERGY FEE
zZ all..Laws of Calibraiu.Dare
O Applicant WATIiR HEATER W/VENT?;LECI'R GRADING FEE
III NOTICE TO APPLICANT.IL ufrer making this Cer ifcme of Exemption.you should WATER SYSTEM/TREATING
a [^ becmne subject to the weaker',Compensation provi.vinm of the Libor Cora,you most SOILS FEE
IZl �r fonhwith comply with such pmvi,iome,thi.s primal shall be decmedfevokee. WATER SERVICE
0
0. CONST SUCTION LENDING AGENCY
UNEW RES 1DENTIALPLMB. SQ.FT. PAID
G0 lffimhu0hcrc construction lending agency for nen
he perfmcc of Dam Receipt#
for whiby ch
m
fL F
the work for which this prmit is issued(See.](197,Civ.CJ
Lender's Name
V Lender's Aedres, TOTAL: TOTAL
F000: 1 certify that T have mad Nis application radiation Nm the aMre information is BUILDING FEE
II
rnrtea.l agree ro comply with all city and county ordinances and stat laws relating to QTY. MECHANICAL PERMIT FEE
V Z building consumer.....and hereby amhoriae representatives of this rile in cubic upon We SEISMIC FEE
above-mentioned ropccry
for inspection purposes. PERMIT ISSUANCE
(We)ag a e,'ndemnify.nJ keep humilcss rhe Ciry of Cupenin......a ELECTRIC FEE � � --
liabilities,jud eat. costs
no
expenseswhich may in anywaya oeagminst said City ALTER OR ADD TO MECH.
onuqucn nfN fin ng Nispermit. PLUMBINGFEE
APPLICAN' UNDI ST N 'AND WILL CO{(PLV 4'TI A 1. N-POINT AIR HANDLING UNIT(c)IgOW CFM) n tr y
SOURCE kI GULAT N. MECHANICAL FEE oL oGV
AIR HANDLING UNIT OVER IO,UW CPM) CONSTRUCTION TAX
Simmons,of ApplicunVConrmcmr ukibeEXHAUST HOOD(W/DUCT)
HA]ARDOUS MAI'F.RIAIS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future buildingrecupanr store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
a,defined by rbc Cupertino Municipal Cade,Chapel 9.12,and rhe Health and Safety
Calm,Section 25532(1)? HEATING UNIT(OVER IW.000 BTU)
0 Ya, 0 No
VENTILATION PAN(SINGLE.RISIU) PAID
Will the applicant or Pamir building occupant use enuipment or desires wM1ial
I hur Nous air contaminants as defnW by the Bay Arca Air Qmal ity Managmncnt BOILER-COMP OHP OR 100.0(ki
Do bid? TOT
L
MNo BOILER-COMP(OVER Upped BTU)aJ rbc haratdnus materials rryuiumenis underChapter 6.95 of rbc Cali- AIR CONDITIONER .t ISSUAN �E
Safety Code,Semiom 25505,25533 and 255,14.T understand That ifthe NEW RESIDENTIAL MECH. SQ.FT.ot currently have a binmm,that it i,my reaptersibiliry mnotify die eemrpanr Sirnts which must he mer prior a i.raenecof a Certinese of Occupancy. 1 need agent Dae TOTAL ISSUE
OFFICE