29631 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
+ CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. �J,I kl•J� J{29631^ ^ ^1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/ O/Dlo L/ A1/)4 4NN PC LoTB t�t,16�(6
O 'SNAME: // �/,pHONE CONTRA NAME: T LIC NO:
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L'DK ,S ,QGfy • Q •..e.NL 37D/11`)' NIC CONTROL
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CEIACTIMNOINEER, VCNO. A DRESS: ❑ (!�o�2
Ai .Y—P.f/f /✓ /17ro2 Nit /9✓2 .� l
CONTACT: PHONE: BUILDING PERMIT INFO _
[�a� ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLU B MECH
c .e d8 2 e!/'VJ A�d BLED i� ;< X, 4<.
LICENSED CO ACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
pW 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
F 8.Z�. with Scarce and ryecDivision 3 of the Businessland PmfeasionsC e,vnd my licenu is pE0.MOISSUANCE WL El KITCHEN REMODEL
in full farce and effect.. 3�D /.�4
IDENTIAL
License Class Conor / APPLIANCES-RESIDENTIAL � ` ADDrrlQN C1 PLUMBING RE-PIPE
Dam ContmcCL
�Ow
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Of/1^Z 1 undrssmrtd my plans shall be used as public records MODIFICATION
Z p UPTO200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR '
,I•-.'�,lqq"'tsl Licensed Professional 201-IMAMPS IMPROVEMENT
542,E OarI me,UILDERUECConn ON OVER Ink AMPS ❑BATH REMODELJREPAIR 0DEMOLITION
LLLy 1 hereby.(firm that I um exempt horrible Connector's o License Law for Nc
xa6V followingrtasoa Perron to
7031.5, t,Business and improve,
demolish,
Codi Any city ormetury SIGNS ELECTRICAL ❑OTHER
YY17 LL. which its assts a permit re conswc4.late improve,demolish,nr repair any swcmre
primmsl isnuanee,also rsuant to de the Prussians
for such Contractor Lidlessle a ne(Chapteat
9 SPECIAL CIRCULUMISC.
Net he is liccrtscJ pursuant to the provisions of she Contractors License law(Chvpter9
��0�0 (commencing with Secdon](g10pd Division3of she Business enJ Professions CoJe)or TEMP.METER OR POLE INST,
d o y that he is exempt therefrom.rid the basis for the alleged exemption.Any violation of p W BLDG/ADpITION []DEMOLITION�,rn Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of POWER DEVICES L ❑TENANT El FOODSERVICE
qy nm more than five hundred dollars(SSW).
Sp ❑ roe,
l.as owner of she ppenor my employees with wages as their sole compensation, SWIMMING POOL ELECTRICIMPROVEMENT
yF will do Ne work.vnd the xtmctumisna intended mafferedfmsvle lSec.70g4,Business - -*.[]OTHER
0.3 and Professions Cale:The Comtmcmr's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or.improves thereon,vnd who does such nark himself m through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEM R S
sale.IL however.the builJingorimpmvemem is sold within one yemof
r.the SQ.FE FLOOR AREA $/SQ.FI'.
owner-builder will have the burden of proving that he did not build or improve fm pur-
Fl 1,as owns
❑Lbst the p of der,
TW,
convecting Cash:)The
condoms Li- MTA Ow-0
'sense La the project apply
]1140,Business and Professions Cale:)The Cnrvmcton,Li-
cense taw does not apply m an pwnerof property who builds or improves thereon,and QTY. PLUMBING PERMIT F
who canners for such projects with a conhacmr(s)IicenuJ purauanuo the Cnntructor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. B&P C for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date _ ^/t 1/7 2
WORKER'SCOMPENSATION DECLARATION 'BACK PLOW PROt[CT.DEVICE pt(
I hereby affirm under penalty of perjury one of the ent to following damlmr's Co
Ihove and Providll ed
by oiisCertificate7M of the Labor
for Worker's Comp the DRAINS—FLOOR.ROOF,AREA.COND. STORIES TYPECONSTRUCI'ION
'workf as provided for by Ss ison 3]W of the Isbor Code,far the perfomwce of the
work haavc and this aindt is issued: - FI%TURES—PF.R TRAP
3700idt andwill mai.far Worker's Compensation work
whiasrequiredby Section
My Wo the Vbmpede,fonthe
suranc carrier told
the work fmwhichte: pemdt is issued. GAS—EA.SYSTEM-I INC.40I1TLET5 - OCC.GROUP APN
My Worker's Compensation Insurance cerrierend Polley numberarc GAS—EA.SYSTEM-OVER4
Carrier. Policy (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR '-
I (Thissectimmadnatbe completed if the permit is foram hundreddollars(glm) BUILDING DIVISION FP.ES
or leas.) GREASETRAP PLANCHECK FEE O
I eeNfy that in the performance of the work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE'. ZO
Z sation Laws of Califomia.Date WATER HEATER W/VENT/ELECfB
O Applicant GRADING FEE
y NOTICE 1'0 APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTF.14TREATING
m
(~ becoe subject to the Workers Compensation provisions of the Labor Cale,you mail SOILS FEE
e'er. forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
.7Z CONSTRUCTION LENDINGAGENCY NEW RFSIDENTIALPLMB. SQ.PI'. PAID
fJ0 kf whichtmthv.iti issued(Ser.30 lending agency for the perl'ormanec of Date Receigp
U Newark for which this permit is issued(Ser.3007,Civ.CJ
CLILenders Name *1EE
LUL, Lenders Address TOTAL:
y 1 certify that 1 have read this and
and stns the the above information s - BUILDING FEE
h correct.)agree to comply with all wiryand coumyordinances vnd.aate car,armingto QTY. MECHANICAL PERMIT' FEE
U z buildingconstruction,
,.,nit yhereby outtionanr"cpresentatives of this city mcnmr up+m rhe SEISMIC PEE
above-(We)arepropene for inspection keepha' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEEliabilides,judgments,costs and expenses which may in any way twelve against said City - ALTER OR ADD TO MECH.in couquence of the grerir,ofod,pc.it. PLUMBING FEEAPPLIC 'UNDERSTANDS AND 'f.17]O LY WITH ALI NON-POINT AIR HANDLING UNITCTO 10,o0BCFM7MECHANICAL FEE
SOU sREGULA'T10 16 9AIR HANDLING UNIT(OVER 10,0110 CFM) CONSTRUCTION TAX
Signature ofAppli onvanor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATIOAZARDOUS MATE) AIS DISCLOSUREWillthe plicate mfuture building«cupantstomorhandlc havNous material HEATINGUNII(1OHIsLos10BTU)Cash.Sectio Ne Cupertino Muicipnl CNe,Chapter 9.12,and the Health unJ Su&ryCode,Section 255321+07 HEATING UNIT(OVER IW.000 BTII)❑YenPAIDVENTILATION FAN(SINGLE RESID) Date
Will the applicant or future building occupant use equipment or devices which
rt harnNous air commitments as defmW by the Bay Area Air Quality Management BOILER-COMP(3HP OR IM."BTU)
District' BOILER-COMP(OVER IW,"BTU) l,- G PTO'T75&41 It
E]Yes -
AIR CONDITIONER q� Q
I have read the herardous materials m]uirements under Chapter b 95 of the Cali..re 1 A p13 J0
fomi.Health feSafety Code.Seek.,25505.25533 and 25534.l ands rid that if the NEW RESIDENTIAL MECH. SQ.FT. IAJO
building d«�^currently heveglwwnk Nm" xibilitym nyfify the ccmean
ofN I uwhicRRn 5(E [t moria +a mora Ccryf f rGe fellI Uf-
/L V nnV
Owneroramhonmdagc Dae TOTAL: ISSUED BY:
OFFICE