29941 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOPCDPERTINO BUILDING-ELECTRICAL PERMIT NO, l! 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL A�./141 .
BUILDING PROJECT IDENTIFICATION J
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
\o\06 L:Sft A
OWNER'S NAME: PHONE: y" ONERACOR'S NAME LIC NO:
i♦ 14 NIC CONTROLIt
CHITE GINEER: `_ LIC NO: ADDRESS: ?0�, y� ❑
CONTACT. PHONE: BUILDING PERMIT INFO
'%r sec•r L1.,�` �'1,fw�"tl�yL, ❑ Consultant Fees Paid by Applicant(Initial) BLDG E�LLEEC�Y•T PLUMB MECH
��Js �PNLI�CENSS-E(DCCON MO'S DDEE'CILAARRATIOON4 Ia-J 5P -4 t •'
I hereby union that I am licensed under provisions of Chupter 9(commencingQTY ELECTRIC PERMIT FET.
a z w .JOB DESCRIPTION
00 with Section nd of of DivisionJof the Rosiness entl Pmfcssinna Csrle,and try is PERMIT ISSUANCE Li full force and effect.
Li<ensb Class Lic.p - WD—WL [I KITCHEN REMODEL
rF'�4ty1 Dme - Cmaractnr APPLIANCES-RfSIDHMIAL MADIYHUON [IPLUMBING RE-PIPE
z8pon ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT C1 STRUCTURAL
yz I understand my plans shall be used as public sa ov. _ MODIFICATION
Oz4� UPT0200AMP5 ❑INTERIOR [I CHIMNEY REPAIR
rliq�u1 Licensed Professional 201.11100 AMPS IMPROVEMENT
J OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Commerors License Law for the OVER]BOB AMPS ❑BATH RFMODEUREPAIR ❑DEMOLITION
3 a following reason(Section 703 I.S.Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
u, which requires v permit to consumer,alter,improve,demolish,or repair any structure
prior to its issuunce,alsorequires theappdicam foroch permit to Elea signed statement SPECIAL CIRCUID!M
} that he is licensed pursuennnthe provisions of the Commctars Limn..., lChvpmr9
00 (commencing with Semion]000)ofDivision3 of the Unsinese and Pmfessimms Cale)or TEMP.METER OR POLP.INS . '
6{y m that he is exempt tremfmm and the basis for the alleged exaniami.Any violation offfl NEW BLDG/ADDITION ❑DEMOLITION
WX
Section 7031.5 by any applicant for a permit subjects the upplieannoucivil penalty of POWER DEVICES
zZ,} not more tban Eve handled dollars(8500). ' ANT ❑FOODSERVICE
Cq ❑1,as nwccl.f the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ROVEMENT
will do the work,and the structure is not intended or offered forwle(Sec.]1/14,Business ❑OTHER
Gm and Professions Cale:The Contractors License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereun,and who dues such walk himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
aide.If, wm
hoev ,the building orimprovemem is sold within one yearefcompletim,the SQ.FT.FLOOR AREA HSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- -��� r �. /�� � $,� 03
pra
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: 6 -
onstrma the Project(Ser.7044,Business and Professions Conic)The Contmctar's Li-
came Low doexaid apply to an owner of property,who builds or improves thereon,and QTY, PLUMING PERMIT FEE - -
who contracts far such projects with a connacrons)licensed pursuant to the Comoctors -
License Law. - PERMIT ISSUANCE 6Q
❑ Ino exemp,madesee ,B&Pe far ria reason Z 2•-/r
ALTER-BRAIN&VENT-WATER(LA) 0
Owner— Dura_
O CER'S MP� SATION DECLARATION BACK FLOW PROTECT.DEVICE 1 9
I herehyuffirm under natty offacquty one of the following declarations:
I have and will maintain v Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,CONI. L`' STORIES' TYPE CONSTRUCTION
section,as provided for by Section 37W of the Labor Code,for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
El 1 have suit will maintain Workers Compensation Insurance,as required by Section
3700 ofthe Labor Cock,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS R APN
My Workers Compensation Insurance carrier and Policy number ate:
Catrin Policy No.: GAS-EA.SYSTEM-OVER 4(FA) !m
CERTIFICATE OF EXEMPTION FROM WORKERS' Ur L,1 IY.-.-.....
COMPENSATION INSURANCE GREASP/INDUSTRL WASTE INTERCEPTER
BUILDING DIVISION FP.ES
(This section need not Is,completed if Ne permit it frrone hundred dollars($100) GREASE TRAP
or less.) PLANCHECK
1 certify that in the pednrmance of the work forwhich this permit is isxued,
Island]
not employ any Person in any manner ser as to become subject to
pen the Workers'Com _ SEWER-SANITARY-STORM EA.200 Ff.
z sation Laws of Culifomin.DDataGNERGV FE 90� 4n
'7�O Applicant' WATER HEATER WNENT/ELECTS GRAD( E / , O
q ti NOTICE TO APPLICANT:IL after making this Ceriricu[b on Exemption,you should WATER SYS'I'FM?RFATING SOILS FEE 92 O
F'+ become subject m the Workers Compenmtion provisions of the[,,bar Code,you must
a' - forthwith comply withauch provisions or this perms.hall be deemedrevoked. WATER SERVICE.
1 ]z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID 2H `! 6
I heechy aftirmthauhem is a constrstion lending agency battle perfonranc,ofclo Date eiptp �(1
�� thewarkrawnienthisprNtiaiaa a(Sa.3o9].civ.c.) / S3 C�-S
G Lenders No. OTA L:
U Lenders Address TOTAL:/ 6-
�" G I certify that 1 have read Nis application and nam that the above informedon ix BUILDING FEE O
V7 correct.l agree to comply with all city and county uninaaces and state laws relatingm QTY MECHANICAL PERMIT FEE
V z building consuacuiun.and hereby adhorac represenmtiva of this city to cntaupon the SEISMIC FEE 5a
r ahovememioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE ! ;Z6 Z.7(,
liabilities,judgments,cons antl expenses which may in any way viceme against said City ALTERORADDTOMECH.
arcansepesecufthegrantingofthispermic. PLUMBING E a/ �(
APPLICANT
SOURCE UUNDERSTANDS AND WILL COMPLY WITH ALL.NON.POINT AIR HANDLING UNIT(TO 10.000 CFM) , MCCHANICAL'FEE
AIR HANDLING UNIT(OVER 10,000 CFM) " CONSTRUCTION T4
Signature of Applican/Contracmr Data EXHAUST HOOD(W/DUCf) HOUSING MIEGA ON FEE OL
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building compact store or handle hazardous material HEATING UNIT(TO 100,000 BTU) If
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health ape Safety
` Code,Section 25532001 HEATING UNIT(OVER 100,000 BTU)
❑Yea ❑No
VENTILATION FAN(SINGLE RESID) PAID Dat Receipt#
Widoesll the air contaminants
orfuturea building by accep
Bayor Amu ipmcmor devices BOILER 100,000BTU)
�it hazardous air comaminon[s u define)by the Bay Arca Air Quality Management TOTAL:
mm�nnY BOILER 100,000 BTU)
' 0Y. ❑No - '
I have mud the harnrdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
" food,Health&Safety Code,Sections 25505,25533 end 25534.1 understand that if the NEW RCSIUIiNfIAf.MEC H. SQFT `
building does,not currently have a tenant,that it b my respunsinility to notify the occupant' . .
'
of the rcyuirements which must be met prior to issuance ofv Cenificmeof Occupancy. I.% w O r••� r a� /�N
Owner or authorized agent Dale ll0 TOTAL: pa,46 ,ISSUED BY: Na( lrrJ_✓�//11'/) '
OFFICE