29154 (2) APPLICANTTO FILL IN INFORMATION WITHIN.RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 29154
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. LVJ JI.1J�4
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS. SANITARY NO. APPLICATIONSUBMITTALDATE
o U,'64.1 Pr.dONER'S AMF.:� Pf ONE: D CONTRACfO SNAME: LCN
5 MNIC CONTROL#
RCHITECTIENGINEER: LIC NO: ADDRES ❑
CONTACT: y PHONE: - „ . BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
IE- El El
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT FEE
9ZaZ
I hereby affirm That I ran licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section 7")ofDivimn 3 ofthe Business d Professions Code,end my hcenveis PERMIT ISSUANCE - r
OO . RESIDENTIAL:
in toll POrce mode ec�r p ry
UZ U License lass Y k-• I.ie.# a b .( " MI. ❑KITCHEN REMODEL
hQL Date Contmcmr APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
1,,,O y ARCHITECTS DECLARATION - 0 MULTI-UNIT '0 STRUCTURAL ..
Z O ,7�- I undersand my plans shall be use)as puhlic reconls � � - ' MODIFICATION
OZa UPT02WAMP5
[�.,tr{, Licensed professional - ❑INTERIOR CHIMNEY REPAIR.
201-IOW AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IOW AMPS t 0 BATH REMODEUREPAIR 0 DEMOLITION
1 herebyaeon.( act that I am exempt Iranian,hComrnstCo License city
o for the
F EjO U following reason,(Section 7031.5,easiness and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
C F which requires a Forman,consumer,alter,improve,demolish,or repair any structure
prionanc.asiseue,alsoremire,theapplicam forsuchiminam fleasigm
nedstateent SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions oftbe Contractor's License Law(Chander 9 _
W aCC (commencing with Section]WO)of0ivisien 3 of the Booresxand Pndessimw Centel a, TEMP.METER OR POLE INST. _ COMMERCIAL:
Section
F c C that i is exempt therefrom end the basis for the allege)exemption.Any violation of - 0 NEW BLDG/ADDITION 0 DEMOLITION
7031 S M1y atiy applicant for a permit subjecd the epplicam to a civil penahy of POWER DEVICES -
} t more thw five hundred dollars($5 W). - ❑TENANT ❑FOOD SERVICE
Q ❑I,asnwnerofthepropmy;or my employee,with wages as their sole compensation, SWIMMING POOL ELECTRIC :IMPROVEMENT
will do the work.and the stmemreis not imendedorofeted far sale(Sec.]044,Business C OTHER
9 and Professions Code:The Commences License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES '
property who builds or improves thereon,and who dres such work himself or through
his own employees,provided that such improvements are act intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale,If,however,the building or improvement is sold within one year of completion,the Q.FT.FLOOR AREA $/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for par- ,
pace of sale.). - q:
0 1.as owner of the property,am exclusively contracting with licensed contractors to ,TOTAL:
ra
oa mue,the project(Ser.70,$4,Business and professions Cade)The Contractors LI- /✓
se Law does not apply to an owner of property wbo builds or hammers thereon,and:
QTY, PLUMBING PERMIT FEE -
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE -
0'I am exempt under Sec. B&P C for this reason ..
ALTER-DRAIN&VENT-WATER(EA) - VALUATION
Owner Dam 1
WORKER'S COMPENSATION DECLARATIONgpCK FLOW PROTECT.DEVICE
hereby affirm im
rm under penalty of perjury one of the following decations:
I have and will maintainer Certifcateaf Consent toself-insure fa Workers Coamen- DRAINS-FLOOR,ROOF,AREA,COND.' " STORIES TYPECONSTRUCTION
cation,as provided for by Section 3700 of the Labor Cade,for the performance of the ,
work for which this permit is issued. FIXTURES-PER TRAP 1.
0 I have and will maintain Workers Compensation Insurance,as required by Section - -
37Wofthe Lab.,Code,for thelarformanccaf the work for which thin Eemmit is issued. GAS-EA.SYSTEM-I INCA OUTLETS Dec.GROUP APN'
My WorkereFonpensmiol,Mjnnde ante Policy
No.:
nn�u�-^��—�.�/{e: O � GAS-EA.SYSTEM-OVER 4(EA)Carrier: -
YY�ryyCEERTIFICAATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASVINDUSTRI.WASTE INTERCEPTOR
Innis section need notbe completed lfthe perhdtis former hundred dollars(SIW) - BUILDING DIVISION MRS
or less) „= GREASETRAP - t PLANCHECK FEE -
Icertifythatintheperformanceofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.2M FT.
not employ any person in any mane so r(3 be 9 int rjca t0 the Workers'Compen- - ENERGY FEE
z cation Lews of Cal}'�''J�a: ' WATER HEATER WNENT/ELECfR
Applicant ( / - GRADING FEE': '
NOTICE TO XPdLIC NT.IL oft, Makin !;'tt�fteste of Exemption,you should WATER SYSTEMOREATING,
EE••�� become subject ti the Worker's Compensation visions of the Labor Code,you most SOILS FEE'
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
_ .. ,n
Z ;
CONSTRUCTION LENDINC AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
ff
V 0 (hereby erm that there contraction lending agency for the performance of 'Date Receipt#y
Gy H the work for which this permit is issued(Sec.3(1)],Civ.C.) 3
19 Z
Q Lender's Name O - TOTAL:
LU Lender's Address TOTAL: -
1 certify that I have read this application and state that the above information is BUILDING FEE
F W correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE - -
V Z building construction.and hereby authorize representatives ofthms city in enter upon rise SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE . -
(We)agree as save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. -
' consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT; AIR HANDLING UNIT(TO IO,oW CFM)
SOURCE REGULATIONS. MECHANICALFEE
AIR HANDLING UNIT(OVER 110,001)CFM) . CONSTRUCTION TAX
Signature of ApplicantAimarrector ,Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicant or future building occupant store orhandle hazardous material HEATING UNIT(TO 100,00(1 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,vad the Health and Safety
,Code,Seetion 25532(a)]' HEATING UNIT(OVER 100,000 BTU) ”
❑Yes ON. PAID
VENTILATION PAN(SINGLE RESID) 'Date Receipt#
Will the applicant or mains a building incby the B ase .Air cut or devices which _ BOILER-COMP DHP OR 100,01s)BTU) -
Disthazardous air conmminvnis as defined by the Bay Area Air Quality Management TOTAL:
District4 - n
O Yes BOILER-COME(OVER 1110,000 BTU)
Otho . ,
1 have rem f,e rdous materials requirements under Chapter fi 95 of Ne Cnli- AIR CONDITIONER " ISSUANCE DATE
forma Health& ate Cnde.Safi ors 25505,25533 vnd 25534.1 understand that if the _
NEW RESIDENTIAL MECH. SQ.FT
building do to ntlyh em,thath' yresponsiloda,anmifyt a occupant
of Oto IhiGl m amore ofaCmifet of c
O rued ag t Da TOTAL: ISSUED BY:
OFFICE