29668 (2) . APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTJNO BUILDING-ELECTRICAL - . PERMITNO. f�(] C/+ O
I BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL L J U VM v
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRE S:_- - .. SANITARY NO. APPLICATION SUBMITTAL DATI
2 4/I,Ib TA(ft �
R'S NA� / - _ ,I ) C RAC R'S ME: O' .N/C CONTROL k
R HITECT GIN LIC NO: Y6 ESS:
G ,w
NTACf: PHONE /� BUILDING PERM O
.0 OWO2
N �j /�,f�t 9/ W� 6 El Consultant Fees Paid by Applicant(Initial) 1 LECT PJLUUaMM% /UEECIII
LICENSED CONTRACTOR'S DECLARATION - ` \( L
0 00
I hereby,affirm that I oto licensed rude,provisions of Chapter 9,(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
{{�Iwith Section]001B.Mivision3.fine Business and Profession.Com,andmylicenseis RESIDENTIAL•
in full force and effect.` PERMIT ISSUANCE ,
�UU License Class Lic.N _ ❑SFDWL .� E KITCHEN REMODEL
.!r-6a Data Contractor APPLIANCES-RESIDENTIAL. brnON ❑PLUMBINGRE-PIPE
otos„ ,ARCHITECT'S DECLARATION - ULTI-UNIT El STRUCTURAL
O Z 0 4 1 understand-1pinus shall be mmJ as public records PANELS - MODIFICATION
UP 9'O 2W AMPS
<<` 1"'1Q Licensed Professional D INTERIOR . �.`�CHIMNEY REPAIR
�5 •l OWNER-BUILDER DECLARATION 201-I000AMPS IMPROVEMENT
UI hereby affirm that 1 am exempt from the Contractor's License Law for the OVER I"AMPS n D BATH REMODEUREPAIR ❑DEMOLITION
iq5 O 0.0 following reason.(Section 703 1.5,Businessland Professions Code:Any citynr county SIGNS ELECTRICAL ❑OTHER
sN WO 1" which taryires a permit to construct,alter,improve,demolish,or repair any structure -
prior to its issuance.also requires the applicant for such perming file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions arts,Corrosion's License Law(Chapter 9
(commencing with Sectinn]fH10)of Division3of the Busin<sx and Professions Code r z'.
00 )o
TEMP. OR PO LE INST. COMMERCIAL, • ,
0. o eG that he is exempt therefrom and the basis for the alleged exemption,pity violation of EW BLDG/ADDRION ❑DEMOLITION
^{N
Section 7031.5 by any hundred
dollar,($50nt for a wit subjects the applicant toacivil penalty of POWER DEVICES ENANT ❑FOODSERVICE
z y not more than five h props property,
dollar,($empl R V NT
Q ❑Lasowner e, .,k,f.d property,remyemntended with wages
ned frsaltheir sole 044,Bsiness SWIMMING POOL ELECTRIC
and do the work,and to ewcture is not intended.,offered for sole(Sec.]044,Business TH
3 and Professions Code:The Contracmr's License Low docs not apply to an owner of OUTLETS SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or trough
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
aale.If,however the building or improvement is sold within one year.(completion,theO SQ.FT.FLOORAREA $/SQ.ET.
owner-builder will have the burden ofproving that he did not build or improve for pur-
pose of sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to
onsmma the project(Sec.]044,Business and Professions Codc)The Contractor's Li-
cen.e Use does not apply to an owner of property who builds or improves thereon, QTY, PLUMBING PERMIT FEE 'r
whocontracts forsuchprojects wit scuntmctor(s)licensed pursuant to the Contractor's JUN 5 1996
License Law. - ' PERMIT ISSUANCE
❑1 am exempt under Sec. _ ,B&P C far this reason ,r 1
ALTER-DRAIN&VENT-WATER(EA) 6ITY C,II- UUr4;FN4N&I
Owner Dote ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE /S 1 ��
�❑ I hereby affirm ruder penalty Offertory one of the following declarations: —`
Ihave and will mein minaction 37M of dm Labtosode,sure for Worker's Ge opene DRAINS-FLOOR,RODE AREA,COND. S_TOR[ TYPE CONSTRUCTION
within,es provided far by Section J]OO.f the Labor Code,for the performanw of the
work for which this
permit is issued, FIXTURES-PER TRAP.
❑1 have and will maintain Worker's Compensation Insurance,es requited by Section ` -
31f10oftheLaborCode.for the performance ofthe work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP •AEN
My Worker's Compensation Insurance carrier end Policy number are: -
Carrier: - Policy No.: GAS-EA.SYSTOLOVER 4(EA) _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFJINDU$TRL WASTE INTERCEPTOR
COMPENSATION INSURANCE - _ BUILDING 91ON FEES
(This section need net be completed ifthe permit is for one hundred dollars($100) OREASETRAP
.r less) PLANCHB FEE
(certify Pat in to any
oast becameork far subject
theperW rkem'Comis ll SEWER-SANITARY-STORM EA.200 FT.
'
not employ any Person in any manner so as m become suM1jecuo the Workers'Compete - ENERGY FEE
cation Laws of California.Date
O O Applicant - - WATER HEATER WNLNT/ELECfR
,-y PP GRADING FEE ��
f•7 NOTICEbj APPLICANT.rsaftermakingthis Cisions of Estmita arear, odyoushould Wpi'Eft SYSTEMf1'REATING
2 become subject y the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
forthwith comply with such rnvisions ur this ermit shell he deemed revoked.. ��
Q PY P P, WATER SERVICE -
a� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.FT. 'PAID`
Ihereby affirm that is a constmetion lending agency for the Performance of Date Re X
P the work for which this permit is issued(Sec.309],Civ.C.)
Undcra Name' '
T AL:
Lender's Address Tp
Fa I certify that I have read this application and slate that the above information is BUILDING FEE I' ��
VI correct.l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
V building conswction,and hereby authorize representativesof this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE��
liabilities,judgments,costs and expenses which mayin any way accme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT _ AIR HANDLING UNIT(TO 10,000 CFM) t
' SOURCE REGULATIONS,
MECHANICAL FEE
m AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
Signature of Applicant/COnwctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(0)? HEATINOUNIT(OVER]FILM BTU) - -
❑Yes F1 No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt k
Will thepppltcantorfuture building occupant use equipment or devices which .BOILER-COMP(3HP OR 100,000 BTU7
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? " TOTAL:
C]Yes ONO BOILER-COMP(OVER 100,00(1 -
I have read the heyartu rs materials requirements under Chapter 695 of the Cali- AIR CONDITIONER - '6' ISSUANCE DATE
f.mia Health&Safety Code,Sections 25505,25533 and 25534.I understand that it the NEW RESIDENTIAL MECH. SQ.PT, m
building does not cumonly have a mount,that it is my responsibility to notify the Occupant
of the requirements which mist U mea prior to issuance of a Certificate of Occupancy,
JA
Owner or authorrud agent Date 1 L. ISSUED BY:
OFFICE