29576 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO. �a may//N .a
BUILDING DIVISION APPLICATION/PEBMIT PLUMBING.MECHANICAL L 1/ I6
RIHLI .G PROJECT IDENT'IFICAT'ION
BUILD/Q%V:q • • / I V IVI{'I�I L SANI'I'AHY NO. APPLICATION SUI{MITTALDATI
OWNER'S NAM C: PHONE: I, CONTRACTOR'S NAME: LIC NO:
C5 _ �f In NIC CONTROL
ARCH E
NEER. CLI NO: Y V AD KESS: ❑
ONTACTPtIONE �,� � BUILDING PERMIT INFO
a 409- ZR% C-40,lso r ❑ Consultant Fees Paid by Applicant(Initial) BI bG ELFCT PLUMB MECH
- J•
LICENSED CONTRACTOR'S DECLARATION
I hereb (firm than 1 am licensed under f Cha ter 9 QTY ELECTRIC PERMIT FEE
yin vrom•iin.a p (comnrcncing JOB DESCRIPTION
OaZ w;Ib Seainn IIXXpifDlvision3oOhe Businessund P...c000m Cade,aN my license is RESIDENTIAL,
FOO in full farce end office PERMIT ISSUANCE
W� ❑SFDWL O KITCHEN REMODEL
�UV License Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RF.-PIPE
ZL Dae Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT 0STRUCTURAL
Z O'n Z I understood my plain shall be used as public records PANELS MODIFICATION
OZ=O UI'TO 2IXLAMPS ❑INTERIOR ❑CHIMNr.Y REPAIR
Fol M Licensed Profesaionol 201-1000AMPS IMPROVEMENT
L�C W Q 1 hereby affirm Ilse T em outman fmm he C nTmmur's License Law for the OVER 1000 AMPS 0 BATH REMODEURFPAIR ElDEMOLITION
hd O d U following reason.(Section 7031.5.Business and Profession,Code:Any tiny or county SIGNS i?LL'CTRICAL ❑OTHER
413 LL which requires a Ferran to cinstme,xlmr,improve,demolish.or repair any common
�u0y-1 prior froitsi.ssuance,atsnrequiresthe opplicam mi
for such permit 1. gm
Gleaaineddateem SP ECIALCIRCUITROISC.
than he is licensed purouant to the pollslonoof lira Comrueors Liame Low lChapter9
41�p0 (commencing with Section7")of Division 3 ofthe Business and Profession,Cale)it TEMP.METER Ok POLE INST. COMMERCIAL
6 cC thin he is exempt therefor+and the basis for the alleged exemption.Any violation of 0 NEW BLDGIADDITION 0 DEMOLITION
Section 7131.5 by any applicant for a Fermin subjects the applicant to a civil penalty of POWER DEVICES 01'ENANT 0FOOD SERVICE
SDnot mom than five hundred dollars(SSW). /
MI.n,.vmaolSWIMMING POOL ELECTRIC IMPROVEMENT
'Ihe pnrpenY,nr my nnployecs with wages as their sole comprnsainn,
P.. will do Ne work,and the swnure is not intended oroffered for sale(SecJo44,Business - OOTHE
Waw and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ore not informed or offered for NEW RESIDENTIAL ELECTR SG FT.
sale.IL however,ihebuddingorimprosommrt is sold within one yearnfcompletion,the SQ.FT.FLOOR AREA SISQ.FT.
caner-builder will have the burden of proving that he did not build or improve for Fur- 3 1
tion of'.1c.). ¢� CJ O
F7 L as owner of the property,am exclu,Ively contracting with lisanted convac,ort to TOTAL: ,Jnr
ennsorder the project(Sec.7044.Business and Professions CNG:)The Connmemr's Li- ( c
crow Law saes not aptly to an owner of property was builds or improve;mS
thereon, QTY. PLUMBING PERMIT FEE �'O t(! 'ZZ.�
who contracts for such projects with a commoners) icensed punaam to the Confucian's
License law. PERMIT ISSUANCE
0 1 am exempt under See ,B&P C for this reason
Owner [)am ALTER ALTER-DRAIN&N -WATER(EA) VALUATION
WORKER'S COtyof po AT1GN Iofthe following
BACK FLOW I'kOTECI'.DEVICE
1 hereby affirm under penury of perjury one of the fnsumfor Worker's Cor
❑Ihave Provided
forbineism37om of the vent toLabor self-Care.teethe Worker'se,of the DRAINS-FLWR.ROOF,AREA,GOND. STORIES' TYPE CONSTRUCTION
scion,as pro h thi for mi See;on 3]W of the IrMsr Crde,for the performance of the -
work for wM1ich,hispermi,isiseued. FIXTURES-PER TRAP s ) A ,^, f '
0 1 have and will maintain Worker.,Cam cion Insurance.as terrorist M1 , t I `
pens 4Iso a y,Section tan
l]W of the trout Code,for the performance of the work for which Ibis Fermi,is issued. GAS-G.SYSTEM-I 1NC.4OUTLIiTS OCC.GROUP APN
My Worker's Compensation Insurance tamer and Policy number a re: ,JUL a^22 91d
(�cL
Camcr. Policy Na: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASGINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISIONFEES
(This section need non be completed ifthe permit is forms,hundred dollar(Mg1) ` irrrkk^^
,it co.) GREASE TRAP PLANCHECK FEE (W
I«airy Naimhe red...ounce at work for which this penin is ixsucd.lshall SEWER-SANITARY-STORM F.A.200 111'.
not employ any perms in any manner our m o become subject a the Workers Cartoon- ENERGY FEE SM.Oa
0 'Z taint laws of Calift..ria.Dare WATER HEATER WNEN702LECTR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption, .should WATER SYSTEM/TREATING
F" heame subject 1.the Worker's Compensaios provlsimss of the Inbar Code,you mnsf SOILS FEE
Lak7 forthwith comply with such pmvis;ons or this permit shall he deemed revoked. WATER SERVICE
as that them iso cIONLENDINGAGENCy NEW kES1UEN'1'lA1.PCMB. SQ,FT. PAID -
U z Doc Receipt M
V pIhertby affirm thin Nem isaronswnion lending agency for the performance a(
Jim work fir which this permit is issued(Sec.3157,Civ.C.)
Lender's Name TOTAL.
WLender's AddressTOTAL ` � BUILDING FEE
1 cenify that I have read this application all state that the solve intiumaonn is
N correct.I agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE /{CT
V Z. building cemOactlm+,and hereby aaho orin representatives of this city enter main the SEISMIC FEE .4
above-mentioned properly for inspection purlroses. PERMIT ISSUANCE
(We)agree to sar
ve,indemnify and keep haolms the City of Cupertino against ELECTRIC FEE
Iiobilitics,judgments,coos and expenses which may i it any way accmc again,,said City ALTER OR A W TO MUCH
in em u luence of the granting of this pe.i,.in
FEE
"ofApplica
STANDS AND WILL COMPLY WITH ALL ON-POINT AIR HANDLING UNIT(TO I Ik000CFM) MECHANICAL FEE ` .ol 1
ONS.
AIR HANDLING UNIT(OVER 10.00)CPM) CONSTRUCTION TAX
Contrana Uae E%HADST HOW(WIUUCf) HOUSING MITIGATION FEE
AZARDOUS MATERIALS DISCLOS E
m or future huildingoccupamaon...handle bamNoe,material HEATI NO ON]'I'(TO 10PWO BTU)
as define)by the Cascniio Municipal Cock.Chapter 9.12,and the Health and Safety
Code,Seednn 25532(,)] HEATING UNIT(OVER 100.000 BTU)
❑Yet ON. VENTILATION PAN(SINGLE RES ID) PAID
Umtc Receipt M
W;11 the amlicant
confir or future building occupant use .An,Qu or devices which
emir hnzamom air anmminan,s as Defined by the Bay Arca An,Quality Management BOILER-COMP(111P OR I01I,00NI BTU) TOTAL:
Eason? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
Ibave renin,hc hmarJous nwmriuLrc is under Cha nerfi05 nf,he Cali- AIRCONDTHONER ISSUANCE DA
air
forma Health&Sane Cede,eatenas 25505,25533 mM25534.IuNersland Nati(the NEW kESIDr:NT1A1.MECH. SQ.FT.
of thengdoes nmcunenlyhoe otenon,,i i,i.amy ma,or.responsibility mn ofytheerney.vt
o[the requirenrxau which mail be inn priuno issvana of a Cmificmc of lkeupancy.
Owneror authorised agent Date TOTAL ',A, ISSUED BY:
OFFICE
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