29579 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICAI. PIiRMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL _ 2957 2 9 C 7 A
��� BUILDING PROJECT IDENTIFICATION Jul 1 J
BUILUI�O/�/ !/{'�V• �"L/I1 � SANITARY NO. J'PLICAIR4�BMI'1'I' L TL'
OWNER'SNAMIi: '�HONIi: �\ CON ACTOR'S NAME, IJCNO: N/C CO I'ROLN
_tl
UM Alaalla
C ITECT/: 'GINEER: is FIND; 1 ADDRGSS: EJ
CONTACT; /V=J PHU(& BUILDING PERMIT INFO
"mo
�8� w 5�� ED Consultant Fees Paid by Applicant(Initial) BLDG ELFCr PLU MIiC
LICENSED CON I RAC TUR:S DECLARATION a QTY. ELECI RIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing B DESCRIPTION
ow=Z with SectionTl00)nf Division 3 ofthe Businessand Pmtesslons Codeand myliecuse is
1-� , in full b,rceaal effect. PERMIT ISSUANCEf�m AWL [I KITCHEN REMODEL
6UU License Class ,iced APPLIANCES-RESIDENTIAL ❑AD TION ❑PLUMBING RI:PIPE
yZ W Date Cnm,memr
'=on DECLARATION PANELS ❑MULThUNIT ❑STRUCI'URAI.
Z p m Z 1 understand my plans shall be used as public record MODIFICATION
CZ-O UP TO 200 AMPS [:)INTERIOR ❑CH IMNEY REPA IR
F�n LW Liccn.md Pmfesaional III-1000AMPS IMPROVEMENT
C C%Q I herby affirm tOhot Nam Bxdmp Efrom the Camrarors License Isco for the OVER IfMYIAMPS ❑BATH RHMODE1JREPAIR 0 DEMOLITION
k�yd .U following reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W aW vHi which on,mors a prom,it,cva swn,alml,imparve,demolish,nr rcPair any,traction V A
F �Q prior to it,issuance.also rcquims the applicant for.such permit to file asi,mad„emnmm SPECIAL,CIRCUI'VMISC.
fly-' that he is licensed pm,uanun the provinans of rhe Camcrvenrs License Law(Chapter 9
6)x00 (commcncingwith Section]00(Do(Division in(NeBusiness and YrofessiomCWe)ur TFh1P.METERORPULE INST. Li'i,�6 09 dot `'
4, C ,bat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADb4 1 N D A l'�ION
of Section 70315 byany applicant foralcmal,abje,s Imapplicant to.civil penalty of POWER DEVICES ❑TENANT,,.,- ❑FOOD SERVICE
nm mom Nan Eves handled Jallm O5M.
f-ZY IMPROVEMENT Lor l.l)f Lfll ukU
=6 wi Lo the work.the property, nmyemplayres wi@wrdfa+ f,(Sege compcnmtian, SWIMMING:L ELECT
will Ju the work.and the someone is not intended or offered for sale(Sec.]U.i.Business [I OTHER -
eu13 and Profa..ior,Code:'The Contmero,I.iwnse Law dues not apply n,en owner of OUTLETS-SWITCUPS-FI%TUR'
C prolxny who builds or improves thereon,and who does such work himseR or through
his own employee,,provide that such improvements am not intended or uRere for NEW RESIDENTIAL.ELECTR SA
sent.If.however,the building or improvement is sold withinove yearofcompletinn,the SQ.FE FLOOR AREA ESQ.FT.
owner-builder will have the human of proving that he did not build or improve for put- O S e k W w"6co tip
4131bO3
pose ofsale.l. q V
01.as owner of the pd,wrt,am exclusively conducting with licensed contractors to '1'O'IAL: A 1l
construct the project(Sec.70.1.Business sod Professions Codc:)The Contractor's Li- 5.3 �"Ik Z-z
cense Law does not apply to an owner ofpropmy who builds or improves thereon,and City. PLUMBING PERMIT FEE 1_7LLP
who conmse,s fur such prajcda with u connacums)licensed pursmmua the Cond:mon s
License law. PERMIT ISSUANCE
❑I am stamp,under Sec. .B&P C for Nis reason
ALTER-DRAIN&VENT-WATER E,M VALUATION
Owner Uam1 �--a
G ---
WORKBR'S COMPENSATION DECLARATION BACK 14000 PRO'pliCl'.DEVICE
hereblium
y am.Jer penalty of perjury one tl'thc following drm
cdaions:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn- DRAINS-MOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Savona 3700 of the fabm Code,for the performance of the I
work for which(his panni,is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance.ax required by Section
3700ofthe labs Cade,for the Nrformamcaof,he .,it for which this permit is waited. GAS-EA.SYSTEM.I INC.4 OUTLETS UCC.GROUP APN
My Workers Compensation Insurance artier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTF.MOVER41FiA)
CERTIIICA'I U OF EXEMPT(ON FROM WOR K17 RS,
COMPENSATION INSURANCE GRF.ASEH NDUSTRI.WASTE IsO HRCEPfOR
(This section n«d n o Is,completed if the Permit is income hundred dollars(SIM BUILDING DIVISION FEES
or Ica) GREASE TRAP PLANCHECK FEE
Icenify that in the parhaatancc of,he work for which this Permit is i...ad,lshall SEWER-SANITARY-STORM EA.Ne.FT,
not employ any Penson in tiny manner so as to beconm subject to the Workers'Cmopca- ENERGY FEE ZQ$e,
OZ cation Laws of Culifaou.Date WATER HEATER WNENCELECTR GRADING FEE
Z Applicant
rn NOTICE TO APPLICANT:If,aftermaking this Certificate of Exemption,you should WATER SYSTEM/IREATING a � SOILS PER
�-
bec,,.,.hjccum
o the WnrJet's Cappm
cnsmtion vi..on,of,hes lahoo
r Cade,yu most
foNtwith romply soled such provisions nr,his panni,shall be dwmcJ revoked WAT HR S17RVICE
a �
7Z CONSONLENDING AGENCY NEW RESIDE,NfIAI.YLMB. SQ.17. PAID
Data RaeiptN I
V� Ihuuby uffrm,hunhem crc i,aronsruction lending mgcney onto,Perfnnnance of
IL the work for which panni,is issued(Sec.3197,Civ.CJ
Lenders Nanta
V TIyTAL:
F
W Lcndcr's Addmss TOTAL: I s
I cenify to.,I have per application and amm dta,he above information is BUILDING HE
V0.i curea.la,me ,,comply ,,It all city and emo,drd'mances and s,.,a lawsrcladng td Q'Ty. MECHANICAL PERMIT FEE
U Z building concoction,and hereby authorize representatives af,hisci,y to on enter upthe SEISMIC PIiIi
abaramemione propcny for inspcctiun puryroso. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamdcss the City of Cupcnino against ELECTRIC FEE
Iahiides,judgman6,co,a,and expense,which may in tiny way acerae a gain,,nail City ALTER OR ADD TO MECH, PLUMBING FEE
in asequence of,he grunting of this permit.
APPLICANI'UNDERSTANDS AND WILL COMPLY WITH \LL NON POINT AIR HANDLING UNIT(TO 10,00( M) MECHANICAL HE
SOURCrfff111���GItLAT10,'j/ ,a
' //� (r/ J AIR HANDLING UNIT(OVER IB.IXIB CFM) CONSTRUCTION TA%
Signature`ofnpp"ad" arc r )u IR—�- E%HAUST HOOD(WIUUCT) I{pU51NG MITIGATION FEE
HA'LSRD US MATFRIAIS DISCLOSURE
Will the applicant or future building occupant store or handle hacmdous material HEAT(NO UNIT TO 100.000 BTU)
as defined by,he Cupertino Municipal Code,Chapter 9.12.and,hes Health and Safety
Cada Section 255321a)'1 1 HEATING UNIT(OV ER I00,(N)(I BTU)
Yes n No
VF:NI'ILA'r10N PAN(SINGLE RISIU) PAID Date ReveiP,N
Will,he applicant or future building occupant use equipment or devices which
,pail hopolou.v air comuminan is as deline by the Bay Are.Air QiallD M anugmmcn, BOILER-COMP THP OR 1110,001 BTU)
1(yi'AL:
Diurim". BOIL(R-COMP(OVER I00.000 BTU)
❑Ye, No
1 have read the hazardous materials requirements under Chapter 695 or the Cali- AIR CONDITIONER ISSUANCVYAV
fold Health&Safety Code,Secoons 25505.25533 and 25594.1 understand thin if the NEW RESIDENTIAL MECH. SQ.Ff,
building docs not currently have a tcwnt.Jut it is my¢s,samobili,y to notify the occupant
of the mquimment which must betas prior ro i,saarecofa CeniGcam of Occupancy.
Owncrar authorised agent Dine TOTAL; ISSUED BY:
OFFICE
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