29585 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERNRT PLUMBING-MECHANICALIt 29585
NI111.UING ' OJEC'1'IDENTIFICATION ,�
17LODIN'ADDRESS: — — , ^ tl I SANITARY NO. APPLICATION SUBMITTAL DATE
R'S N
OWNEA E: Ig�y�TV�Sch PHONE: C TRACTOR'S NA LIC NO
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4 H IiCr/F.N INI:ER: IC NO: V DDRCSS: ❑
G A ` -(M'VA (0
- BUILDING PERMIT INTO
1M )40& `J AP ❑ Consultant Fees Paid by Applicant(Initial) RLD ELECT PLUMB MECH
LICENSED CON I RAC IOII:S DECLARATION • QTY ELECTRIC PERMIT FEE
`p'�[
I hereby,affirm that I am licensed under....War,of Chapter 9(cnmmeudng JOB DESCRIPTION
O�Z with Section 7001n.f Division 3 ofthe Btumexsand Professions Cale,andary license is
WOO PERMIT ISSUANCE.
F ty full force and effect ` _ S• WI. [I KITCHEN REMODEL
�UF License Class Ls.p
Rub APPLIANCES-RESIDENTIAL. AUDITION ❑PLUMBING RE-PIPE
N f i Dare Commctor MULTI-UNIT ❑STRUCTURAL
Dwo ARCHITECTS DECLARATION
F voi7, I understand at,pIanx sh.I be ussd us puhhe records PANELS MODIFICATION
z'Oy^ UP TO 201 AMPS
OZ— ❑INTERIOR ❑CHIMNI?Y REPAIR
W Licensed Pmfe.¢i...I 201-I000AMPS IMPROVEMENT
Q 2'.-t; OWNER-BUILDER DECLARATION OVER IIXXIAMPS ❑BATH REMODFUREPAIR ❑DEMOLITION
6 I hereby affirm that 1 am exempt from the Contractor's License Law for the
x1 O6 U following remora.(Section 703 1.5.Busineax and Professions Code Any city o.county SIGNS ELECT RICA]. ❑OTHER
I+I 31r-N which requires a permit m c.nsauct,alter,improve,demolish,ser¢pair any stmaum
prior to its issuance.also requires the applicant for such pertnino file a signedstatement SPECIAL CIRCUIOMISC. 10
E�y that he is li¢mxed pumuare In thcproviv,nas of the C.museum's license Law(Chupmr9
WW=CC (commencingwith Sectior,70000f Division 3ofthc Rusinessand Pmfession%CWOm TEMP.MET ER OR POLE INST.
Q.d e C that h,is exempt therefromad d the basis for the alleged exemption.Any violation of W BLD DITION ❑DEMOLITION
Section 7131.5 by any applicant for a permit subjmts the applicant to a civil penalty of MOWER DEVICES
t more than five hundred do16m 08500). ❑ ' NT ❑FOOD SERVICE
Z Y MPROVF,MENT
=6 ❑Lashewrk.Thepropoucam nryemntended withwred frsaile(See compensation, SWIMMING POOL ELECTRIC
�p..0 will do the work.anJ the strvcmmis not intended oroffertdforsalcfSmAtW,Nwiners OTHER
i 3 and Professinas Gde:The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHLS-Fl%TURES
prnpeny who builJs nr improvcx tlmrmn,unA who dues sucM1 work o''If nr lot ugh
his own employres.provided that.such improvetmms am not intended or illi=for NEW RESIDENUAL ELECTR SQ ET
sale If,however,the building art improvement is mld within one yearofc.mpletion.the 1 •� SQ.ET.FLUOR AREg1 $/SQ.IeT.
ownerbuilder will have the hunlcn of proving That he did nmbuild.rimprove for par- LO'6
�+�-a" f^('Q •T2
Ns.of sole.). 1T,1
❑1,as owner of the property,mn exclusively contracting with licensed contractors In TOTAL:
construct the project(Sec.9014,Business and Professions Cade:)The Conwcmh Li- k.X V zz s\lG
c to Luw Jsws not applYrou^owner Of pnmcny who.ours or in,pmves memo.,and QTY. PLUMBING PERMIT FEF '�,-1,,,L�` J
whoemans s forsuch projects with a contortions)licensed pursuant n The Contractors
License Law, PERMIT ISSUANCE
❑ I am exempt under Sec ,B&P C for this reason
ALTER-DRAIN&VENT-WAIP,R(EA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION following
NACK FLOW PROT[CT.DEVICE
• IhercbY affirm under penalty of perjury one of the following Jedamtions: LJ [I �-CT
❑Ihnve Prowled for
37M of hesauer Code
the Wmkcrs Comp The DRAINS-FLOOR,ROOF.AREA,COND, STORIES TYPHCONSTRUCf10N
scion,as provided for ro Section 3900 of the Lauer Crede,for the perf.m,anee of the
0.k far which Nis minim is orW. FIXTIIRP$-PER TRAP
❑ 1 have and will maintain he,,ft Compensation Insurance,as required by Station
3]IXlofthc labor Gale fonhc perfnrm:nmc of the work for which this permit is i.vmed, GAS-PA.SYSTF,M-I INC,4OUTLETS OCC GROUP- APN
My Worker'sCompensation Insurance carrier and Policy number are: GAS-EA.SYSTEM-0VER4(EA)
Cartier: Policy Nn: 111 n
CERTIFICATE OF EXESIP7DON FROM WORKERS' CREASfIINDUSTRI,WASTE INI'ERCF.IsfOR f 0 -IlUILUINGD ^
COMin?NSA'UON INSURANCE f912)f4 FEES
fifiissati.n need not he cnmplerW ifine permit isfor.ne hundava llars($100) GREASETRAP
or less.) PLANCHECK FEED IJYL'ft I IM 1
I Terrify that in the performance ofthe work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.2011-7.
not employ any persons in anymanmc. ,,us le monnee.bjcc,to the Worker,Compcn- ENERGY FEEOLA
Z virion laws of Ca"wr i..Dae WATER HEATER WrVENT/ELECI'R
Z Q Applicant GRADING FEE
NOTICE TO APPLICANT:11,alter making this Certificate of Exemption,you should WATER SYSTEM(TREATING
7 become mbjem m the Worker's Cme'remicn pnwisions Of me Lobar Gdc,you must SOILS FEE
W foMwilh.amply withauch InusmorTs or this permit shall he deemed revoked. WATER SERVICE
CONSI is a const LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.Er. PAID
V Q Ihertby affirm that isaconarvction lending agency for the performance of Uma Realptp
LL. F the work for which his permit is issued(See 3097.Co.CJ ��X-k
C) U Lende.'s Name - 1 TOTAL:
Lender's Address TOTAL:
�.T a i BUILDING FEE 0,
[.. I verlifyg.that L ply mad this application and¢am than The above antennae.,,s
N cortect.I agree to comply with sell cry and county call uances and na¢laws relating to QTY. MECHANICAL PERMIT FEE
SEISMIC F
Ula huilding eonaructinn,and heruhy nwhove reprexnwtives of this city to enter upon the
PER
above-meni.ned proper,Lor inspection purposes. PERMIT ISSUANCE
We)agree e,save,indemnify and keep harmless Ne Ciry of Cupertino against ELECTRIC ITE
liahilities,judgmems.costs and expenses which nay in any way accrve again.said Ciry ALTERORADDTOMF,CH.
PLUMBING FEE
in mequcnce of The granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON['r(TO I LOO CFM) MHCHANICALFEE
SOU E EGULATIONS.
AIR HANDLING UNIT(OVER 10.3010 CFM) CONSTRUCTION TAX
Sigammof ppllcanl/( mmm.. )arc EXHAUST l IOOD I WIDUCT) HOUSING MITIGATION PER
HA' RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant srom or handle hazad.us material HEATING UNIT GO Ifp,000 BTU)
as defined by the Cupertino Municipal Care,Chapter 9.12,and the Health and Safny
Code,Section 25532(x)9 HEJsTING UNIT(OVIi 100.00 BTU)
❑Yes ❑NO VENTILATION FAN(SINGLE RESLD) PAID Dme Re,mipta
Will the applicant Or future building occupant use equipment or devices which BOILER-COMP IJIII'OR IIXLIMXO BTU)
emit haeallous air contaminants as defined by me Nay Arta Air Quality Management TOTAL:
District BOILER-COMP(OVER 100.000 BTU)
0Yet ❑NO
I have real the harvJ.,..out,re9airemcnu'ander,Chapter 695of the Cali AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 255..1 undendaq that if me NEW RESIDENTIAL MECH. SQ.Er.
buildingd,esrant cutmntly haveatmam,that it is my revpnnsihiTnym n.afythe eventa t
of the requirements which most he met pour to icmance of a Certificate of Occupancy. g'T
Owner or authored agent Dam TOTAL: 1�I ISSUED RY:
OFFICE
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