29572 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C ITY OF CUPERTINO •'• BUILDING-ELECTRICAL PERMIT NO. /JJ'2^ ^ ��wL
BUILDING DML.S )N APPLICATION/PERMIT PLUMBING-MECHANICA
BUILDING PRO :CT IDENTIFICATION
ILI I R SS: ` SANITARY NU. APPLICATION SUBMITTAL.DATE
IfN :S AMCN : Ci M T.S J .. PHONE: `� RACTOR:S NAME LIC NO: •�'
--1 n�{..�1 NIC CONTROL If
4Q&ssITECTM GINEER: CNO: ADDRESS: ❑
PH : BUILDING PERMIT INFO
��rn ee 5F h 40b•"z4E *461V PLUMB MECH
❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLIfCp
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afrhm that 1 am licensed under provisions of chapter 9¢ommenrtng JOB DESCRIPTION
�aZ with Section'/IXXq of Divisam3olHv H.,mr,, nd Professions Codemd my license is
0 0 PERMIT IlSUANCIi
F Iy F DENTIAL
in foil face aril effect. 'Films ❑KITCHEN REMODEL
PUV Liccnx Class Lics
aa cnmmc
APPLIANCES-RESIDENTIAL Q UITION [I PLUMBING RE-PIPE
vFi nae t
E.Dm ANCIIII'IiCI'S DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
O Z.N.z I onw,,li n l my Plats shall he naed.a,Public records MODIFICATION
QPIO200AMPS 0INTERIOR ❑CHIMNEY REPAIR
W Licensed PromWonol 201-Hm0AMrS IMPROVEMENT
OWNER-BUILDER DECLARATION
C t86 1 hereby affirm rM1m 1 um exempt from the Comractols License Law for the OVER ION)AMPS C1 BATH REMODEUREPAIR El DEMOLITION
6 3 L U following reason(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL. C1 OTHER
W "'hwhich requires a permit to construct,alter,improve,demolish,or repair any structure F.I, priorto its issuance.also requiresthe applicant forsuch Fromto file a signed statement SPECIAL CIRCUIT/MISC.
EE that he is licensed pairs uanttothe provisionsof the Courant,License Low(Chapter 9
WX C) (commencing with Section 9000)of Divisam 3.fine Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
Z,.a om that he is exempt themmon and the basis for the alleged exemption.Any violation of [INEW BLDG/ADDITION ❑DEMOLITION
WmN Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of POWER DEVICES OTENANT ❑FWD SERVICE
I-Z
not mart than five hundred dollars(5500).T / IN ROVEhfENT
_-S Q Lo the wor.fthe pe strut or myemployees d wiNwagesas their sole compensation. SWIMMING POOL ELECTRIC
�F-O will Bo the work.0 d is The Cum is not intended w does rsale(Se,to
Business TI1ER
I�il-m_ soil Profcssiom Code:The Commcmr's License Low does not apply to an owner of OUTLLTS-SWITCHES-FI%TlIRFS
a 3 propcny who builds or improves the¢on,and who does such work himself or through
his own employees.Provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEGTR SQ FT.
SO FT.FLOOR AREA S/SQ.FT.
sale.If.however.The building or impowemem is sold wiNin one yesro(completion,the --a
mer-builder will have the burden of proving that he did not build or improve for put- Z-L-L (, ,a']•'7 �-gT dC?'•�
pose.!sale.), TOTAL: 1 fl• O G�G. I�j D O
❑ 1,as owner of the prnscri,am exclusively contracting with licensed contractors to \ / 1
construct the project(Sec.7014.Business and Professions Code:)The Contractor's Li- 2(,F�! �j �-X •�S
use Law does nor apply nt an owner of property who builds or improves amretnt.and QTY. PLUMBING PERMIT FEE
who comruns for such projects with a convectors)licensed pursuant t.the Convector's
License Law. PERMIT ISSUANCE
❑ I um exempt curer Set. ,B&P C for thlnrcaam
Owner Dote ALILR-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PRO y1'EC7C DEVICE
Ihcreby affirm under penalty of perjury one of the following declarations: V
❑ I have and will mountain a Cerificam of Conacnt to self-insure for Workers Camper- DRAINS-FLOOR.ROOF,AREA,CONE. STORIES TYPE CONSTRUCTION
ration,as provided lir by Section 371X1 of the Labor Cade,for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensmion Insurance,as tequimd by Section
3000.fthcLabor Code,6rthe peAomtnnce of the work furwhich this permit is i...id. GAS-EA.SYSTEM-]INC.4OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number art:
Carrico Policy No.: GAS-EA.SYSTEM-OVER 4(EA) J/IIut O� ' ,^
CERTIFICATE OF EXEMPTION FROM WORKERS' GHEASFIIHUUSfRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIIAS16N FEES
(Bussection need not he completed ifthe permit is for one hundred dollars IS 100) GRFASETRAp
or less.) 1'LANCf{ELK PEL�UYLCI I t o o 4 C
I certify that in the Performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Penson in any manner so as to become subject to the Workeri Compen. ENERGY FEE Zb
O Z nation Laws of California.Date WATER HEATER WNENT/ELECTR GRADING FEE
Z Applicant
NOTICE I'O APPLICANT;If afar making Nis Certificate of Exemption,you should WATER SYSTEMO7REATINC
a ; become subject ur the Workers Comprmation provisions of the Labor Code,you muss SOILS Plili CC
forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
.�ti. Z CONSTRUCTIONisacmm
LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT PAID Date Receip%
L)� Ihcreby afOrm that themem is construction lending agency for performance of
LL. Fthe work for which this permit is issued(See.3097,Civ.CJ
.t 'L'O'CAL:
[U
Leodcrn Nmnc I-
fix
Isndcrs AAJruss TOTAL: �• BUILDING FEE
f..t I citify that 1 have read this application and state that the above information Is
Lt h correct.I agree to comply with all city ondeoonD ordinances and ante lowereWdngw QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby astarine representatives of this city it)enter upom the SEISMIC FEE L17100
at.wcmemioned property tar inspection pooposes' PERMIT ISSUANCEELECTRIC FIiF. UQ
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way aceuc against said City ALTER OR ADDTO MECH.
in onstap race of the harms ng.f this pemtit PLUMBING FEF. •U
APPLICANT UNDERSTANDS AND WILL COMPLY WIT i ALL N-POINTAIR HANDLING UNI'((TO Ey"CFM) f0
MECHANICAL FEE
SOI' 'REGULA�{['NS.
/`.a' qL AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicautic acne Da EXHAUST HOOD IW/DUCD HOUSING MITIGATION FEE
HA WUShfATF.RIALSDISCLOS RE
Will the applicant or future building occupant store orhandle harallous 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(a)'( HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RFSID) Date Receipts
Will The applicant or future building occupant use equipment or devices which
emit hasNous air contaminants as defined by the Bay Arca Air Quality Managemem BOILER-COMP(3HPOR 100,00.BTU) TOTAL:
❑Yea F7 No DinrioP BOILER-COMP(OVER 100,000 BTU)
I have read the harmdons rocenals a under Chaier b.95 of the Cali- AIR CONDI TION ER IS ANCE DATE
Codc, 5.25
fomia gddl,&S ontty contend,
Sections ,thin I I,my and 25534.1 u mail,td than if the NEW RESIDUN'1'IA1.MIiCH. SQ.PT.
building doer nen c which novo a ananp Ilio it is ory rceofasihllity mnotify the lso,y.m
of Ibc ruyulmmmnle which must M mut prior m ismunce oCo Ccnilicaa.f O¢aPuncy.
Owncr.r authorized agent Dam TOTAL. icin•w ISSUED It Y:
OFFICE
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