29566 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINESaUSE BALL POINT PEN ONLY L
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29566
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BUILDING DIVISION APPLICATIONPERMIT PLUMBING-MECHANICAL L
BUILDING PROJECT IDENTIF'ICAH'ION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
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ERS NA J;i • ¢X`4 1'�ASCPHONE: w h a RACfOR:S NA E: LIC NO:
YY' N/C CONTROLX
=(�7/1`.NGINEER: 'IC Pk'.O ADDRESS: e ❑
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\A^L HONE:544b BUILDING PERMIT INFO
11�OQf hka� ❑ ConsultantFcesPaidbyApplicant(Initial) CT PLUME MEaI
LICI?NSED CONTRACfOR:S DECLARATION QTY ELECTRIC PERMIT FEE
CWZI hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Sa iNo7ODBaf Division 3a0he Businessand Professions Ctde.fnd myliceme is
E�� in full force and effect. PERMIT ISSUANCE
WL O KITCHEN REMODEL
6F.0U Li cense Class LicX APPLIANCES-RESIDENTIAL ADDITION C]PLUMBING RE-PIPE
NQS Date Contractor
I,,,pq ARCHITECTS DECLARATION PANELS
MULTi-UNIT El STRUCTURAL
z 0 v2 Z I understand my plans shall be used as public records MODIFICATION
Oz—, UPT020LAMPS - El INTERIOR C1 CHIMNEY REPAIR
Licensed Professional 201-1100AMPS IMPROVEMENT'
CLARATIN
C 6 1 hereby affirm hwNvm anER- UemplLfnm LDER Cth COnreurr's Li<cnx Law fur We OVER BUILDAMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
fa,f� 0.U fallowing rasion.(Section 70315,Business and Professions Codd Any city or county SIGNS Id,ECTRICAL [I OTHER
193 tL y which requires a permit a+mnswa,alar,improve,demolish,or repair any slrvcmre '
F'u'r prior to its issuance,also requires he applicant for such permit file a signed statement SPECIAL CIRCUIT/MISE.
F,y} mm he is licensed pursmm la the pmvis+ons of me Cmaracmr's License Law(Chapter 9
Iy�j DO (commencing with Seatinn7000)af Division 3 Of the Business and Professions Code)or THNIR METER OR POLE INST. COMMERCIAL
dX e ly mm he is exempt mercGnm and me basis fur me alleged exemption.Any vinlmion of 0 NEW BLDG/ADDITION,s 0DEMOLITION
Section]B3 LS by any applicant ore peonil subjaulhe applicant to a<ivil penalry of POWER DEVICES OTENANTO FOOD SERVICE
F y M more Wan fivehundreddollaryempl IMPROVEMENT „
�< no Lax owner+sehundredn.11... employees with wages as their sole compensation, SWIMMING POOL ELECTRIC VEMENT n--�
�_� will do the work.and the sanctum is not immured(it attend for sale(Sec.9W4.Business 11OFHE N L
W 3 an aur professions Code:The Contractor's Licen¢law does not apply tom owner of OUTLETS—SWITCHES—FIXTURES ylx�t,a
property who builds or improves thereon,and who does such work himself or thmugh (,I(V
his own employees,provided that such improvements one not intended or offered for NEW RESIDENTIAL ELF=R SQ FT. VI• I r s'—
sale.If,however.me building orimprovement is sold within one year ofm+mpletlom,the7-0w,
A SQ�FT.FLOORAREAIIIIEV $/SQ.Pr.
ter-builder will have the burden of proving that he did not build or improve for par- 7, W2 Q ZZ
$8• a��a{
puse of sale.). ` V .d3
0 I,as owner of the profs ny,am exclusively contracting with beenw l contractors m • TOTAL: Vbn-UC
tartar the project(See.9044.Business and professions Can,Tho Contractor's
uLaw does notapplymmowneTofpmpenywhobuild,orimpmvestherean.mit QTY. PLUMBINGPERS411T FEE 3q o 2Zx�S
who contracts for such projects with a connotations)licensed pursuant no the Commences Pv
License Law. PERMIT ISSUANCE
❑1 am.,m I under Sec. .B&P C for min rcumn
Owner Dam ALTER—DRAIN&VENT ATER VALUATION
WOR K HR'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I herchy affirm under penalty of perjury one of he billowing declarations:
I have and will maintain a Cenificale of Consent to self-insure for Worker's Cuisines- DRAINS—FLOOR,ROOF.AR C D. STORIES TYPE CONSTRUCTION
sadrn,as provided for by Section 39011 of the Labor Cade.for the perfmmo ace of the
work for which this permit is issued FIXTURES—PER TRAP
0 1 have and will maintain Worker's Compen.smion Insurance,as acquired by Salim
37W of the Lahm Code.fm We perfannance of the work far which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance tamer and Policy number art:
Curries Policy NO: GAS—EA.SYSTEM-O V ER 4(EA)
CER'I'IPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRIiASF/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the Permit is for one hundmddollars($100)
GREASE,TRAP
Or Icss.) PLANCHECK FEE ctodl,.Ac
Ioy anylMto me efforatioany banner
ork berm,subjectch in
permit the Wrken'Cssued,l.xhall SEWER—SANITARY—STORM EA.200 F7.
notemployL.w any person in any manner so ax nc become svbjecl m the Worker'COmlxn- ENERGY FEE a?6
ZZ ,pian Luws of Ccifnmia Dam WATER HEATER WNEM'/ELECTR
Applicant GRADING FEE
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTHM/IREAI'ING
become subject to the Worker's Compensation previsions of the Labor Code,you must SOILS FEE
ti forthwith comply with such prnvisinnx or this permit shall he deemed revoked. WATERSERVICE
6 A
CONSTRUCTION LENDING AGENCY agony NEW RESIDENTIAL PLMii. SQ.Ff.
7 Z PAID Date RecciptM �
V p (hereby atTrm that mem isaconswniun lending agency for performance of
the work for which this permit is issued(Sea.3099.Civ.C.)
u" ULender's Nanta TOTAL:
V Ltnder's Address TOTAL:
I snits that I nave toed his appliamios and state that the shave mf ernaian is ' BUILDING FEE '0 00
►V) correct,1 ugme to comply w0M1 all city and county ordinances and state laws mmling to QTY. MECHANICAL PERMIT FEE
U 7 buildingcnmlmedon,andherebyamhrri'seaprmenwHvetafthiscitymcneruponthe SEISMICFEE .00
a son,ro boned pmpeny for imspmlion purposes. PERMIT ISSUANCE
(We)agree to save,taciturnity and kem
keep hdexs the City of Cupertino against ELECTRIC FEE
Iiabililies,judgmenls,costs and expenses which may in any way mems against said City ALTER OR ADD TO MECH. T
ncc rf the graining of thin permit. PLUMBING FEE V
APPI s' NTUNDERSTANDS AND WILLCOMPLYWITIIL NO POINT AIR HANDLING UNIT(TO IO,"CFM)
SOI cC.RT ,UfATI MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Ap,faanJCmr nr i! am EXHAUST HOOD(WOUCT) HOUSING MITIGATION FEE
HAZAR US MATERIALS DISCLOSUR
Will the applicant or future building occupant store or handle haamdous nrterial HEATING UNIT(TO 100,000 BTU)
as definul by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)9 HEATING UNIT(OVER 101000 BTU)
❑Yes ONa VENTILATION FAN(SINGLE RESID) PAID
Will then applicant or future building occupantance l or devices which
Done Reeeiplq
pp gequipment BOILER—COMP(3HP OR 100,Bfxl 133'U)
emit havNous air ronmminmis or def neo by the Bay Arca Air Qualify Mnnugemem
TOTAL:
Ulstnq^ BOILER—COMP(OVER 100,000 PTU)
❑Yes F7 No
1 have real the hvsrdom materials resignations under Chapter 6.95 Of the Cali- Alk CONDITIONER
ISSUANCE DATF.
from.Health&Safety Cafe,Sections 25505,25533 or 25534.1 i nderslmd that if me NEW RESIDENTIAL MECH. SQ.FT.
building does nut con amly have it tcaml,that it is my responsibility m notify tha ntcapanl
Of the regairememx which mast be noel prior it i...anneal a Certificate of(luvapmmy.
Ovarrmvuthodmdagcnt Date TOTAL: 1 �sgo ISSUED BY:
OFFICE
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