29582 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-UgE BALL POINT PEN ONLY
CITY OF CUPEi RTINO BUILDING-ELECTRICAL PERMIT fs
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29582
RUILI)ING OJFICf IDENTIFICATION
BUILDIING ADf1RSS: 21V SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PRUNE: ONTRACI'OR'S N li: LIC NO:
_ _ NIC C M'ROLN
ARCHI'CCf/1iNGIYIiIiR: IC NO: DHCSS., ID- 1 Z L
.ONTACf: ,,MM.. PHONE' � BUILDING PERMIT INFO
1'ImY Cs+�Inb ileo zJq >_ti4U ❑ Consultant Fees Paid by Applicant(Initial) ELET PLUMB NMI
1 h -Z l
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed ander provi:ion:of chapter 9(commencing JOB DESCRIPTION
OaZOn Section 7000)of Division 3of the Bailors and P...fcsvions Code,and my Ievnsr.i.
FOO foil force and<Rul PERMI'FISSUANCF-
W� i" WL [I KITCHEN REMODEL
<UyUin
License Class Lic.a APPLIANCES-RESIDENT AL ADDITION [:)PLUMBING RE-PIPE Q G Dam Contractor
F O m PANELS ARCHITECTS DECLARATION MULTI-UNIT ❑STRUCTURAL
Z p m Z 1 undcrsmnd my plws shall 1w.,cd as public cos MODIFICATION
OZ=" UP TO 2M AMPS I El INTERIOR ❑CHIMNEY REPAIR
Licensed profeasianal 201-I0410AMPS IMPROVEMENT
a C Q 1 hereby uffm:OW I am
OWNER-BUILDER
froDECLARATION
the Contractor's AILicense Law for dhc OVER HMAMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
3 6 N
following reason.(Section 7031.5, I ❑
,Business and Professions Code.Any city or county SIGNS I"LI.C'RICAL OTHER
41 u,y which raptures v permit to mnswn,slice.improve,demolish,or repair any structure
fpp"�C'n prior to itsissuance,also requires the applicant for such persniuo file a signed statement SPECIALCIRCUIT/MISC.
2�} that he in licensed pursamn to the provisions of the Contractor's License Law(Chapter 9
1r1�C0 (aommenci,.it Section]BW)of Division 3 of the Business end Professions Cade)or TEMP.METER OR POLE INST. COMMERCIAL:
Lyon' that he is exempt Iherefmm and the basis far to alleged cxcmptian.Any riolistim.of NEW BLDG/ADDITION ❑DEMOLITION
al y Section 7031.5 by any applicant fm a permit subjects to applicant m a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
s mon,than Eve hunJrtd dollas(SSW).
IMPROVEMENT
SWIMMING NAL ELECTRIC
2,rC will Jo the work.and the structure is not immnJW onrHercd for sale(Sce.9044,Business ❑OTHER
W 3 m
it professions Cade:The Comrecmes License law does Out apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own mnployecs.Pnisided that such improvcmmnrs are not intended.,offered for NEW RESIDENTIAL ELECTS SQ FT.
sale.If.however the building or improvement is sold within one year ofcompletion.the Q� 2) SQ.F`L FLOOR AREA S/SQ.IT.
owner-builder will have the burden of proving tat he did not build or improve for par- a -N. -N�, p r/'\�
ast of sale.). 4 spa-.-/� („11..1 o V
Fl 1.n owner of to Property,am exclusively contracting with licensed contractors to TOI'N.:
censwn to project(See.7044.wariness and Professions Code:)The Convectors Li-
cense
i- 3�s�
selawdwsnmappr man with
acofproperry Hermes!
pursuant
imp roves thereon.and QTY. PLUMBING PERMIT FEE
wM10 rommck for such projects with v cammnart�O license)pursmm m the Cnntacmrs
License Law. PERMIT ISSUANCE
Ian,intermit tinder See. ,B&1'C minis reason
ALTER-DRAIN&VENT-WATER(BA) VALUATION
Owner Uv e /r�,�/y g�
WORKERS COMPENSATION DECLARATION PACK PLOW PROTECT.DEVICE I V G� 'a�1 / 1
I hereby affirm under penalty of perjury one of the following declarations: ✓ ��//( -.5
❑I have and will maintain aCeinficate of Consenuo self-insun,for Walices Compcn- DRAINS-FLOOR.ROOF AREA,COND, STORIES TYPE CONSTRUCTION
sa, as provided far hr Section 3700 of the labor Code,for to a fbmwnce of the
work fm which his pcmtil is issued. FIX'NRES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section -
3000of the labor Code,for the performance fthe work for which his permit is issued. GAS-EA,SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Instance carrier and Policy number arc:
Cartier: Policy No.: GAS-FA.SYSTEM-OVER 4(CA) I UL o� OI C
CERTIF ICATE OF EXEMPTION FROM WORKERS' CREASPJINDIISTRL WASTE INTERCEPTOR k/
COMPIiNSA'TION INSURANCE _ BUILDING DIViSI(1N FRES
(ThissecdionnpednolbettnviSchl ifthepnmil isfnumuchundrddollars(SFW) GREASETRAP - (dQff
ofless.) PLANCHECK FEEr(/rCh l dsJM.P.
Ioy any perhatson
nthein any maner ner
as he
work for whadi subject
perthe ail WlsissacJ,lnhnll SEWI?R-SANITARY-STORM EA.20X)FT.
oat employ any person in any manner m os to become subjem m the Workers'Cnmpcn- ENERGY FIiF.
O Z sation Laws of California.Date WATER HEATER WNENT/ELEC II GRADING FEE
Z O Applicant
NOTICE TO APPLICANT.If.vfier making tis Cenufinm Of Exempdan,you should WATER SYSTENUTREATING
became subject m the Worker's Compensation provisions of to Labor Cade,you must SOUS FEE
rortbwilh comply with such provisiann Or this peril shall be dvenal revoked. WATER SERVICE
a4.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O 1 Inearbyeffina that here is a construction lendmg agency fnnhe prifnrmaneeof Dam Receipsp
F to work for which this permit is issued(See 3097.Civ.CJ
Q U Lender's Name I TOTAL:
r IJ.I Lender's Address TOTAL: w�
y I codify that 1 have read this ii,ficmiom end Inde thin to above Information is BUILDING IsEE A s ti+
iF. lin correct.l agree to comply with all city and county ordinances coof laws relating to QTY. MECHANICAL PERMIT FEE
UZ building compaction,and hereby tafhorire representatives ofthis city loeracr upon the SEISMIC FEE
30
r above-mentioned property for inspection purposes. PERMIT ISSUANCE '
(We)agree m save,indemnify and keep hornless tc City of Cupertino against ELECTRIC FEE
himilifes,judgmcnb,costs and expenses which may in any way accmc against said City ALTER OR AILD TO MECH.
in consequence oldie granting of this permit PLUMBING FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0JjW CFM) rn
,tCEREGnNS, I l a.r CONSTRUCTION
N I ` � p 1
(�L AIR HANDLING UNIT(OVER I0.1MA1 CFM7 CONSTRUCfION'IAX
Signdareef Applicant lont'amor Da EXHAUST HOOD(W/DUCf) HOUSING MITIGATION FEE
H ZARDOUS MATERIALS DISCLOSURE
Will tevpplicamor future building occutimumm or handle hazardous material HFATING UNIT(TO I Il0A00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cafe.Section 25532po? BEATING UNIT(OVER 100,000 BTU)
C]Yes ❑No VENTILATION FAN(SINGLE RFS ID) PAID
Dae Receipt N
Will the applicant or future building occupant use equipment or devices which emit hazardous air corporations as defined by fire Bay Area Air Quality Management BOILER-COMP(3HPOR IOLOWB'IG) TOTAL:
District? BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
I have read the h®ardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE
forma Heath&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.17L
buildingdoes not currently have a ton m,shut it is my responsibility in notify the coot pend
of me requirtmcnrs which most he me,prior to N%tainm of u Cenifcwe of Occupancy.
Owner Of amhorizeJ agent Date TOTAL: -NI ISSUED BY:
OFFICE
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