29564 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING FROG CI IDENNIrIC �-'9 U0 4
BUILDING PROJECT IDI?NTIF'ICA'1'ION
BUILDING UDRE$S: � ��� ` �� SANITARY NO. APPLICATION
b6aB TTALDATE
W1NER'SNAMM•E8 HONE: g/1—'r1-v/I '1'RACTOR'SN E: LIC NO:
N/C CONTROLM
ARC ITECT/T: GINGER: LIC NO: APApDRESS: I "1 ❑
C
SONTACE, `_- P NE: �k BUILDING PERMIT INFO
.JIM `tt �CIIAX� Q�w ��"'FLI ❑ ConsWlanl Fees Paid by Applicant(Initial) BLI)cy ELECT' PLUMB MECII
21011#
A LICENSED CONfRACTOR:S DECLARATION • QTY ELECTRIC PERMIT PEE Ise}[` Irjur\
D Z I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION '
11yy with Section7000)of Dicknon 3 mbe Ism,incsnaml Promssio I,Code,and no,breme int I
F-00 in full forceand effect. I'IiRMIT 1551JANCL 3S.
W tsl f, " WL ❑PLUMBIKITCHENG
REMODEL
V Data Class Conn
Q V APPLIANCP_S-RLSIUENTIAL ADDITION ❑PLUMBING RE-PIPE
Q L Data T'S DE L
ARCHITECT'S DECLARATIONMULTIANIT ❑STRUCTURAL
z0% ludn
nsland m .a
y pIanshsll be used as public recallsINN[LS MOD1171CATION
N UP']DIM AMPS
QZ�pW ❑INTERIOR ❑CHIMNEY REPAIR
F�.F..i Licensed Professional 201-11300AMPS IMPROVEMENT
OWNER-BUILDER DIithe ContmenRATION OVER 10g)AMPS ❑BATA REMODEUREPAIR ❑DEMOL.ITION
OUC A.Q 1 hereby affirm that 1 1. exempt from an the Contrns Co s:Any
law for the
Lx L U following reason.(Seaton tU3L5,construct.after. and ve,de oli Gale:Any city or coumY SIGNS ELECTRICAL ❑OTHF,R
W 3 a y which requires n meant.to resthealar,improve,demolish,ore a signed
any swchore
ICC'�{0{nn QJ [hat hetslts cense prounnait)me thovisio so foemchpctori Eleasigned.aa¢mem SPf:C1A1.CIRCUIT/MISC.
H,Q conamencio,saedpmsuonnnde povisinnsof the Contmarn'mnd Prof Loons Code)or
��sa (cat he is xem it therefrom
a std th basis for di theegeBusiness anJ on,An vi Code)nr TIiMR METER OR POLE;INST. COMMERCIAL:
d fi e C the he is exempt Ihereftom anJ the Iasis for the alleged excmptioo.Any violation of C3 NEW BLDG/ADDITION C1 DEMOLITION
W
Section 703Li by any applicant for a permit subjects the applicant to a civil penally of (•OWER DEVICES
rNa more man five hundred dollar, ❑TENANT ❑FOOT SERVICE.
H Z Y '
=6 D 1,azowner of the pmpcny.or my employees with wages as Meir sole compensation, SKIMMING POOL ELECTRICIMI'kOVEMEN'I
FFG will do the work.and the somehow,is not intended proffered for sale(Sec.1014.Business ❑OTHER
3 m and Pnsfessionc Core:The Cmnmctvr's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURLS -
propeny who builds or impruvcs thnnon,and who doesmachwork himself nr though
his own employees,provided that such improvements are not intended o.offered for NEW RESIDENTIAL ELECTS SQ FL..
mle.If.hoi the buildingor imPmrcment issald within one ycarofcampletion,the 1— SQ, 4REA LSQ.Fr..
ner-builder will have the burden of proving that he did not build or impmve for pur- ( 1 �m S
-1--Fjil 88 .(3 rJ
yor1 ^e afsde).
Las owner of the pmpenX am exclusively contracting with licensed contractors ho TOTAL: 1 `3
em some.the popeat(Sec.701 Rosiness and Professions Code:)The Comracmrs Id. v
me law does not apply to an owner of mutiny who builds or improves dereon,and QTY, PLUMB ING PERM IT FEE
who contracts for such projects with o commemi licenced pursuant to the Contractors
License Law, PERMIT ISSUANCE
❑I am exempt under See. :B&P C(or this reams
Owner Data ALTER-TRAIN&VENT-W IEA) ..a((( VALUATION
WORK1iRS COMPENSATION DECLARAI'ION RACK FLAW PRO FECI'.DEVICE
m un / 1
I hereby ofrrder pcnahy of perjury one of am fallowing deenti
laons: `
71 I have and will maintain a Cenificata ofConscm to cdf-inseam fur Workers Compcm DRAINS-PLOOR,RCsOI AI CON STOi )I TYPE CONSTRUCTION
cation,as provided for by Section 3100 of the Labor Code,for the performance of the r 1`ka
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation moment,as required by Section
37M ofthe Labor Codc.for the per(mmmove ofthe work for which ors permit is issued. GAS-G.SYSTEM-]INC.4 OUTLETS ILP Z -19 b APN
My Worker's Compensmian Insurance camer and Policy number are: � ,RO
Currin Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMn]ON FROM WORKERS'
COMPENSATION INSURANCE OREAST•/INUUSTRL WASTE INTERCEPTER rt
'UUIEDING DIVISION M1F.LS
(This sec tion need not be completed ifthe pcman is Ennne hundred dollars(SIM) GREASETRAP n
or less.) PLANCIIIi FEE ci s
Icarty that in deperformanceafde work fnrwhichoi,permit savored,I shall SEWER-SANITARY-STORM F.A.200 FT, p/k
not employ any person in any manner sen as o become sub w to the Workers'Cont ENERGY FEE z0a pU
ZZ smion Laws of California.Date WATER HEATER W/VENT/ELECIR
Applicant GRADING FEE
ret NOTICE TO APPLICANT:If,after making this Ceoi6cam of Exemption,you should WATER SYSTEM?REATING
a ? become subject to the Workers Compensation provisions of file Labor Code,you must SOILS FEE
LIJ forthwith comply with such Provisions or this permit shall he deemed revoked. WATER SERVICE )
aQ
CONhemis aTI(INLENDINding army
NEW RESIDENTIAL I'LMH. SQ.FT. PAID
7 Z Thereby affirm dm dere isaconstmnion lending agency for the Performance of Doc RutiptM
U r the weak for which this .if is ismed(Sec.30G.Civ.C.) I'
4. Lender's Name
TOTAL:
V Landers Address TOTAL: .4 ant
` 'I BUILDING FEE W
F Icenify that 1 have read thisapplicationand coon and stateboa that the above information is A
Vi building construction,
agree mmmand wise all city and coonryotdmaneof and store laws miningvm QTY. MECHANICAL PERMIT FEE `ASO
V � building nmswcuon,and hereby oudomu representatives of this city ser enter upon the SEISMIC PEE 1
above-mentioned property for inspection purposex' PERMIT ISSUANCE ��
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FiiI3
liabilities,judgments.costs and expenses which may in any way accme against said City ALTERORADDTOMECH. 2 Al
in consequence of the granting of this permit. PLUMBING FEE sA
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO�POINT AIR HANDLING UNI'I'(TO 10,01)(ICFM) MECHANICAL ME 145 A\
SOURCERULA S.
�('//y AIR HANDLING UNIT(OVER Ig000CFM) CONSTRUCTIONTAX
Sigm of plicunt :nntmemr 1 to EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
H ZARDOUS MATERIALS UISCIASORE
Will the applicant or future building occupant store or handle Intendants material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,end me Heald end Safety
Code,Section 25532(1)? HEAT]NO UNIT(OVER 100,001)BTU)
E]Y. E)No VENTILATION FAN(SINGLE RISID) PAID Data Raciptt
0011 me applicant or future building occupant use equipment or devices which
. emit hasarMus air contaminants as defiHOLLER-
ned by the Bay Area Air Quality Management COMP(3HPOR IMAM BTU)
TOTAL:
Dicoria? HOLLER-COMP(OVER 100.000ETU)
❑Yes i]Nn
1 have read the mmmen
dnum materials mquirets under Chapter 6.95 of the Cali AIR CONDITIONER
hISSUANCE DATE
to Health&Safety Cute.Sections 25505,25533 and 25534.1 undermmnd that if the NEW RESIDEN']'IAL MECH. SQ.PT.
building dar not currently have z mmol.dot it is my reapnmsibilay o nobly the occupant
of de requirements which must be met prior to Ismance of a Ceuftcate of Occupmrcy.
Owner or authorlud agent Date I'QTAL: 14AAIISSUED BY:
OFFICE
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