29563 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USP-BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 29563
RGUA)ING PROJECT'IDENTIFICATION
BUILDING ADDRSS. ����� � � � SANITARY NO, APPLICA'I'IUN SUBMI'1'1'AL DA'1'L
OWNERS 'f•�X'S+a' PHONE: �5 CONTRACTOR'SNA is n ^ —L'CQ)1 RIC CONTROL
us
ARC V ITECT/ENGINEER: LICNO: ADDRESS: ❑
` I
cc,00NTACB PHONE: BUILDING PERMIT INFO
(�4elnberg�408- ILLS'°)44(0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT/ PI.UMB MEC
LICENSE)CONTRAC FOR'S DECLAKATION QTY F.LECT'RIC PERMIT FIiE f013 DESCRIPTION
1 hereby affirm that 1 am licensed volar provisions of Chapter 9(commencing
0W�Z with Section 7000)of Division 3 ofthe Business and Professions Cude,and my license is R I
LL1 O O PERMIT ISSUANCE
CET• Lifull cene Ons,)effort. DWI. ❑KITCHEN REMODIiI.
GUU License Class Lic.M APPLIANCES—RESIDFMIAL —AlION ❑PLUMBING RH-PIPE
HZW Doc Contmaimr
.<= ❑MULThUNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
p.7 rn PAN 0S MODIFICATION
w Z I unJcrnanJ my plena sbe ud ns
hall sepublic records
OZH"p UI'T02g1AMR5 ❑INTERIOR ❑CHIMNEY REPAIR
F:Q�FW Licensed Professional 201-1000AMPS IMPROVEMENT
CY ; OWNER-BUILDER DECLARATION OVER HXIOAMPS El BATH REMODEIJREPAIR ❑DEMOLITION
C 4 1 hereby attinn that 1 um exempt from the Commctor's Limme Law 0u the
kO i U following reason.(Section 7031.5.Business and Professions Crate:Any city or countySIGNS ELECTRICAL ❑OTHER
LL7 3 LL which requires a permit to construct,alter,improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such Arnot to file a signed statement 51'ECIAL CIRCUD'/MISC.
pp� } that he is licensed pursuant to the provisions of die Contmcmr's License Use(Ch,mar 9
I+I 00 (commencing with section n)(M)nf Oiskinn3ofthc Business and lhofvsaionc Code)ar 'TEMP.MITER OR POLE INST. COMMERCIAL,
6 2e that he is cxcmpt Ihercfrom and the basis far the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
XON Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
al more than rive hundred dollars($501). IMPROVEMENT
=0 01.as ownerof the pmparr,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
Fwill do the work,and the structure is not intended ormered for sale(See.]DI4,Business ❑ETHER
lay`m and Professions Code:The Contractor's License].am does not apply In an owner of OUTLFrS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself ar through
his own employees,provided that such improvemcri,arc not intended or offered for NEW RESIDENTIAL ELEC9R SQ FT.
mle.if.however,the building or improvement is sold within one year afcmnplcuor.the n SQ FT FLOOR AREA bSQFri.
.
owner-builder will have the harden of pmviag that he did not build or improve for Aur- Z2 • S 'LZ•�d �$z ` y.e� 0.;
pom of sale.). LJ
h as owner of the n y cornering N limnsed contractors to TU'TAh:
Smpe y,am exclusive g wi \S 3Q�5 Z•I..•\S
construct La the es a,,, (Sr,.o rr Business and Professions Cade)The Contracuafx Li- 'C
se Law docs nm apply m'en ownerof prupcny who M1uilJs or improves thereon.and QTY, PLUMBING PERMIT FEE
License Law.for xuchp jce¢withneumructorts)IicenxJ Pursuant to the Cnnuuwr's
License law. PERMIT ISSUANCE
� � 1 am exempt under Sec. ,B&P C for This reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Doe l^l�
WORKER'S COMPENSATION DECLARATION BACK PLOW I'kOT[CI'.UEVICE ` _\ h�J C _
1 hereby aflimt under penalty of perjury one of 0c following Jttlarmions: _CCP
❑ Ihave andwie mom my Seanit 7M of CeLabor ode.furefirz Worker's Cc of the DRAINS-FLOOR.ROOF,AREA,COND. STORIES _ TYPE CONSTRUCTION
moon ass okla hi for by Section 3]W(it the 4rbett Cdc,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 ha the Lawill maintain Worker's roomm''draw In.surmae,h his icro by Section P 1 w
l]ann(the labor Csde,for the performance of the work htt which this permit is issued GAS-fiA.SYSTEALI INC.40UTLE'r5 OCC.GROUP r AIN
M Worker's Compensation Insurance carrier and Policy number are: ]�
My GAS-EA.SYSTEM-OVER 41EA) ss 11 U'
Curries Policy No.: t LUJ"LlSI YU
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUS3'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE, BUILDING DIVISION FEES
(ThissationneN nothecomplctd ifthe permit is(Drone hundred dollars(Sl W) GREASETRAP `51 A—(
or less) PLANCHECK FEE {,JCC �i
I cemly that in the perfonnuneral the work loot which this permit is Issued,l shall SEWER—SANITARY—STOHMEA.2WFr.
not employ any Person in any manner so as to become ruttiest lir the Workers'Compem ENERGY PEE `ck s
Z sation Lawsof Cagurna.Date WAT17R HEATER WNENDELECTR
zQ Applicant GRADING FEE
NOTICE TO APPLICANT.If,after making this Certificate of Escroldim,you should WATER SYSTEM'REATING
(•-' � become.suhjccrto the Worker's Crmpcmmiun provisions of the Latin,Coca,You mull SOILS FEE
forthwith comply with such Prov"inns or this permit sIml l be deemed ie,okad. WATER SERVICE
UO ertCONSTRUCTIONLENDINGAGENCY NEW RESIDENTIAL PENCE SQ,FT. PATO Dau keceiPta
I hhy affirm that themem is is.a ctmatmction ledin6 agency for Ne perfomtantx of
the work for which his permit is issud(Scc.3W].Civ.C.)
TOTAL:
U Lender's Name Lender's AddBUILDINU PET.
res 'I'UfAL.
Iy I certify that I have read this application and state that the above information is
r U
Fry comet.I agree or comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE SEISMIC FEE `
U Z building construction.and hereby outhoris repre.senutives of this city m enter upon the C�•'� 1 _f
asove-mentioned property for inspection puria,ms, PERMIT ISSUANCE ELECTRIC FEE �V I,IYI
(We)agree to rove,indemnify and keep harmless the City of Cupaninu against
liabilities,judgment<,cans and expenxa which may in any way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE
I,,conscqucacc of the li n i ing of this pcnnil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AIL NO -POINT AIR HANDLING UNI'1'(T010,UW CFM) MECHANICAL PEE
5 tCEREGUL >NS.
AIR HANDLING UNIT(OVER 10.0010CFM) CONSTRUCTION'fAX
re of APPlicanVCn vumor ire EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
! —
HAL RDOUS MA'IPRIAIS DISCLOSURE
tgpffum
r future building occupant some or handle hamormas nalerial HEATING UNIT(TO Indiana BTU)
as derined by the Cupertino Municipal Cale,Chapter 9.12,and the Heath and Safety
Cdc,Section 25532m)'1 HEATING UNIT(OVER 100.000 BTU)
❑Yes 0 N VENTILATION FAN(SINGLE R[SIU) Data ReceiptJa
PAID
Will the applicant future cu
re building ocpant use equipment or devices which BOILER—COMP OHP OR 1 W.000 BTU)
mit haraNuus air contaminants as define)by the Bay Area Air Quality Management
TOTAL:
Diseicl'I BOIL!R—COMP(OVER 100.001 U'1'U)
❑Yes ON.
I have read the haarpdousmaterials requirements under Chapter 6.95 o1 the Cali- AIR CONDITIONER ISSUANCEDATE
fomia Health&Safety Cute,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have o tenant,that it is my respensibil try to notify the recupant
of the rtquiraments which must he met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data TOTAL: \ ISSUED BY:
' OFFICE
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