29083 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMFFPLUMBING.MECHANICAL 2 O8
BUILDING PROJECT'IDENTIFICA'T'ION
flUl �DD9ES5: � SANITARY NQ. APPLICATIQN S�MI�LDATE
OWNER'S AME: • PIIOWx' 'n�(T C ORIS LI
c�EXM%V%/YUDY//VV1l NIC CONTROL
ARCHICT/ENGINEER: LIC NO: AD IIS ❑
(VI
CON fCT': PHONE: �/ IIUILDING PERMIT INFO
'A
/ ❑ Consultant Pecs Paid by Applicant(Initial) LDC ELECT PLUMB ME�
e-a� ❑ ❑
C' SED CONTRACTOR'S DECLARA PION QTY. ELECTRIC PERMIT FEE
1 hereby affmt that 1 em harmed under provisions of Chep¢r 9lcomrrencing JOB DESCRIPTION
O0 with Section]000 fDivnion 3nfthe Business an dl ofesai d yliceme's RESIDENTIAL:
1+100 ' PER M IT ISSUANCE
NSF• in full force and f �❑S)PDWL KITCHEN REMODEL
QUV LiccLlf.M APPLIANCES-HESIDE'JTIALDDITION C1 PLUMBING RE-PIPE
of 4 i Ume Cnmmmor
ARCHITECT'S UFCL ❑MULTIUNIT ❑STRUCTURAL
F y Z I rodent nd my plant shill he used m public meredx PANELS MODIFICATION
OZ
UPT0200AMP5
[I INTERIOR ❑CHIMNIiY REPAIR
[=a.we y01 O
Licensed 201-1000 AMPS IMPROVEMENT
CXSOWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEIIREPAIR t_1 DEMOLITION
oC w Q I hereby affirm that 1 am exempt from the Comomin',4cense Law for the
X F following reason(Section 7031.5,Business and Profession.Code:Any city or county SIGNS ELECTRICAL ❑OTHER
m which requires a permit to construct,alar,improve,demolish,or repair any structure Prior,.its issuance,also requires thetpplicatn f).such permit w tile.signed statement SPECIALCIRCUI'UMISC,
f�} thathe is lipowd pursuant nthe provWonsofthe Contractors License law(Chaprar9
Test, (commencing wird Semimn]gXl)ofDivisinnJ afthe Business and l'mfesxionsCWe)or TEMP.METER OR PoLE!NST. COMMERCIAL
q q o¢ that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tXil 4• Section 0031.5 by any applicant for a permit subject, he applicant In a civil penaltynf POWER DEVICES ❑TBNANT OFOOD SERVICE
SSCy m more than five hundred dollars 0500). IMPROVEMENT
❑Las owner ofthe property,or my employee,with wages as their sole compensation. SWIMMING POOL ELECTRIC
Sq� will dome work,and th—limenru is tiny lntendedondfered fa..a].(See.]044,Rexin.ss ❑OTHER
a 3 m and Pophosions Cede The Contractor's License Law docs not apply to an owner of OUTLIH S-SWI TCITES-FIXTURES
Aper y who builds or improve,thereon,and who does such work himself or through
fix own employees,provided that such impmvcmemn arc not intended or ffcmd for NEW RESIDENTIAL ELF.CTR SQ FT.
sale.If.however.the building or improveamon is sold within one ycandcompl.piom,the SQ.[7—FLOOR AREA E/SQ.IT.
owner-builder will have Ne burden of proving dust he did not huild or improve for,,a missile.).of sale.).
1,as owner ofthe property,am exclmxivcly conlmming with licensed contmenns to TOTAL:
consmai dtc project(Sec.9044,imnnexs and Profession,Co..:,Thc Commcna's LI
-
nselawdoesnotapplytoanownerofpmpertywhobuildxorimprovc.x thereon.road QT'Y. PLUMBING PERMIT FEE
who contmclS for such Project,with a contractions)licensed pursuant to the Contmee/s
License law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this rcasun
Owner Dae
ALTER-DRAIN&VENT-WATER(EA) ai VALUADO
WORKERS COM of do I on DIiCLANA130N RACK FLOW I'NOTECT.DEVICE
I hand will mai under 1'enofic err pcfjury one of the insure or declarations:
r7 1 on..a.and ofCarvern die Lab ,Code fare for Worker's Compen- DRAINS-FLOOR.ROOE,AREA.CONT. STORIES TYPO CONSTRUCTION
week
as provided for by Section 3]IXI ol'phe Labor Gde,Ire the performance of the 1
i work for which chis permit is'nsued. FIXTIIRP_S-PGR TRAY /
I have an 1TI t m Worke- Compensation Insurantt,as required by Section
J]W of the a or a the performanccoflh.x r rift d�'fy 1="z�' GAS-GAS-PA.SYSTI M-O CNY(OEAm�S C.GROUP APN
My Wnrkor rr r 'a d1'. F (/
Carrier. Policy
CERTIFICATE FAEMPTION FROM WORKERS'
COME ;NSNrION INSURANCE. GREASFANDUSTRL WASTE INTERCEPR)H
(This sermon nand not hecnmplemd il'the permit Ie far nue hundred unit.is IfgB BUILDING DIVISION FP.IS
m less) GREASETRAP PL C E KEEE
I certify that in the performance ofthe work for which dn%permit is imued,I dril SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner sous to bcmnre subjectin the Workers'Groper- ENERGY FEE
O Z alio.Laws of Celitirmia.Dec WATER HEATER WNENT/ELECTR GRADING FEE
Z Q Applicant
NOTICE'TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENITREAI'ING SOILS FEE
a ; become subject m the Worke,Cumpcnxmion Provisions of'the Lana Code,you must
foMwith comply with such provisions at this permit shall b:deemed revoked. WATER SERVICE
0
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date Receipt x
L)O I hembyaffrm that there iso compaction lending agency for the if.,f.ncc.f
the walk for which this permit is issued(Sec.3097.Civ.C.)
OI•" Lcndels Name TOTAL:
C.1 I<nder'x Address - TOTAL:
W� BUILDING FEE
1 agree that 1 have read phis y antic un end ince thus the above information,musing n
layZ correct logreemcotnply with all cityand
mpresnrdtivesos and sinus bwsr.p.ngm QTY. MECHANICAL PERMIT FEE
L) Z building conswmion,andhereby authorize rcprexnmtivm of this city meaterup�n the SEISMIC FEC
above-mentioned property for in.xpeaim Purposes. PERMIT ISSUANCEFEEl �—
'e)agne towave,indemnify and keep harmless the City of Cespcnino against ELI[CTRIG
liabili s m na.costs andexpemcs which may inanywayaccruetilpimtsaid City ALTER OR ADD TO MECH.
cqa a, f:�
of phis lwrndt. PLUMBING ItiE
APPI CA. U DS AND WILL COMPLY WITH ALL NO POINT AIR HANDLING UNTI'(TO 10,(1!10 CFM) /t
SOU!CER"Uin co MECt{gNICAI.FEE v —�
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signalmot Ap Rica. manor m. EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wt c...le.ntor future building occupant Inn:or handle hamrdaus material HEAT]NO UNIT(TO 104000 BTU)
as defnW by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cod.,Section 25532401 HEATING UNIT(OVER 1010.000 BTU) �!�/•a��
❑Yes El No VENTILATION PAN(SINGLE RESID) J'.WVlaru'�1 Vt°clJ
Will 0e applicant or future building weapon u,c equipment or devices which BOILER-COMPf3HP OR 100,110(1 BTU)
emit hazardous air contaminants as defned by the Bay Area Air Quality Management TOTAL:
DixtrimR BOILER-COMP(OVER 100,00011TU)
❑res ❑No 0 //A
I have mad the M1''""''PPIrJous'nat srequirementsonder Chapter 6.95 of pee Cali- AIRCONDITIONER .J ISSUANCE DATE:
fomite Health&Safety C c So tin m 259115,25533 and 25531 I undcmand thus if the NEW RESIDENTIAL MECH. SQ,FT �•
building does not cur I have a tenant,that it my resprmsi ility to notify pec occupant
of the requirements when cusp be mer poor to iuuwex ate Certificate of(kcupmcy. A
TOTAL:
Owner or aulhoria<d agars Date I:S 'u�"
OFFICE