29055 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION �� 11,I11 TION/PERMITPLUMBING-MECHANIC L C C
III111.DING PRf ACT IDENTIFICA'I']ON 29055 C�L .705 ail
BUILDING ADDRESS: SANT"fARY NO. APPLICATION SUBMITTAL DATE
OWNER'S N PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONI'kOL#
'�0.CHITECI'/IiNGINIiI.R: LIC NO: ADDRES: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) �k BLDO ELECT I'LUMB MECH
V
LICENSED CONTRACTOR'S DECLARATION QTY. ELECPRICPERMIT FEL D
1 hereby arm that I ant licensed ander provisions of chapter 9(commencing JOB DESCRIPTION
,0C with Section Aglo)of Division 3 at the Bminessand Pmficssi...Code.!AJrnyl{censeis PERMIT ISSUANCE
F-kc� full force and effeel. FOWL Ll KITCHEN REMODEL
LicG m D
Vs66 UmeLicemx Class C^dtracmr 0.� APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RIF-PIPE
F-=y i 16
ARCHITECTS DECLARATI IS PANELS ❑MULTLUNIT []STRUCTURAL
y py Z 1 understand my^laps.hall M used as public records - MODIFICATION
CZ—G UP TO 200 AMPS ❑INTERIOR C1 CHIMNEY REPAIR
F',3 Fqq'p1 laccase s 201-1000AMPS IMPROVEMENT
Oat I..escorts
DECLARATION OVER HXUAMPS ❑BATH REMODPLREPAIR 0 DEMOLITION
C C< 1 hereby affirm that 1 L5 exempt from the Contractor's o e An, Law forme
X 31 U which ng mason(Seninn]031 s, l.sfor and improve.
de imnn Coote Any city or County SIGNS IiLEC'1'NICAL ❑OTHER
a N which requires a permit re conswcr.alter,improve,demolish, file
ea sig any swcmrc
j n1= poor tomr,bel scrececaalso sumans res the applicant for such Connector,toicense Lawned(Chapter
SI'IiC1Ah CIRCUITMISC.
Sa�y thmheislicorooJpursunmtothepr�vmion.nfthe Cnmriress LicenseLiw(Chopmr9
m�00 (commencing wit Section 7000)of Divisi 3nf0i Business ani Pro fessionxCWe)or TEMP.MITER OR POLE INST. COMMrR IAL: V
66 a that he is exempt therefrom ani the bei. or the alleged exemption.Amy violation of ❑NE\('BLD��kDDIT10N ❑DIiMOLITION
m V. Section 7031.5 by any applirnm fora pert subjects the applicant to a civil penalty of POWER DEVICES ❑ 1ANT VUr:Hj[A.9UD SERVICE
F Z Y t more tan five hundred dollora(5501 IMPROVEMENT
6 E3 I......ernfthe pmpcny,or mye with wages as tcirsale emopemalme, SWIMMING POOL ELECTRIC
wtlldolhewnrk.andteetmnumt%nn In JederofBmd forsale(Sec.7044,Busincas [I OTHER
and Professions Cade:The Contractor's Lice w Nas not apply to an owner of OUTLETS-SWI FCHES-FI%TURFS
progeny who builds or improves thereon,cad sv such work himself or through
his own employees,I m sed that such represent to um not intended m offend far NEW RESIDEN'T'IAL ELECTS SQ 1'I'.
sale.IL however.me building orimprovcme I Id a year of completion,the �• SQ.FT.FLOOR AREA $ISQ.FT.
owner-builder will have the buNen of pmvingN di tM1uilJ or improve for par- 'SV O �' ♦ //��� O�
�si'atasowner of the pmpenY,ata exclusively sonde g with ceased contractors to T - 4VR j/,�J�J�, t{�•
cca swct the pmjem(Sec.70FL Business and Professions CM , e Contractors Li-
ense Law does not apply to an owner of property who builds or improves thermm.and QTY. PLUMBING PERMIT FEE
whocontmets for such pmjem,with a contractor(,)Ilcemed pursuanuo the Contractors
License Law. PERMIT ISSUANCE
1 am exempt under Sac. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Owner Date
WORKEk:SCOMPENSATIONDECIARATION BACK FLOW PROTECT.DEVICE � /O 7 (S� • O�
I hereby allrm under penalty of perjury one ofthe following dedantions: v J o J
t]I have and will maintain a Cerilicate of Consent to seniinsum for Wader.Compen- DRAINS-FLOO .ROOF AREA,COND. STORIES TYPE CONS'I'FOCI(ON
,.tion,as provided for by Section 37W of the Latin Code,for the performance of the
work for which Ni,permit is issued. FIXTURES- AP
1 have and will rani nein Worker's Compensation Insurance,a..required by Section
37W of the Libor Code.for the performance of the work for which Nisp.it is issued. GAS-EA.. TEM C.4O0TLET$ OCCGROUP N
My Workers C s io I sec d Policy number are: GAS-EA.SYSTEM-OVE A
Cnuicn - s R n F cP]ON FROM
.: /2A ��
CERTIP 'A pENS1 ON INS PRAN RK-F.-RS GREASUINDUSTR 5 E TOR
COMYIiNS TION INSURANCE. BUILDING DIVISION F1i
(Tle—slion m,rdnot Fe ondeted if thepennit is far one hundred dollars($100) GREASETRAP
or less.) PIANCHIiCK 003E
Ic nify that in the Performance ofthe work for which this Permit is issued,I,hall
not employ any Person inany manner at ns to Mnrmm subject to the Workers'Conniver- SEWER-SANITARY-STORM .A. T. IiNERGY PEE D�
C)z cation Iawnof C.lifomia.Dam WATER HEATER W/VEN'/ELECTR GRADING FEE
Q Applicant . 00
NOTICE'10 APPLICANT If.after making this Cenifcale of 12mornier,you should WATER SYSTEM/BEATING SOILS FEE
laeome subjwt m rhe Worker's Compensation provisions of the Inhor Code,you must
faMwith comply Isith.such provision,or this gamut shall he deemed revoked. WATER SERVICE
Q
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL IsLMD SQ.EE PAID ceipt#
V 0 I hereby umrmlhauhcrei.s.consmiclmn lendidg-gency for the performance of
F-' the work for which this permit is issued(See.304].Civ,C.)
0 Limdefs Name TOTAL:
V Lcndce,Address TOTA • S
�s a BUILDING FEE U
[.. I certify,the I have real this application and sum the to above inLnmmiun is
rA correct.I agree m comply with.11 city and county ordinances andstme laws relatingm QTY. MECHANICAL PERMIT FEE
U 2, building canntnctingmd hmchy authoriec repmsummivex of this city to emerupen the SIi1SMIC PEE . �0
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m cave,indemnify and keep handless the City of Cupe^inu-gains ELECTRIC FEE #
Iiahilities,judgmem,ecn>send expense,whichnny i^any warittemea'ainm,.ol City ALTER OR ADD'10 MECIL
PLUMBING FEE
in asequence of to granting of Ni,pemtb.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000 CFM)
MECHANICAL ITE
SOURCE REGULATIONS.
i �� If AIR HANDLING UNIT(OVER IO.OW CFM) CONSTRULTIONTAX
Stgn n- BSI ApNW' nt AZADam E%IIAUS'i'HOOU(W/DUCT) Ilc]USING MITIGA9'ION PEE
HAPARDOUS MATERIALS DISCLOSURE
Will the npPlicam nrfuture building occupant sore or handle hnzarJuus material HEATING UNIT TO I00,0011 BTU)
on de ined by the Cupertino Municipal Code,Chapter 0.12,and the Heohh and Snfmy
Code.Section 25532(u)7 HEATING UNIT(OVER EXXIMO BTU)
El Ye, I]Nn PAID
VCN'I'ILATION PAN(SINGLE RIiSID) Dam Receipt#
Will to applicant or future building occasion use equipment or devices which
.mit hnzurdou,air contaminates a,defined by the Bay Arco Air Qu-my Mnnagenm n BOILER-COMP(3HP OR 100,000 BTU)
OTAI,:
Diann{
❑Yes 0N BOILER-COMP(OVER 100,800 BTU)
AIR CONGO'ION17R
I have mad the moonlit,unmdds regairemenm udder Chapter 6.95 of the Cali- ISSUANCE D
fomia Health&Safety Coda Sections 25505,25533 and 8531.1 understand that if Jac NEW RPSIDENTIAL MECH. SQ.IT.
building does not currently haven tenant,dent it ie my re punsihility to notify the oconpant
of the requirements which must M met prior to issuance of a Certificate of t]ecupermy.
0wncroruutheriod agent Ilam TOTAL' ISSUED BY:
OFFICE