29844 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29844
BUILDING PROJECT LDEN7IFICA'1'ION
Bl11LDINGADDRE,SS: SANITARY NO. APPLICATION SUBMITTAL DATE
/0 ? / Nv R SK So4de e—
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OWNER'S ME: PHONE: C AC OR:SNAME: LIC NO y�
07 Miles vet So Assoc+ 41 l.ar' 60q / NIC CONTROL#
ARCHITE /ENGINEER: LIC NO. ADDRESS V ❑
'CONTACT: PHONE VBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELF,CIPLUMB MECH
❑ ❑ }� ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECFRIC PERMIT FEE
C 1 hereby affirmthat 1 am licensed under provision%of Chapter 9(commeocing JOB DESCRIPTION
M=Z with Sation 90W)of Division3 oflM Business andl4oefesspians Cude.mdanyllcenanms PERMIT ISSUANCE RESIDENTIAL'
FpWon,m= Infullforceand cff, 8 42 GSFDWL D KITCHEN REMODEL
F-zW License as Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RGPIPE
F-G 6 Tum Contra
ARCHITECT'S DECLARAT� ❑MULTFUNIT C1 STRUCTURAL
PANELS
Z O-Z I une
dmmmJ my plans drobeusll ed as Public rtcoNs MODIFICATION
OZ— UP DO 200 AMPS ❑IN'1'IiR10R El CHIMNEY REPAIR
Li<cnsed Professional 2111-I(XIU AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS D BATH REMODEUREPAIR C1 DEMOLITION
OwlC wl Q 1 hereby Moran that I aan exempt from the Convector's Lima.law for the
X 06 following....(Spatinn 703 L5,BusineasanJ Professions Code:Any city or county SIGNS F.LE Hu"L ❑OTHER
y which requires a permit to conavuct,alley,improve,demolish,or repair any sonctum
C prior to its issuance,also requim.a N �J��• {�•\�•,/
e applicant for such Permit file a signed statement SPIiCIAh CIRCUITIMI.
�ryy//��11y that he is licensed pursuant to the provisim,of the Convacmr4 License Law(Chapter 9
CaQr�
(commencing with Section 7000)of Division 3ol the Business and Pndcsxinnv Gzlc)or '1'I?MLI MP.'fF,R OR PO1.44S I COMMERCIAL:
W aqJ5 a y that M1c is exempt Ihenlnim and the basin for tow alleged exempJnn.Any vinlation of ❑NEW BLDOADDITION D DEMOLITION
W�h Section 9031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT DFOOD SERVICE
t more than five hundred dollars(8508).
H Z Y IMPROVEMENT
_< wiCo the
the popery,ort myomntendedwith endfiaalhcirrolec .Business SWIMMING POOL ELRCTRLC
f F.� will do the work.and the swcmmis not intended or o8eredforsale(Sec.91Ha,Buxinecs ❑OTHER
W 3 m and professions Cole:The Contractors License Law does not apply to an owner of OITI'LFffS-SWITCHES-Po ES
property who builds or improves aherron,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ 1-.
Mule If.hawcvcl',the buildmgor improvement iasod wiahinnneymrnf,ounplenon,he SQ.FT.FLOOR AREA SISQ,FT.
er-builder will have Ire hmdcn of moving that he did nor bui1J ser improve torpor-
pace m mlcJ.
D 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the Project(Sm.]Oise,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an wivanT of property is hat builds or improves therson.and QTY. PLUMBING PERMIT m
who contracts for such pmjcns with a contmctarad licensed pursuant to the Contractor's
Liccme Law. PERMIT ISSUANCE
D l mnexemptundef Sec. ,B&PCfor this reaxmPon
O Dan ALTER-DRAIN&VENq'-WATT?k(EA) .ALUA' gS�9
ncr WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ��� /S� {/
1 hereby affirm under Penalty of perjury one of the following Jeclararions: f Ur (,I �-
DIhaveandwillmaintainaCceificasofCommatoulfinsureforWorker's Copper- DRAINS-FLOOR,ROOF AREA.CONT. STORIES rT IE,50NSTRUCTION
nation,as provided for by Section 37M of the Labor Code,for the performance of the
k for which this Permit is issued FIXTURES-PER TRAP
� 1 have and will maintain Worker's Compensation Insurance,as mi mrsd by Section /
S O�IXIorthe LaborCale.for the errnrmmce nl'the work for which this permit is issued. GAS-ZA.SYSTEM-I INC.d OUTLETS OCC.GROUP APN
My Wor rg Vy,l su' non or ca inrand Polley ylyf�J7e7 OV GAS-BA.SYSTEM OVER 4(EA)
Ctcovr: J� �IICC IYN1il. `nhey Nn.:IY r
awripiCATE of; MPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thissation need notbcamplered ifthe .or is(Drone hundred Mllars(sINT, GREASE TRAP
or Icaa) PLANCHECK FEE
Icertify anal in the performance ofthe work for which this penait is issued,l shall SEWER-SANITARY-STORM EA.2W Fp.
not employ any Person in any manner so a%it)became subject to the Workns'Compen- ENERGY FEE
0 z saaion Laws of Calilbrnia.Date WATER HEATER WNENTIICLECTR CRATING FEE,
z Applicant
NOTICE TO APPLICAlstp If,after making this CcNllcatc of Exenmption,you should WATER SYSTEMaREATING SOILS ITER
become subject m the Worker's Compensation provisions of Ne Labor Code5: ,you must
{JJ forthwith comply with such Provisions or this permitshall he deemed revoked. WATER SERVICE
0.
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PM1IB. SQ F. PAID Date Receipt#
GQ Ihemby affirm Mm there is acanswetion lending agency for the perrormunce of
the work for which this permit is issued(Sec-3099.Civ.CJ
Q UL<nJCR Name TOTAL:
Lender's AJdrens
I ecrtify that I have need di,application and atluc fluids,above informmlom is BUILDING FEE
F fA correct.1 agree to comply with all city and county ordinances and stale laws relating to QTY, MECHANICAL PERMIT FEE
V z building contructionand hcmhyamnome mprossmwtivean
s ofthis city to enter upon e SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harnlcss the City of Cupertino against ELECTRIC FEE
Iiobilities.judgment.s.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECII.
an nsequ cc of the granting of this permit. FLUSHING FEE
APPLE, ONDF,RSTAND ND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNI'I'(TO 111.1X11)CFM) MECHANICALFEE
SOUR I 9'ION'
S, AIR HANDLING UNIT(OVER 10ifflo .M7 CONSTRUCTION TAX
mamnof Appli anV mean., Date EXHAUST HOOD(WIDUCF) HOUSING MITIGATION FEE
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupamammor handle hazardous material HEATING UNIT(TO 100.OW BTU)
as defined by the Cupertino Municipal Coda,Chapter 9.12,and the Health and Safety
Code Section 25532L0,1 HEATING UNIT(OVER IN),(=BTU)
DYcs No VENTILATION FAN(S INGLE R ESI D) PAID
Dale RCmind#
8511 the applicant or future building occupant use equipment or devices which
emit haxerdons air contaminants as definW by the Bay Area Air Quality Management BOILER-COMP(3HP OR 00.000 BTU)
TOTAL:
UastnaP
D Yes GNa BOILER-COMP(OVER 1010(X)BTU)
AIR CONDITIONER
L ha ereaJ the hvurdous material, uiremcnts under Chapter fi95 of IM1e Cali- ISSUA
fimmia Hen &Sofeay C de,Scaio 5( 25513 and 45534.1 nnJcrntnnJ that if the NIiW HGSIDENTIAL.MECII. SQ.FT.
huilAingt al cummnlly hav �WII Lvnosy lbatnmviM1lliay to notify thctzwpnnt
of the cat ser Ise is...:mre of s Cer ilicam of(kcopancy.
is XA�
Tho'ed ager a ate TOTAL: ISSUED BY:
OFFICE