29390 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECRANICAL 29390
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: cx �11 � SANITARY NO. APPLICATION SUBMITTAL DATE
SSII1VOhl
O :R'SN MPHONE CO ] :SNA LIC NO:
`E SP/01aIx .2z. N/C CONTROL#
A HITECT/I'NGINF,ER: LIC AD � S: /�j# ❑
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CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ j� ❑
LICENSED GONnsed TORSunder p DECLARATION QTy, ELECTRIC PERMIT FEE
1 hereby affirm That 1 am fflensal under previsions of Chapter 9 my licensees LOB DESCRIPTION
�yy1 a
I-:Wweed Section lost Uivision3oftc Business and Professions Qde,and license is PF,RMI'f ISSUANCE
e0e in toll force and efts y t RESIDENTIAL:
�Ut' Lic,h.Cass Lic.g ❑SPDWL ❑KITCHEN REMODEL
tts�� Date o cmr APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE.
[[--.. W RC E . DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Zp�Z e d PANELS -
Plans toll u.JmpuM1lic rttoNs MODIFICATION
O Z.-. UPTO 21%1 AMPS
q fens El INTERIOR ❑CHIMNEY RIiI'AIR
a 301-H%IUAMPS IMPROVEMENT
IyY W OWNER-BUILDER m the RATION OVER MOREAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
W C 1 her affirm Nat 1 em exempt from the fessions oa License law for the
3 L U 1/1,wing s a (Semina 701 L5,Business and improve.
demob Code:Any city or county SIGNS ELECTRICAL ❑OTHER
0.0
rimc inquires n permed to ctmawm,ofter,,pliv improve,demolish.m repair any structure
y pRochetslicesedpo lsorequireste akitux.fabc Ceng ehpern',License aw pChdrr9 SPECIAL CIRCUIT/MISC. L �
uentran
i Q Ihma'bi 4.a.xdpursuunno Neprovisions atlascBtrirsess ed PruLnw(Chapter9
(commencing weed Seainn 70(116 of Oivisionlaf the Business and Pndcssions Ctde)ar TE COMMERCIAL:
r.0 MP.METER OR POLF.INST. El NEW BLDG/ADDITION El DEMOLITION
0.{y=C: Na he is exempt therefrom and the basis for the alleged exemption.Any violation of
Ii+CI al Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES QTENANT ❑FOOD SERVICE
not more than Eve hundred dollars(35110). IMPROVEMENT
E"z>.
01.as owner ofthe praised,or my employees with wages as their sole compulsednm, SWIMMING POOL IiLGCI'RIC
' q will do the work,and the sanctum is not intended oroRcred for sale(See7044,Business ❑OTHER
W end Professions Code:The Conttanm's License Law does nm apply to an owner of OUTLETS-SWITCHES-FIXTURES
a 3 Property who builds or improves(hereon,and who does such work himself or through
his own employas,pmvided that such impmvemcnds ore not intended or alert for NEW RESIDENTIAL ELEC IZ SQ Ff.
m1e.If,h...ver.the building Or improvement is sold within one yearofrompleiion,the SQ.FT FLOOR',AR $/SQ.FT.
owner-0uiWr..EII have the home.of proving that he did not build or improve far par-
pnseofsale.).
1,as owner Of the prtpery,am exclusively contracting with licensed comtmmors to TOTAL:
construct the project(Sec.7541,Business and Professions Code:)The Contractor's nsLi- MAD `
cee Law does not apply to on nwner of property who builds or improves daemon, AR ay QTY, PLUMBING PERMIT FEE In / 19
who contracts for such projects with a contmctorlq licensed pursuant m the Commetnr's
License Law. PERMIT ISSUANCE
C l am exempt under Scc. ,R&PCfordhismaann �O a��ti UY GIJI'CnILIV
Owner Date ALTER-DRAIN&VENT-WATER(EA) - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTCC..DEVICE
I hand w uffitstt under penalty of perjury one of the following J Worker's
Ca
❑lavasvra,ide t for by Section 37ateafnamcnuoCossnsure for Worker's.,of
DRAINS-FLOOR,RODE AREA,COND. STORIES TYPE CONSTRUCTION
smion,as pmvided for by Section 3]IXI of the Labor Cade,for the performance of to
work whichfar this Permit is issued. FIXTURES=PIiR TRAP
1 haveaveadd will m Code,
Works/s Compensationof Insurancewhich required by Suwon
3]y of theWorer LCo podgfon Insurance cancer and work fnumran
permit is isuW. GAS-EA.SYSTEM-I INC.40I1TLETS Ori OCC.GROUP APN
My Worker's Compensation Insurance career andPolicyNo y number ore:Carrier, Policy No.: GAS-FA.SYSTEM-OVER 1(PA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASP/INDUSTRL WASTE INTERCEPTOR
less)
('fi issectionneednot he completed Has,permit is fors.ehundred GREASE TRAP ILdollars($100) BUILDING DIVISION FEES
nr
PLANCHECK FEE
Icytery that in the pedarmnncenfte theemork mwhich this ThepermitWisissued,I'Conrad-
dl SEWER-SANITARY-STORM EA.200 FT.
omen Law any person in any manner m u to become subject m the Warkcrs'Campcm ENERGY FEE
O ,� station Lowe of Ctdiforn'ut.Dam WATER HEATER WNENT/ELECM
Z O Applicant WATER GRADING HE
y NOTICE TO APPLICANT:IL niter making this Cenifieme of Exemption,you should WATER SYSTCMTREATING a SOILS PEE become subject to the Wmkefs Compe...imi provisions Of the Labor Ctme,you must
!il
forthwith comply wit such previsions or this Permit be domed revoked. WATER SERVICE
Q
�O CONSTR UCTION LENDING AGENCY NEW RESIDENTIAL PI-SIB. SQ.FT. PAID
I hereby affirm that there is a construction lending agency for to perfammnce of Dam Receipt#
work for which his permit is issued(Sec.3197,Civ.C.)
C) (~ the Lender's Name 6 TOTAL:
[U Umber's Address TOTAL:
I certify that 1 have reed this application and mote that the shove information is BUILDING PER
N correct.I agree In comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
V Z building contraction,and hereby authorize reprexmmdives of this city to ender upon to SEISMIC FEE
above-mentioned property for inspection pwposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless to City Of Cupertino against ELECTRIC FEE
liabiliaes,judgmems.costs and expech may many wayxccom against said City ALTER OR ADDTO MF.CH.
incomsequwnmting ccof lh iof �cr til. PLUMBINGFEE
APPLICANT WEE N A ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO 10,000 CFM)
SOURCE ONS ��qaa MECHANICAL FEE
AIR HANDLING UNIT(OVER IB,Ofp CPM) CONSTRUCTIONTAX
n VConoactor ate EXHAUST HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSUR
HOUSING MITIGATION FEE
Will applicam or future building occupant sdmc or hamllc hazardotu material HEATING UNIT(TO IW,11dd BTU)
as defined by the Cupenino Mmoeipal Code,Chapter 9.12,end the Health and Safety
Code,Section 25532(x)4 HEATING UNIT(OVER 100,0011 BTU)
E]yes 0 N VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building tunequipment or devices which Date Rettips#IIIIIIIIIIIIIIIIIII
pp dbythenBOILER-COMP(3HP OR 100,0110 BTU) •l I
amid hazamous air cunmminanrs as defined by the Be,Arta Air Quality Management TOTAL:
DistrictC]Yes ❑Na] BOILER-COME(OVER 1011000 BTU)
I have read the lewaromes materials requirements under Chapter 6.95 of the Cdi- AIR CON DITION ER ISSUANCE DATE
Theme Health&Safety Code,Sections 25505,25533 and 3.33x4.1 understood That if one NEW RESIDENTIAL MCCH. SQ.Ff.
building docs nod eminently Tavern,...T,thm it is my mspmsihility to notify the oecupant
of the requirements which most be met prime.issuance of a CCN cele of Occupancy.
Owner nr muthorixed agent Date ITOTAL: ISSUED BY:
OFFICE