29393 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRLCAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL. 29393
IIUI DING PROJECT IDENTIFICATION
BUIL NG�DURESS: 'b• 1 SANITARY NO APPLICATION SUBMITTAL DATi
UI Pct'
W 'SN E I'HQNE: CONTR Cf 'SNA L O:
NIC CONTROLg
ARIITECIENGNEER: 1.1 NO: ADD —� ❑
CONTACT: THONG BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLO B NIECE
❑ ❑ ❑
LICENSED CONTRACTORS QTY. ELECTRIC PERMIT FEE
I hereby aRrm that I am licensed underderProvisions of Chapter 9(commencing JOB DESCRIPTION
B'Z a uStttion7fXNB of Division 3o(the Business and Profevinns Cade,and mylicen.e is
OO PFiRMI'I ISSUANCE RESIDENTIAL:
in fall force and ef'
Vl�' ❑SFDWL ❑KITCHEN
p U Circuses C�ss Lic.M
FGZ y) Dem � Cnntracmr APPLIANCES-RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPE
Fla, HITELT. RATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O n Z 1. n s I public rallo . MODIFICATION'
OZ—O UPI'02W AMPS El INTERIOR C:1 CHIMNEY REPAIR
4j=u7 Lic sed Pr ,,o 201-100I)AMPS IMPROVEMENT
�`,Cy�K�£-all WNER BUILDER DECLARATION OVER I1N10 AMPS ❑BATH REMODEUREPAIR E]DEMOLITION
y0,U
1 herehy u' a thin Lam exempt from the Cnntructnr's License Luw for the
�(3 LL V following reason. Semon]031.5,Business and Professions Code:Any city or countySIGNS I?LF.CfRICAI. ❑OTHER
Perron41 4. which requires a peut to construct.ober,improve.demolish,or repair any structure
111tP. prionoitsissuanm,also requires the applicant for such permino file a signed statement SPECIAL CIRCUITIMISC.
N
an1p. that he is licensed pursuanuothe provisions of the CnmrmTnr's License law(Chapter 9 L
Nsic
pA�oM0 (emormneing with Section Taal)of Division Sof Ne Bmincssand Prnfessinns Cnde)or TEMP.METER OR POLE INST. COMMERCIAL'
y that he is exempt therefrom and the basis for the allayed ocumnl .m.Any violuinn of ❑NEW BLDGIADDITION ❑DEMOLITION
�y Section 7031.5 by any applicant for a permit subjects the applicant m a civil forulty of POWER DEVICES []TENANT ❑FOOD SERVICE
ZD• tram than five hundred doll...S50n. xew
IMPROVEMENT
C T,as owncrofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
wJl Bo the work.and Ne nructul,is not intended orofferad for role(See.7044,Business ❑OTHER
a 3 and Professions Code:Tho Contmemrs License Ines does nm apply m an manner of OUTLE'T'S-SWITCHPS-FIXTURES /
property who holds or improves thereon,and who does such work himself or through
his we emplmyccs,provided that such imp...coems ort nut intended m offered for NEW RESIDENTIAL ELEM R SQ FII. 17
sale.If.however,the building or improvement is sold within Ine ycarofcontpletian,the SQ.FR FLOOR AxxRE,AL, $/SQ.Irl..
owner-builder will hove the buNen of proving[list he did not build orimpmvc fur pury �'
pose mf sale)
CI 1,as own ar of the property,nm exclusively contracting with licensed contractors to TOTAL: 1n]
console,Ne peojea(Sao.7044,Business and Profession Code:)The Conwcmrs Li- 7 1996
nm law dues me apply to an ownerul'propeay who builds or imroves pthereon,and QTY,, PLUMBING PERMIT FEE 171Hn
who contracts for such projects with a contractors)licensed pursuant to the Com olon's
License Law. PERMIT ISSUANCE ('�
C31 em exempt under Sec. ,H&PC fonhis reason co UY ver LrI l lNV
Owner Doe ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herehy infirm under penalty of perjury one of Ne following declarations:
❑I have and will maintain a Certificate of Consent to self-insom for Workers Compen- DRAINS-FLOOR,ROOK AREA,COND.
amino,as provided Iia by Section 7700 of'he Labor Come,fnr the po f......a of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
El I have and will maintain Worker's Compensation Insurance,as required by Section
37W of 0c lnMu Cal far the performance of the work for which this permit is lamed. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance cattier and Policy number are:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(PA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPANDUSTRI.WASTE INTERCEPTOR
(This section laced not bo mmplowd If Tho permit is forme hundeval dollars(S 100) BUILDING DIVISION FEES
or IessJ GREASE TRAP
PLANCHECK PEE
Loy a n,perthatm.in perfotmae,sonce as hamar which this thePerW is issued jJ, axcr. SEWER-SANITARY-STORM EA.2W FT.
not employ any permn in any trmnnerw as m become subject to the Workers'Cnmpen- ENERGY FEF.
OZ section Taws of California.Date WA'T'ER HEATER WNBbIT/ELECTR
0 Applicant GRADING FELT
NOTICE TO APPLICANT:If,after nmking this Cenificnto of Esemptinn,you should WAIT?R SYSTEM?REAPING
abecome subject to the Workers Compemsminn pmvidom If the Labor Code,you nutn SOILS FEL?
forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE .
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Thereby affum Net llureisaconstruction leoding egrncy for the pennrmancc of Data Receipts
W. ti the work for which this permit is issued(Sec.3097,Co.C.)
o E' Lonsi Name TOTAL.
L) Lenders Addmss TOTAL:
P. 1 rectify that 1 have read this application and state that the above information is BUILDING FEE
h correct.l agree in comply with all city and county ordinances and state laws belating to QTY. MECHANICAL.PERMIT FEE
U z building construction,and hereby a dunme represenmtivel,of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgmems,cnstsandexN so which ywayaccmeagainslsuid City ALTER OR ADD TO MECH.
in consequence of the groping of phi..perm PLUMBING ITE
APPLICANT UNDP _ SANT ILL iPLY WITH ALL NON-POINT - pIIt HANDLING UNIT(To IBM()CFM)
SOURCE REGU MECHANICALFEE
AIR HANDLING 10,000CFM) CONSTRUCTIONTAX
Signs eo p nmcmr - Doe EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
AZARDOUS MATERIALS DISCLOSURE
til th P mould,fare.building morlont storcor handle factorials material HEATING UNIT CFO I W,IXIB BTU)as defined by Cupertino Municipal Code,Chapter 9.12,rand the Health and Safety
Code,Section 25532Iu)'! HEATING UNIT(OVER W,IXIO BTU)
❑Yes . C]No
VEMf11AT10N FAN(SINGLE RFSID) PAID
Date Receipt X
Will the upplicam orfurore building by the Bayon Arco Air
M.e.which BOILER-COMP OR IW,WO BTU)
emit District'
us air cmmaminants as definW by the Bey Area Air Quality Menragemcnt' O
DlsuieB BOILER-COMP(OVER 100J)OD BTU) TOTAL:
❑Yes E]No
n
I have mull the barardous mumrds p AIR CONDITIONER ISSUANCE.DATE
r5,u 5 3 an under Chapter understood
of the if the
Iola Health&Safety Coda.Section 255115,25537 and 25534.I u notify l pact if the NEW RESIDENTIAL MECH. SQ.FT.
building does notswhitcurrently have a tenant.Not.is my.ofn Cortpy tonodfy the nuoy.m
of the requiremcros which most be ran Pa.,,.a....nfa Certificate of Occupancy.
Owner or hmhnrized.gear Date TOTAL: ISSUED BY:_
OFFICE