29010 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO. ^^ 0,k 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIh'ICA'1'ION Ly 1
BUILDINGADDRESS: SANITARY NO. APPLIC.ATTIIO}/Nk�SUBMITTALDATE
5 (WN. 'SNAME:, I'IIONIi: CONTRACTOR'SNAME: LIC NO: '
NIC CONTROL L#M
IRCHITECf NEER: _dCN1: D SS:
CONTACT,' - - PHONE: - BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) BLDG- ELECT P.UMB MECH
LICENSED CONI FACTOR'S DECLARATR)N QTY HLECI'121C PERMIT FEE - ❑ ❑
I hereby armor nun 1 on,hrem,d ander provisions of Chapter 9(oommenaing JOB DESCRIPTION
QWZ with Semi.0000)ofoi ., 3mnhe aasm maw Pro hmximtxeoae,anam ucenxelx
f�W O Y- PERMIT ISSUANCE RESIDENTIAL,
in full for and effect//jj /,,�
aUF LicenseC x_(.1 Lic.I 7 �2It ❑SFDWL KITCHEN REMODEL
yah Dam �a.� '�/�_ Conuacmr APPLIANCES—RESIDENTIAL PI UP HUNG
/� .j/ ❑ADDITION ❑STRUCTURAL PIPE
ARCIITT[CTS D[CLA AT )N PANELS ❑MULTI-UNIT 'OSTRUCNRAL
Z'Dial�4 I undkcx y�Pla hall ix used as public records - MODIFICATION
OZ-OZ— /� UPT02MAMPS
Licensed I 201-UMIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
1 IMPROVEMENT
�d OWNER-BUILDER DECLARATION OVER 1000AMPS
C I hereby affirm that I um exempt from the Contractm'x License Law for the [I BATH RF.MODEIlR13PAIR DEMOLITION
flu
following reason.(Section Tlq L5,Businenn and Pmfe,Aan,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
EMCy which requires a permit to construct,alter,improve,demolish,m repair any swnure
prior to its issuance,vlwrequitr,the applicant forsuch penniOo Elea signed statement SPECIAL CIRCUTUMISC.
tvy�"y thin he is licenud pursuant to the provisions of the Contmcsors License Law(Chapter 9
�u1 C0 (commencing with Sweden T000)ofDlvision 3 of the Business and Professions Coafor TEMP METT:R OR PoLE INST COMMERCIAL:
6 6 o that he is exempt therefrom and the basis for the alleged exemption,Any violation of
Section 7031.5 b an applicant for .. ❑NHW BLDG/ADDITION []DEMOLITION
y y re permit subjects the applicant penalty of POWER DEVICES
not more than foe hundred dollars H500), ❑TENANT ❑FOOD SERVICE
2 Cl ❑Lothe worofthepurpeny,nr myemntended mourned gesasalei(Sec.c04,Busiiess SWIMMING POOL CLCCTRIC IMPROVEMENT
C will dn,hewons Codthe she Core owlinnot i LicenseLdoe,nml apply 1 .;r Nosiness ❑OTfILR
onJ Professions Code:'I he Cnmmctor's License law Jncx nw apply ro en owner nI' OUTLCTS—SWITCIIP.S—FIXTURES
property who builds or improves thereon,and who does such work himself nr through
his own employees,provided that.such improvements am not intended or offered for NEW RESIDENTIAL HLECTR SQ Fr.
side.If,however,the building or improvement is sold within oneyearof completion the ,SQ.FT.FLOOR AREA SISQ.FT.
wnenbmilder will have the burden of proving that he did not build or improve for pun
pose of sale.). +
❑Las own rot the propeny,am exclusively cnmwming with licensW<ammnurs to TOTAL:
consumer the project(Sec.7014,Business and Profesxions Code)The Conusemr's I,
cense Law does not apply nn,an owner of property who builds or improves thereon.and QTY PLUMBING PERMIT FEE Nov
who contracts for such pmjecls with a cenlracmr(x)licensed Pursmant o rhe Co^rmamr's 19 (j9
License Lvw.' ` PERMIT ANCR moi/ 'On5
71I am exempt under See. ,B&PCfm this ream" vs7
4 Owner DamALTEk WATER(EA) s VALUATION
WORKIiR'S COMPENSATION DECLARATION BACK FLOW PROTC ICE `lillA!(�
I hereby affirm under penalty of perjury one of the following declaration
� I have and will maintain a Certificate mf Consenuo self-insure for Worker's Cunneen. DRAINS—11.00 )F. OND.
sation,as provided for by Section 3700 or the Labor Code,for the performance of the STORIES TYPECONSTRUCTION
work for which this Penni,is issued. FIXTURES—PP,R TRA
❑ 1 have and will maintain Worker's Compensation Insurance,as omitted by Section
3710 of the Labor Code.for(be Perfonnnnee of the work for which this permit is issued CAS—FA.SYST'IiM-I INC 40UTLETS OCC.GROUP
APN
My Worker's Compensation Insurance canter and Policy ndmher are:
Carrico Policy No.: GAS—EA.SYSTEM-OVER 4(FA)
CERTIFICATE OF E%F.MP`GON FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSI'RL WASTE INTERCEPTOR
(This motion need not he completed if the permit is Lorne hundreddollars1S100) BUILDING DIVISION FEES
or less) GREASE TRAP PLANCHECK FEE
I certify that in the Performance of the work for which this Permit is issued l shall SEWER—
not employ any person in any manner so as m became subject the Workera Com m. SANITARY EA.200 FT.
1 R ENERGY FEE
z nlawsof CrO �✓ /[/' WATER HhATI?R WIVIiN'TIL'LGC'tR
Applicant ,GRADING FEE
NOTICE LIC Nl:If,atter,making this C!,Icns of of E ifthar o Code,yma ushould
oma WATER SVSTI:M/IRIiATING
IZ heeame suma,lyam,he itW,hroi Cambia shantuationcomit onsofthc Laboruland. must SOILS FEE
4L1 Bmhwithcomply with such provisions ter this Penni,shell he deemed invoked. WATER SERVICE
UC) CONSTRUCTION LENDING AGENCY NEW RPSIDENTIAI.PLMB. SQ.FT PAID
I bar which his Pe,there issued( ce.iron len ding agency fonhe performance of Date Receipt
W F+ the work for which,his pemtir is issued(Sec.](19],Civ.C.) ,
O U Lender's Name 'TOTAL: -
GTaLenders Address
041 comity the,I hive read this upplioatidn and drue that,hc above Information Is BUILDING FEE
A mrrect.l agree to comply with all city aad county nlinanee,mo melowsrela,ingto QTY, MECHANICALPERMIT FEE
U building construction,and hereby authorize representatives of bis city m enter upon the SEISMIC FEE
above-numbonN progeny far inspection purposes. PERMIT ISSUANCE
(We) Me to save,indemnify and keep bamtless the City of Cupcnino against ELECTRIC FEE 5 `�
Indilinin,,judgmenrs,costs and expenses which may in any way secure against said City ALTER OR ADDTO MECH.
in consequence of the growing of this permit. PLUhIB ING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'['(TO j
0)CFM7
sOURCP GItLAT10N5. MEET AN FEE
// �.F AIR HANDLING UNIT(OV0,00001M) CONSTRUCTIONTAX
Si eof Apphcen nmincror Date EXHAUSI'I1000(Wq>UCHOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thert,licamor future building compant.dore m handle haraeme,materiel HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health end Safety
Coda Section 25532(aft HEATING UNIT(OVER UK."BTU)
EI Yes Oba PAID
VENTILATION PAN(SINGLE RESID) Dp
Will the applicam or loom boiling rccmpam use equipmem or devices which are Receipt
BAILER—COMP(3HI'.OR IOgWO BTU)
.mit hnor ous air contributions as defined by,he Bay Aura Air Quality Management
District? TOT'
❑Yea FI No BOILER—COMP(OVER 100,000 BTU)
I have tend the hazardous mamdNs requirements under Chapter 6,95 of the Cali. AIR CONDITIONER ISSUANCE DATE
remain Health&Safety Cade,Sections Z5505,25533 and 25534.1 understand that if the NEW RFSIDCNTIAI.MECH. SQ.FT.
building does notcunently have a mnaw,that it is my msponsibilityro notify the«capon,
of Bac requirements which must he mer prior to issuance of a Cendicate of Occupancy.
Owner or amhonzed age^, Date ✓
_ ISSUED BY,
OFFICE