29081 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
HUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL 29081
BUILDING PROJECT IDEN'I IFICATION
BUll,p}ir`®�C� /-Y f/�� y��� \ ,ate -//1f�/� SANITARY NO. APPLICAT7 LYl�12LDATE
OWNE NAMp: I/K`/V/•11/I♦'JI! ✓MVI'/-� ��A`1/I� to t. W /'�� GN'fRAC7'O N M : CNO 7 ``/
tAk
N/C CONfItOL4
4RC1{ ECT (NEER: LIC NO: ADDRESS:
CO/pl+'ACTI/I1;0NF.: / HUILDING PIiRMIT INFO
/ 74qPHONE
4,-,a
[ I� ❑ Consultant Fces Paid by Applicant(Initial) BLDG I. PLUMB E
V q4,-, 1:1 ❑
I.TrENSED CONTRAC'IY)It'S DECI.ARAI'ION QTy. ELECTRIC PERMIT NEE
I hereby affirm Ina I an licensed order provisions of Chapter v(rcuromndng JOB DESCRIPTION
��Z with Srcdon]011p)of t 3 Ne Businesxund Pro�:�gn gy.opJ rhy license's RESIDENTIAL,
F. in full foreeandeffe i I-1l"e �!/�{/D b PERMIT ISSUANCE - �t �SFDWL ❑KITCHEN REMODEL
QUU Lisnna Cla. Lic.M APPLIANCES-RESIDI3NTIAL.
�Ga Dmc Convector HADDITION ❑PLUMBING RE-PIPE
FDm ARCHITECTS DECLAR PANELS ❑MULTI-UNIT El STRUCTURAL
Z O n^ I undemnnd my plans shall x used ae public records - MODIFICATION
OZ—Q UPTO 21M AMPS El INTERIOR ❑CHIMNEY REPAIR
��tW Licensed Prof esein^ul 201-1000AMPS IMPROVEMENT
,g,i..4I OWNEin exempt to DECLARATION
�¢ I hereby affirm that 1 am exempt from the Convenor's License Law for the OVER 10IXI AMPS El BATH REM01]F.IIREPAIR 0 DEMOLITION
�y(06 U Following mass .(Studios 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHHR
41 a W FvJ which requires a permit to conttrvn,ape,improve,demolish,m repair any stricture
prior to its issuunea,also mqulmsthe appgcvm for such permitwflcvsignWstmn^ent SPECIALCIItCUIT/MISC. 2
}'-� that he is licensed personal to the previsions of the Contractor's license Law(Chapter 9 k
apo (commencing with Section 7000)of Division]ofthe Business and Professions Code)or '111.IP.MEfIik OR POLO INST. COMMERCIAL•
M y m eC that he in exempt therefrom and the basis for the alleged exemption.Any violation of ❑NIiW BLDG/ADDITION ❑DEMOLITION
tisCi-WN Section 7031.5by:myupplicint fnrapernol,uglea,the applicant m ncivil penultyof POWER DEVICES
oat more form live hundred dollars S500). ❑TIiNANT ❑FOODSERVICE
^ppi.as ow^er of thepropeny.or my employ«s witM1 wvges as their snlerompensminn, SWIMMING POOL ELECTRIC IMPR`OVEMENT '
will do the work,and the structure is not intended mattered forsale(Sec.]014,Business ❑OTfi6
and Professions Cotte:'Rte Contractors I.icense Law dues not apply m an owner of OUTLETS-SWITCHES-FIXTURES
R' property who holds m improver thereon,and who docs such work an a f or through
his own employees,provided that such improvements ore am intended or offered for NEW RESIDEN'GAL ELECTR SQ FT.
sale.IE however,the building or improvement is sold within one year u(completion,the - SQ. .O EA E/SQ.Irl(
owner-builder will have the burden of pausing that he did n t h old or improve for Pur-
posv of sale,. 7
I,as owner of the'm'e"},at,,exclusively coursed,with licensed canonicals m TOTAL: y/
onslmct the project(sa.](164.Business end Professions Code:)The Canvacmrs Li- C Cagy is1
moss,Law does not apply to an owner of property who builds or improves turf and QTY, PLUMBING PERMIT FEE �G
who contracts for such projecs with a commeor(s)licensed pursuant to the Contractor's -
I.1ccnsc Law. PERMIT ISSUANCE
❑I am exempt under Seo. ,B&1'C for this rcasnn
ALTER-DRAIN&VENT-WATER(EA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE uA
I hereby infirm under Penalty of Perjury one of the following declarations: 1'�b o f
oD
❑IhaseanJ will maintains Certificate of Conunuoself-insure for Worker's Compcn- DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 37W of the labor Code,for the STORIPS TYPE CONSTRUCTION
y performance of.work for which this pcmtit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worko's Compensation Instimnce,as required by Section
JJW of th Mn e, rhe performance ofthe work for whit t i 'noir' issued. OAS-CA.SYSTEM-1 INC.40UTLETS OCC.GROUP 'APN
My Work t ns in anter and Policy"
Cam¢ Policy No.: GAS-EA.SYSTEM-OVER 4(PA)
-CERTIFICATE FROM WORKERS'
COM .NSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR
(This section need not 1w eomplded if the pe.I,i,Famol undred dollars($100) 131111,DING DIVISION FEIiS
or less) GREASETRAP PLANCHECK FEE
I.,.,iythatinthe anyperformance
meroi.e, ,,vol,
courewhich this pee Wooer,'Croatssued,I ian.
SEWER-SANITARY-STORM EA.200 FT
not employ any .1ifor in any manner so as m become subject m the Wnrkeri Camper- ENERGY FEE
O.Z Armon Laws ol'Celifnmia.Date _ WATER HEATER W/VENT/ELECTH
z 0 Applicant GRADING FEC
y NOTICbeemna TOAPPLICANT:the WoT:IL unermromio pr Certificate of Exemption,you should WATER SYSTEM/IREA'I'ING
f" become comply
the Workers pro Coons or is provisions of the Labor Coked. must SOILS FEE
fnnhwith comply with such provisions or his permit shall he deemed revoked.• WATER SERVICE
D Q
Uz CONSTRUCTION LENDING AGENCY NEW RF_SIUIiNTIALPLMB. SQ.1.7. PAID
U0 l for whihthisermit i isaco (See.i097,Ch,agency fonhe performmnceof Data Receipt'
w t-y
'he work for which this Permit is issued(Sec.3Q9].Ch,C.) -
F' Lenders Name 9UTAI.:
4 Lenders Address TOTAL: '
I certify that 1 have read this application aid state that he above information is BUILDING FEE
COV1 correct l agree to comply with all city and county ordinances and state laws relating to Q'rY. MECHANICAL PERMIT FEE
Z building construction,and hereby^mboriu representatives ofthis city to cntarupon the SEISMIC FEE
above-rammo nal pre,my f inspection pnryous. _
(We)agree to save ndemnify and keep harmleu the City of Cupertino against PERMIT ISSUANCP. ELECTRIC FEE '
liahuhties.judgm acs,cost.and expn us which may in anyway accrue against said City
in cnnsegoenc hegrun'ngofthispermi, ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT BURST, NJ) D"LI,CO . E WITH'Af,NON-POINT AIR HANDLING UNIT(J'010,000 CPM) —O
SOURCE RF;U AT ONS. / MECHANICAL PEI'
1/4w AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCf10NTAX
SlgnatmapfApplimm/ nvucs 'Date EXHAUST HOOD(W/UUC'19 HO1151N0 MITIGATION FEB
H RD( S MATERIALS DISCLOSURC -
WillNenpplic torfum building occupant nate nr handle hazvNaas material HEATING UNIT(TO 100,000 BTU)
m defined by the Cupe nicipal Cale,Chapter 9.12,and the Health and Safety
Cole,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No - . . .
VENTILATION FAN(SINGLE RESIDI PAID
Will Neo applicant or four,baildin ><cu nt use c t or devices which Data
pP lb W .Air u BOILER-COMPJHPOR 10(fol BTU
mit hazallous air contaminants as defind'by the Pay Area Air Quality Management ( I
Diavict? V TOTA
Oyes ON. BOILER COMP(OVEN 100,000 BTI])
I have teed the harathms materials AIR CONDITIONER
malcontents M53 a under Chapter on Cali- ISSU E DATE
forma Health&Safety Coda Sections 25505.i,my aid 25534.I understand rhes if the NEW RESIDENTIAL MECH. SQ,Fr.
buildingdoesnmts which
hovent metpthatn inuace ofa ibllitym notifytheoaracy, t
of the requirements which must he met priormissuance nfu Certificate of Occupancy,
Ow^erorauthortzed age., Date TOTAL: Il �D
-OFFICE