S 2829 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING,.ELF.' TR1 PERMIT Nn
I, ,
CITY OF CUPF.RTI`IO
BUILDING DIVISION APPLICATION/1'F.RJIIT PLcanrvr.-hu:run.Nu:AL S 2829
1. BUILDING PROJECT IDENTIFICATION l!
BUILDING ADDRESS SANITARY N(l. .\PPLICAI'I(IN SUBMITTAL DAI
OWN- :NAME: PIIONG
/ C NTRACI'ORS \MFLIC No
N(C
CONTROL"
jC ' Gei
ETINIiIiRLICNO A S ❑ -3c �syy 4o
CONTACT: ///1 PHONE: 6UILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG/ ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT - FEE
1 hereby cRrm duct 1 a,licensed.tare pmdrsmo,of Chapter 9¢nmmeneing JOB DESCRIPTION
WOZ .,in Section 70R)mf DismalJmf the Busines,and Professions Cale.and my license is RESIDENTIAL:
�Ul` lineCla ante �� PERMIT ISSUANCE ❑SFDWL [I KITCHEN REMODF.1.
aUU License Clus 'L APPLIANCES-RESIDIENTIAL []ADDITION ❑PLUMBING RE-PIPE
rF Q C zew Date " Com.am
F.D. R 1fITECTS DECLARATIO PANELS 0mun-UNIT ❑STRUCTURAL
Z Q can Z 1 understand my plans shall he used ms public records MODIFICATION
UP TO 200 AMPS
JZ�❑
E3 INTERIOR El CHIMNEY REPAIR
mFW Lioemsx!Prdexaonal 281.1000AMPS IMPROVEMENT SWIMMING POOLS
yE;
OWNER-BUILDER DECLARATION OVER IOM AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
C C 4 I hereby trillion that I am exempt from the Contractor's License Law for the
i 3 a U falbwing reason.(Section 7011.5.Business and Profession.Code:Any city nr county SIGNS ELECTRICAL ❑OTHER
^O y¢ which requims a permit to emmance,.cher,improve,demolish,or sepal,any macon,
wJ poor 10 hs issuance.also requires the applicant for such permit to file a signed sta¢ment SPECIAL CIRCUTDMISC. [� J/N
try chat he is licensed purloarn to the Pmvi,ra%Of the Contractor's License Law(Chapter 9 h
W 0 (commencing with Section 700(gofDivi.sion 3ofdm Business and Puri...Code)or TEMP.METER OR POLE MST. COMMERCIAL:
1 E e 18 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
p• Section 7031.5h an applicant fur a Permit subjects then applicant a civil Penalty of POWER DEV ICES
�y Y Y re 1 PP - ❑TENANT ❑FOODSERVICE
oat marc woe rise hundred y,or
y empl.
IMPROV IEMENT
c=0 ❑ bas owner ropenyor is Bimam1cc1m.ffamd m,theircompensation, SWIMMING POO ELECTRIC
F ad ",ucwork.amdc:The Cumiccon,License
FJe,no.apply 701. Business � ❑OTHER
L 3 m and easy whirr h Cole.The C es thereon Licence Law sees nm apply is an net of OUTLETS-SW CH IXTURES
papery who bands or improves thereon,improvements
who Jsns such tinter himself or through
his own employee,,provided that such i ant is old within art not i a ofd or plEred lar NEW RESIDENTIAL F.LE SQ FT.
owner,uilcar ill have to bur impmvemcnt ithalhddone yearof provetianthe SQ.FT FLOOR AREA LSQ.FT.
wnerbuilJer will have the burden of proving cum he did not build or improve fur par- -
mofwlcd.
0Las owner of the pnmpeny,,B exclusively contracting with......L commencer m L:
lomear,La the es not (Sec 1t1U,Business atop property
who bud Calc:)The Comramon,and
w Lewdmcsnaapply mon air aontrioury was bed pursinmrovc Comm.and QTY. PLUMBING RMI FEE
who
enseU ,lar suchprojects wlthuconaactnrp)Ilmn,eJ pars am to the Cnnrudnr's
L.avnw Law. PERMIT ISSUANCE
❑ spc
IamcmunJer See. ,B&PCfor chi s reason
,
Owner Data ALTER DRAIN&VENT-WATER WAI VALUATION
s WORKER'S COMPENSATION DECLARATION BACK .OW PROTECT.DEVICE
I hereby affirm under penalty of perjury one at the following declamcions, 1Q OQ V
Ihmmmd will maintain aCertifcmemf Consent mself-insure l'ar Workers Compere DRAIN -F R.ROOrackEA.,GOND.
,anon:as provided for by Section 37M of the Labor Cale,for the perf0mmnee of the STORlIiS 11 I'YPF-CONSTRUCI'IOf
warkfinvidchlhispemalmiesmN, FlXTU 'R TR
I have and will maintain Workels Compesa ien Insurance,as required by Section
3 )of the Labor Creole.for the performance of the work for which this Permit is is.sued, GAS-EA.SYSTE. .JOUTLE OCC.CROUP MIN
My
ork es
er and Price,
Cattle Wr' v ns OF Ee camfi 17ION No,FROM
ytdy� � GAS-EA.SYSTEhf OVER ( )
CE I'll Al:OF S T (TION FRANCE'ORKERS'
gY'
COMPENSATION INSURANCE GREASFJINUUSTRL WAS' TERCZPTOR
(TTi.v.acd..need not he completed if the commit is finance handreldollars I$IraB • '' t.^.BUILDING DIVISION FEES',
nr les.) GREASE TRAP PLANCHECK FEE
I«nlfy that in the perlmrn:mcenfd Le work tin whlchthi,panic is issued,[shall SEWER-SANITARY-STORM F.A.2pO F1'.
not employ any person in any manner so as to become subject m the Workers Cmmpem ENERG 'I',
ZZ. Wtimn Laws of California.Date WATER MEATIER W/VENT/ELECfR
� Applicant
ti
NOTICE 10 APPLICANT IL niter making this Cerilicme of Exemption,you should WATER SYS'1'IEMRREsrING
> b come subject to the Workers Compensation pmvi,ion%of the Labor Cale you must LS FEE
wforthwith comply with.such pros%inn,or chi, .it,hall be deemed revoked. WATER SERVICEQ
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 111,MB. SQ.FT. PAID
U 0 1 hereby affirm that drum is a compaction lending agency for the Pertmmanee of Receipt is
D. F-' the work for which chis permit is issued(Sac.3091,Civ.C.)
0 U Lenders Name TOTAL
:
Lender's Address TOTAI-:
f4 1 verify that 1 have read chi%application card%tate that the above information is BUILD c FEF.
can coact.l agree to comply with all city and county ordinances and,tam laws relating to QTY. MECHANICAL PERMIT FEE
LJ Z building construction,and hereby authorize representatives of this city to.merupon the SEISMICF
above maminad proµny fur insµccion purpnss.,
(We)agree to save,indemnify and keep hamless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way azcme against said City ALTER OR ADD TO.MECH.
in of PLUMBING FEE
App-wyne UNDI RSTAN SLuis Permit.
APPLIC R UNDIiHSTANUS AND W'ILI.COMPLY WITH ALL NON-I'OIN'f AIR HANDLING UNIT(TO IQINMI CFM(
SO ' �NEGI' IONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER In"CFM) CONSTRUCTION TAX
-conn I pp.ic ducoamisho ' Data EXHAUST HOOD(W/DUCT)
HAl RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
ill the applicantor future buildingaccupanuare of handle hazardous material H17ATING UNIT(TO 100.000 BTU)
as defined by the Cupcninm Municipal Code,Chapter 4.12,and the Health and Safety
Code,Section 25532fu1? HEATING UNIT(OVER 100.01 BTU)
❑Yu [i VENTILATION FAN(SINGLE RFSID) PAID
>,
Data Receipt x
VIII the applicant or future building occutapm uuse equipment or devices which
"plans r contaminants a%defined by the Bay Area Air Quality MaamBOILER-COMP CHIP OR IIg1.IMd1 BTU)
TOTAL:
—.�rie?
❑Yc, [}.Qo BOILER-COhIP 10VF:µ100.000 BTU)
I have read the hazmdous material,«quimmenu under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety C '•cions 25505,25533 cad 2,W.I mxlersmal Ihm it the NEW RESIDENTIAL MECH. SQ.FT.
building) I capaybase a tenant.dhat it is my rt%µnsibility,to notify the occupant
of N' IFa:mecpnn wissuunccnfa Ccniti- f y.
ror Ime degent Date TOTAL: ISSUED BY:
OFFICE