29097 (2) APPLICANTTO.FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO..
BUILDING DIVISION ' . • APPLICATION/PERMIT `PLUMBING-MECHANICAL 29097
.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: �\ ,SANITARY NO. APPLICATION SUBMITTAL DATE
v e Ti ` "IS-OW A_
OWN R'S P!RNAME: ONE: CON3'RACTOR:S,NAME: - 9 LIC NO:
NIC CONTROL#
1— Sckohe-t— QAVld� 82 3.1s
ARCHI ECUENGINEER: ,LIC NO: ADDRESS: .. - ❑ ,
CONTACT:. i - PHONE: AUILDLNG PERMIT INFO
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB 'MECH ,
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm th t fare licensed de p vt.inns of Chapter 9(aimmencing " JOB DESCRIPTION
QRZ with Section 7000)of Division 3ofthe Business and Professions Cade,and my license is RESIDENTIAL: -
w 0 n PERMIT ISSUANCE
F m full force and effect 6!i �SFDWL - [I KITCHEN REMODEL
�UF Lcaawsi ss Lich 7! APPLIANCES - []ADDITION- ❑PLUMBING RE-PIPE
r
y d� Data I}�rl 9/q Contra . L f. _
••��'' ALCHITECT'S DECLARATION,' PANELS ❑MULTI-UNIT ❑STRUCTURAL
z Np l understand my plana shallM.,ad d ns publicrecMODIFICATION
O,Z4p UP TO 200 AMPS ❑INTERIOR ED CHIMNEY REPAIR
F4t Licensed Professional 201-I00OAMPS -(IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IOOOAMPS N BATH REMODEUREPAIR [IDEMOLITION
W 1 hereby affirm that 1 am exempt from Ore Contractor's License Law for the
ippi$$,,O�U fallowing reason(Section]O3L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
i++W no
pF' wh h 4 p, a t t alter'np demolish, p y t cbre
Pont t s: ten a a1 req rc 0applies.,I hp 'G fl g d t mnev SPECIAL CIRCUIT/MISC,thathelicensed p pursuant Cheprovisions loseCommodes L- La (Chapter 9 _
yQ� (commencing with4 l 9W0) fD'visin3 ftheB : es dP f Code)or TEMP.METER OR POLE INST. COMMERCIAL,
qo O that h is exempt therefrom and the basis for the staged exemption.Any.violet on of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wq Section by any applicant for permit subjects the upFlicanl it) pcnslty of POWER DEVICES
{elm. s ❑TENANT ❑FOOD SERVICE
Onot more Nan five hundred dollars($500). IMPROVEMENT
❑1.as owner oftheproperty,or my employees with seages.es their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the aruumre is tat(mended redacted for sale(Sec.7044,Business ❑OTHER.
4 and Periscopes Cade:The Contractor's License Law does not apply to an owner(if OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such over himself or through
his own emplayees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL ELECTR SQ FI: r
male.If,however.the building or mprovement is sold within one year ofcompletion,the ,r - SQ.'FI:FLOORAREA $/SQ.FP.
owner-builder will have the harden of proving that he did not build or improve for our- `
Pose of mala).
E]1,as owner of the activity,am exclusivity contracting with licensed stainers to 'TOTAL ..
...swat the project(Sec.7044,Business and Professions Gide)The Gmwctor's Li-cerise Law does not apply to an owner of property who builds or improves thereon,and QTT. PLUMBING PERMIT FEE
who contracts for such projects with a conwctor(s)licensed pursuant o the Commerce's
License Law. ' PERMIT ISSUANCE ''' S•SJ
❑I am exempt under Seo: B&P C for this reason
Owner Data
V
ALTER,-DRAIN& ENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE "7 .0
1 hereby affirm under penalty of perjury one of the following deelection,: -5,000
•❑I have and will maintain a Corti fcate(if Consent to mel f-insure for Worker's Cunei- DRAINS-FLOOR,ROOF,AREA,COND. .STO IES 'PTFE CONSTRUCTION
scion,as id
peveB for by Section 37W of the Labor Code,for the performance of the -
work for such this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worked,Compensation Insurance,as required by Section -
39fgofNCLebotCrede,Yor the perfnmmnco of lho work for which this pennll is Vasu,d. CAS-EA.SYSTEM-IING4OUTLBYS OCC.GROUP APN
My Wmke omensmianlnsr rand Pulicy ( '
Csrticr. R'� G',AZ/ enrriePolley No.:� 1�V'�y_`Ps ACAS-Eh SYSTEM-0VES4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE IM CEPTDR
(Thissectlon need not he cnnpdm,d ifthe Permit is feted,hundred delta,,($100) .b c BUILDING DIVISION FE&S
or toss) - GREASETRAP 'PLANCHECK FEE
I cenlfytbat Innis commence ofthe work for chicbur,permit is Issued,I shall SEWER- NITARY,S :200 PT.
a.,employ any person in any manner so as m ha proo sans. .the Worker,'Camper- ENERGY PEE
cation Laws of Califomm.Date -AT R H> MY/ELECTR P
Q Applicant GRADING FEE `
y NOTICE TO APPLICANT:If,after making this Cenifnito of Exemption,you should WAT' YSOILS EEES'r BEATING
aoccur subjeeno the Worker's Compensation provisions of the Labor Code,you must _
W forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE _
Q
CONSem Not,ONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. YA1U
V I for which
theuhemisaed(Sec.30lending vgency fnrthe performance of Date Receipt#
the work for which this permit is issued(Sec.309],Civ.CJ _
Q U !snit,,',Name - TOTAL:
W I� Iznder Ade TOTAL:�3 ��
I ...ms comity that 1 have reaJ this application J state that the above information is BUILDING PEE
fr rA driee9 l agree to comply with II city and county ordinances and state laws renting to QTY. MECHANICAL PERMIT FEE
U i� brill' g corstractime,and hereby mmhonma,pr eat tivesofth'. if,in enter,upon the SEISMIC FEE
above-mentioned property for inspection pu Tosca. - PERMIT ISSUANCE -
(We)agree to save,indemnify and keep hannleem the City of Cupertino against ELECTRIC FEE
iiabilities,judgmenes,costs and expenses which may in any way aocme against said City ALTER OR ADD TO MECH.
in consequence of the 6mmirg of this parent 1, PLUMBING FEE 't 30v
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NQN-POINT AIR HANDLING UNIT(TO I0,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE v'
- AIR HANDLING UNIT(OVER 10,000 CFM) CON,,ft, T.NTAX•
sSignmum of Applicnnl/Cnmrenor Dora EXHAUST HOOD(W/DUCT) HOUSING MITIOATI
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoompant stem or handle haomous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sandy v. r
r Code,Section 25532(a)P Lo - HEATING UNIT(OVER 100,000 BTU) ; ` CII Y� Ir�ye,I Illy
VENTILATION FAN(SINGLE.RESID) PA ,ID 2 /9 c D
Wit theapplicant future building ant ue, u' rteir devices which Data Receipt# -
pp goaup sq p BOILER-COME(3HP OR 100,000 B'I'll) -
emit hexameter,e'r conmminams as defined by the Bay Area Air Quality Management
_ :'InrAL: L�
Dlsu'a. ,, � � BOILER-COMP(OVER 100,000 BTU)
Yes �Nn
I haverwd the hakerdousmaterial.sr macenmitt,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forela Health&Safety Code,Sections 25505,25533 and 25534.1 ondersmnd that it the NEW RESIDENTIAL MECH. SQ.FT. -
building does not currently have a mrmnl that it is my mspensihitity to notify the occupant
of VJ' � LpooissuanfaCI nQOu-teoCrIO'ae9upSimoy.
04Own orauNonzedn"m i
Use � TOTAL: ISSUED BY. J,.-sL� ✓'��`-d/k�kL4.�C-s
OFFICE