29228 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO . BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL - 29228
_ 1 BUILDING.PROJECT IDENTIFICATION '
BUILDING ADDRESS: - SANITARY NO. APPLICA'I']ON SUBMITTAL DATE
80Q1.LNA,11 WAU /- 19-9G
O PHONE: CO ACIOR'SNAMELIC NO:` r rr&1
NIC CONTROL.#
MITZI if rECT ISCINEFR: LIC NO: - ADDRIE, ❑
CONTACT: PHONE: " BUILDING PERMITINFO
1 t ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ L ❑
LICENSED CONTRACTOR'S DECIARATION QTY ELECTRIC PERMIT FEE
1 berehy afEma That I am liaerred order provhim.,of Chapwr 9(anmmeneing SOB DESCRIPTION
O ceZ slid,Seeion]OW)of Di ,mir and 3ofthc Business Pmfesriam Code,and my license
Poo is RF_CID N
FOOfull farce anJ effaL PERMIT ISSUANCE
�UU License Class, Lie# ❑SFDWL ❑KITCHEN REMODEL.
GL Date Canuaaor APPLIANCES-RESIDENTIAL. []ADDITION G49a6LQ,UqG RE-PIPE
'Don ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z 0 ZK lundentnnu Tny pinre shall he used as public rnords - MODIFICATION
O Z— UP.T0 2d,AMPS
r4F' License)Pmfessionul ❑INTERIOR ❑CHIMNEY REPAIR
qq 201-1010AMPS IMPROVEMENT
Syk2
OWNER-BUILDERexemptDE Ce ContmON OVER]"AMPS
y 0 CCS I M1emhy affirm that 1 am exempt from the Comractoh License Lew for the El BATH REMODEUREPAIR El DEMOLITION
sd 3 L F following reason.(Section 71131.5,Business and Professions Coda,Anycity or county SIGNS ELECTRICAL ❑OTHER
a] u. whicM1 requires a permit to constmct,nl¢r,impmve,demolish.or repair any stmcture
prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUITIMISC.
�r!iy that he is licensed pumuant,,the pnrvlsions of the Cmmmelm's Lieense Law(Chapter 9
`00 (commencing with ScNO.]WIB of Division 3 of the Business and Professions Code)or TEMP.METI7R OR POLE INST. COMMERCIAL,
6{y m C
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 9 -❑y8W BLDCUADDITION [I DEMOLITION
i4Ci ty�
Section 7031.5 by any applicant for a permitsnhjec,,d,.gpllenmma civil p::unity of POWER DEVICES V/1'ENANT ❑FOODSHRVICE
>y not more than five hundred dollars($51X1).
� 6 I,as owner of N< n,arm Io ecce with wa es ar their sole cont tion. SWIMMING POOL ELECTRIC IMPROVEMENT
❑ prose y yetis y g ,ansa
O will do the work,and ria he m,is notumerm t Livensterecil or of doesed net apply,.IYM,Bunn of ❑OTHER
W and property
woos Code:The Conuamnr's License Law docs net vpply m an owner of OUTLGTS-SWITCHES-FIXTURES
6 3 property what builds or
improve,thereon,and who dues such work himself m through
his own employees,provided That such improvements are not infrared Or offcted for NEW RESIDENTIAL ELECTk SQ FT.
sale.If,howcve9 the building or improvement is sold within one year of completion the SQ.FT.FLUOR AR E{ &SQ.Tr
owner-builder will have the burden of proving that he did not build of improve for pur-
po.e of sale.).
❑ 1.as owner of the property,um exclusively contracting with licensed contractors to TOTAL: -
common the Trojecr(Sce.]M4,BusinesscadPmfe,siamCOdrJThe CmmacudsU. 19
18 96
ase law docs not apply to an owner of property who builds or improves Thercmn,and QTY. PLUMBING PERMITPERMITPEE JAN
who contracts for such projects with a contracums)licensed pursuant to the Cmnraao's /x
License Law. PERMIT ISSUANCEobs V�T,I f (f(' (aV�.l�ll r,
C] m &I uexempt under See ,B P C for this reason N
Owner late ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPHNSA'1'IONDECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations
❑I have and will maintain a Cenificute of Con.scnnn self-insure for Workers Comprn. DRAINS-FLOOR,ROOFARHA,COND.
satiun,as presided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,in required by Section
3700 of the Inbar Code,for the performarecofthe work far
rw�which
9{this aP�eQrmit is issued. GAS-RA.SYSTEM.L INC.4 OUTLET'S OCC.GROUP APN
Cc Work Ca pensnf Intim ucartie Palle Nci l I.:a =iC77`�-� OAS-HA.SYSTEM-OVER 4(EA)
CERTIFICATEUFL'XEMPHON FROM WORKERS' IF
COMPENSATION INSURANCE ORE ASFANDUSTRi.WASTE INTERCEPTOR
(This section need not he complefed;fits,permit is forme hundred della,,is Ian) BUILDING DIVISION FF.IiS
m lees.) GREASETRAP PLANCH[CK FEF.
Loy anythmimhe Ticuany mannrortbewmkfor ncesu Muchthisfarrod,is me Worued,I hill
kers'
SEWER-SANITARY-STURM F.A.200 FT.
not employ any person in any manner w as m become subject m the Worker'Cnmpen- ENERGY PEE
'0 Z ..tion taws of California.Dare WATI7R HEATER WNENT?:LECIR
z 0 Applicant - GRADING FEF.
y NOTICE TO APPLICANT:If,after making this CrAificate of Exemption,you should WATER SYSTEMeDlEATLNG
abecome subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
forthwith comply whhsuch provisions or fhisprndt he bedcemNmvoked, WATER SERVICE -
0.
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
V Ifor hih,hi That e,ihurre is.constructionjSoc. Alen ding agency for the parfonnunernf Date Receipt# -
ILF..: the work for which thispermit is issued(Sec.3119],Civ.CJ
0 U Lender's Name TOTAL:
LU Lender's Address ( L
61 a
y 1 certify that I have it this application it ams dim the.have information is BUILDING FEE
r.t to corten.Iagree u.complywithallcityand countynntinuncexvnd sone laws rclmingm QTY. MECHANICAL.PERMIT FEE
U' building ronswction,and M1erchy amhnri>.e rcpresemdtives of thin city mentor upon due SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree t9 save,indemnify and keep hanfle,,the City of Cupenlnolopur l PERMIT ISSUANCE ELECTRIC THE
liabilities,judgmem.,costs and expemesw ' ay in any way acerveagaiml said City ALTER OR ADDTO MECH.
in consequence grant got this nit PLUMBING FEF.
APPLICANT u ?R$ NO l h C PLY WITH AL1,NUN=DINT AIR HANDLING UNIT(TO 111,000 CFM)URCF ATI S. MECHANICAL FEE
AIR HANDLING UNIT(OVER I0,00)CFM) CONSTRUCTION TAX
Sign re Appl' nVCo near Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
S MATERIALS DISCLOSURE
Will Oteupplicuntor Town,building occupant slorear handle humour.,material HEATING UNI'I'(TO I00,00)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)9 HEATING UNIT(OVER 100,000 BTU)
❑Yc. ❑No 11
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or more building y use equipment or devices which _
Dare Receipt#
emit hmardons air cmnmmbthe B
inemv as darned by we Bay Area Air Quality Management HOILHR-COMP(311P OR 11X1.000 BTU) -
Dtanm+ BOILER-COMP(OVER 100,000 BTU) TOTAL:
❑Yes F1 No Asx
v
I have ,Safer bode.wsmmeduN requirements under Chapter fitandthe Cali- ALR CONDITIONER ISSUANCE DATE
builddefh A,Safety Came,Sections 2min i 25593 and 25534,' understand thus Ifthe NEW RESIDENTIAL MECH. SQ.IT.
building ricesnmcmrcndy have a rent,theo ismyresponsibilitymnotifytheoccupant -
9Tthe requirements which most barrel prior m issuance of a Ccnihcam of Occupancy.
Owner or awhanzed vgem - Dae TOTAL: ISSUED BY:
OFFICE