29272 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICAL �n �7 r1
BUILDING PROJECT IDENTIFICATION 97 1 G
ILDING ADDRESS: - - SANITARYNO. APPLICATION SUBMITTAL DATE
:
PHONE: RACTORS NAME LIC NO
�µ IXAi -
CONTROL#
�SRCHITECTMNGINEER: C /s ADDRESS. -
CONTACP. ,— PyQws: /1`� BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG_ F. MCI
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERMIT FEE lYv��'
CMZ I hereby effirmthutlmr,Ilmrsod mdm,rovixione of Chapter 9(consmicamr, JOB D$SCRIPTION
�s100
with Seetiean]g10)ofDivision3ofthe Business and Professions Cole,and mylicense is PERMIT ISSUANCE RESIDENTIAL:
to full force and effect.
�FUt�tJs License Cluss LIC# ❑SFDWL ❑KITCHEN REMODEL
),It Conhanor APPLIANCES-RESIDENTIAL DITION El PLUMBING RE-PIPE
ARCHITECPS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
b.'wl
O Z�� I undersmnd my pions shall he used as public records PANELS MODIFICATION
UPTO200AMPS
��.F.O Licensed Professional El INTERIOR [D CHIMNEY REPAIR
201-IIIIXIAMPS IMPROVEMENT
y OWNER-BUILDERacimptDECLARATION OVER IRHIAMPS
O� I hereby affirm that am cxcmpt from the Cssions o License Low for Ihu El BATH REMODEL/RIEPAIR DEMOLITION
iq 04 U following reason(section 0031.5,nosiness end Professions Cole:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 4I" which requires a permit to construct.cher,improve.demolish.or repair any structure
FSO prior,,it,issuance,alsorecem,the applicant forsuch gamut n,file axigired.cmteln I SPECIAL CIRCUITIMISC.
that he is licensed pursuantzo Neprovisionsufthe Comracmrs License Law(Chapm
a1y00 (commencing with Sasion9000)of DivisionJafthe Businessand Professions Cade)ear TEMP.METER OR MLIi 1NST. COMMERCIAL:
4 as a that he is exempt therefrom and the basis for the alleged exemption.Any violation, [INEW BLDG/ADDITION ❑DEMOLITION
, in Section 7031.5 by any applicant for a pesmit subjects the applicant,a civil penally rPOWER DEVICI?.9
t marc than five hundred dollars($500). []TENANT ❑FOOD SERVICE
F-ZO ❑1.as owner of the property,or my employees with wages as their sole compcnsainn, SWIMMING POOL ELECTRIC IMPROVEMENT
aS will Jo the work,and thasorman,is not immndal or offered for sole(Sec.90,14.Braraws ❑OTHER
NO anti Prolessinnn Code:The Cammmnrs License law docs not SW
apply to vn owner of '1 S- ITCHES-PfXTURCS
progeny who builds or improves therc.r,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered R E ESIDEM'IAL ELECTR
SQ FT.
sale.If.Imwevm the building.,improvement issold within one yemcifemopletimiflet SQ.FT.17LOOR AREA $/SQ.
r- i
bulder will have the burden of proving that he did not build or improve for par- l
posr-of attle.).
❑ T s�rlT7^+
'L as owner of the property,am exclusively contracting with licensed contractors m
construct the project(See.'RHA.Business and Profession,Cedi The Contractors Li-
censeUsedoesnonapplymanownerofpropertywhobuildsearimprovesthereon,and Q'pY. P.UMBING PERMIT FEE
who contracts forxuch projects with a couracmr(s)licensed pursnn all rude hContractor x
License Law. PERMIT ISSUANCE
❑I am exempt ands,Sec. ,B&P C fear this reason
I Ir ALTER-DRAIN&VENT-WATIER(EA)
Ca
Pr
Dale - VAIAA'1'ION
/// WORKER'S COMPENSATION DECLARATION s BACK FLOW PROTECT.DEVICE /�
y I hereby affirm under penalty of perjury one of the following declarations: f�
6 ❑I have and will maintain a Certificate of Cnn.eemw oril'-insure(..Worker's Cooper. DRAINS-FLOOR,ROOF,AREA,COND.
sution,as provided for by Section JT(M)of the Labor Csde.for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will abortion Worker's C.mpensadma bbrmrea,ns m,mool by Section
TIDO of Ne Latton Code.for the perfomsance ofthe work for which this permit is issued. GAS-EA.SYSIHM-I enINC.4OUTLHTS OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Croner. Policy No.: GAS-IEA.SYSTEM-OVER4(BA)
CERTIFICATE OF(EXEMPT ION FROM WOR K HRS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE IM'ERCEPTOR
(This section need not he completed tribe permit is for one hundred dol Ism,1$100) HUILDING DI SON FEES
or less) GREASETRAP PLANC1112CK FIEIE
I employ
my that im the anypermanner
aven r o as tothe become
far which this thePerW,kers'Coarpued,I r-
notempiny�nypersoninvnymannerseaasmhaomenub'eco to the Worker�Com _ SEWER-SANITARY-STORM EA.2tlO F1'.
,Z sation Luwsof Culilnmia.Dmc ) pe^ ENERGY FF.E
z0 Applicant WATT?H HEATIEIi WNIEN'1'IELIECTR GRADINGP
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WAIF R SYSTEMaREATING
become object to the Workers Compensation provisions of the Luhe,Cale,you must _ SOILS FIFE
forthwith comply with such provisions or this pimation shall be deemed revoked.
WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. SQ.FT. PAID
U 0 (hereby affirm that them is o c.omusrion lending agency lir the performance of arc Remimis
Da f+ the work for which this permit is issued(See 3II4/,Civ.C.)
0 U Lender's Name
TOTAL:
LA Lendcr' Addl -
ly I certifyyl that 1 have read this application and ding that the shove information reforms is BUILDING F E
y building agree mcomply
and withal]city and county
ntativsofthid site laws QTY. MECHANICAL PERMIT PEE
building Formed,herebyinspectiorizerposcs.ntmivee of this city menterupon tM1a SEISMIC FExO
abovcme e).9 J propene for inspection purposes.
(We)egrt<msave.indemnify and keep harml<anhe City of Cupcnino against PERMIT ISSUANCE ELECTRIC FE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD I'O MECH. -
in consequence.1 the gremlin,of this parm, PLUMBING PELrt
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(TO IO.fIfNl CFM)
SOURCE REGULATIONS. MECHANICAL FE
AIR HANDLING UNIT(OVER 1,000 CFM) CONSTRUCTIONTA
Signaturco(Applicent/Contmctor Dam EXHAUST HOLD(W/DUCT) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURIi
Will theappiiemao,future huilding occupant smre or handle hazmdous material HEATING UNIT(TO 100,000 BTUj
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'I HEATING UNIT(OVER 100,00(1 BTI) ��ss
El Vic, El No aV .
VENTILATION BAN(SINGLE RESID) PAID
Dam Rpt#
VIII the applicant ear furore building occupant use equipment or devices which BOILER
earn[ (311'OR 000,(000 BTU) (('�
emit hazardous air communities unarts as dcGred by the Bay Area Air Quality Management, B e�A TOTAL:
District? BOILER-COMP(OVER 100,000 BTO).
r EJ Yes ❑No
Vr
Iluve and the hvuNotu materials reyuiremenls order Chapter 6.95 of We Cali- AIR CONDITIONER p (SSU
(.rota Health&Safety Code,Smtions 25505,25573 anti]SSJ4.1 understand that if the C
huilAing does not currently have amnum,that it ismyrexpnmihilitymnotify the wcupunt NEW RESIDENTIAL MECH. SQ.FT. h�
of the myvirements which must be met prior Io issuance of a Certificate mOseupancy.
Owner ear outhonzed agent Dmc A ISSUED IIY,
OFFICE