29296 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. ^�•S ^A
BUILDING DIVISION APPLICATIOWPERMIT PLUMBING-NIECIIANICAL 9
L6 L,9 L
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI'.
Z-Z-�16
NF. :S NAME: a(� � P IONF CI'OR'S NAME: LI No
/rIy 9-061 NI❑C CONTROL.#
ARCHITCCT'IGNGINIi13R: LIC NO: ,IIIIRESS
otfm
,i ; I
CONTACT. PHONE: BUILDING PERMIT INFO
/ ❑ Consultant Fees Paid by Applicant(Initial) pLD4 EL PLUM ME
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 'L4L�
1 hereby a�rn that I am licensed under provisions of Chapter 9(consmencing JOB DESCRIPTION
PLZ with Section 71100)of Division 3 ofthe Business and Professions Code,and my license i. RESIDENTIAL'
00 PERMIT ISSUANCE
ar in full farce and effect. n
g6 U V License Clas Lic.a 6—Y _ - ❑SFDWL ❑KITCHEN REMODEL.
FnZW Date Commemr APPLIANCES-RISIDIiNTIAL DITION ❑PLUMBING RE-PIPE
F.Dw HITE-M'S IIECLARATION PANELS MULTI-UNIT []STRUCTURAL
landemtand my plum use] a oblic records �, MODIFICATION
OZ O UP TO Z(10 AMPS ❑INTERIORy r (''g El CHIMNEY REPAIR
F Licensed l'rofew - 201-1000AMPS IMPROVEMPNf+d,
�bd OWNER-exempt?N DECthe RXI]ONCmandua OVER 10110AMPS
G K� 1 hereby alarm that 1 am exempt from the Commetor's License Law for the I Rat),�OOEIIRC•PAIN �DEMOLITION
RI LLOAU following reason.(Seed''7031.5,Business and Pzofesaions Cade:Any city or county SIGNS ELECTRICAL ❑OT El�j 4 n
AO F' which requires a permit m construct akar,improve,demolish,or repair any dricund rf
prior,,it.issuance,ahorequir..the applicant hnach Perini,to fileasiXtedaunemem SPECIAL CIRCUIT/MISC. yr E3
N that he is license]pussuum to the provisions Lf'-
of the Confirm,',License Law(Chapter 9
p0 (commencing with SelionlMllofUivisionlofthe Business and Professi,,ns Code)or TEMP.METER OR POLE INST. COMMERCIAL-(IV
Aqi5 z that he is exempt therefrom and the basis for the alleged exemption.Any Antonio of NEW BLDG/AUDITION ❑DEMOLITION
W�H 111ion1031.5 byanyapplicantforapermitsubjectstheopplican,loacivil peoultyaf POWER DEVICES ❑TENANT ❑FOOD SERVICE
ZZ y Q ret mora than rive hundred dollars(5500).Ol,osownerof the Poprny,or my employees with v,.as theirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
situation,do the work,and the situcis not intended or offered for sale(Sec.71W.Business ❑OTHER
A and Professions Code:'Do,Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-Fl%TURES
r property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,Ne building or impmvemmat is sold within one year ofcompletion,the - SQ.PT.FLOORAREA mq Ff.
rdmid
ownefisdacr will have the burden of proving that he did not build or intpnsvc for pury
Fine J
\
p
e . UY
O 1,as owner of the property,an exclusively contracting with licensed commands as
construct he project(Sec.2044,Business and Profession.Cede:)The Cammnor's Li-
cense Low does not apply in on owner fit prignity who builds or impwvc%thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed puramnn,,the Contractor's
Lavine Law. PERMIT ISSUANCE
l am exempt under Sec ,B&P C for this reason
Owner
ALTER-DRAIN&VCM'-WATER(EA) VALUATION
Date /—
WORKER'S COMPENSATION DfiCLARATION BACK PLOW PROTECT.DEVICE
I hereby affirm under pntnhy of Perjury one of the following Jedurutinns: LA31q_LQst`t`
(have wit will maintain nCertifeme ol'Cnnsennn adGinsore for Worker.Cnmpen- DRAINS-FLOOR,ROOF,AR G,COND, STORIES TYPECON UCTION
initial.1.as provided for by Sermon 3700 of the Labor Code,for the performance N doe
work for which this permit is issued FIXTURES-PER TRAP
O I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Cale,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM.I I NC.4 OUTLETS OCC.CNWP ANN
My Work ed,,CorpPe tion lfinance currier and Policy number are'
/- Cartier: Se'l ns• Policy par, GAS-EA.SYSTEM-OVER rCERT'IFICATE OF EXEMPTION FROM WFOA0 Jig
COMPENSATION INSURANCE GREASI%INUUSTRL WASTE INTERCEPTOR
('this section need nm he comple ad ifthe permit isforceforced,hundred dollar;IS I W), BI/TIDING DIVISION FEES
carless] GREASHT'RAP
I'LANCHF.CK PCE
I ttnily that in the performance of the work for whi<Mhis permit is lssueJ,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in tiny manner so as to become subject m the Worldim Compen- ENERGY FEE
,Z sation Ltwsof California.Date
WATER HEATER WNENT/ELEMR
pis A-0
O Applicant GRADING1.13
:C
FN-t NOTICE TO APPLICANT:If,after ranking this provisions
ncum of h Exemption,you should WgTlik SYSTEMf1'RCATING
a become inhjcet m the Worker's runt,,,,this anis hal of the Labor Cock,. must SOILS FE
foMwith comply with such provisions nr this permit shall be Deemed rcvN:eJ. WATER SERVICE
Uj
0
UO CONSTRUCTION is.co mans.leading
AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID O
Iforv,holfrm thatthere30 len ding agency for the performanceof Tote Be
W U the work for which thi.permit is issued(Sec.309],Civ.CJ
p U Lenders Name TOTAL:
yWLI
' Lenders AJJreas
[-. M. 1 certify that I have read this application and nam that the above information is BUILDING FIs
UrA correct l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V building condraction.and hereby authorize representatives of this citym enter upon the SEISMIC PE/
abovcmmitionW prnpcny fur Inspection purpose,.
Wo)agree to save,indemnify and keep harmless the City of Capetian rivamt PERMIT ISSUANCE ELECTRIC TH G.
liabilities,judgments,costs and expenses which may in any way oceme against said City ALTER OR ADD TO MECH.
in mnaequrdce of the granting of this permitPLUMBRJIT FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CFM)
SOU P.REC JLATIONS. 1 MECHAIIICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONST UCTION TAX
Signatitic of ApplicenJCmmmcmr Dare EXHAUST GOOD(W/DUCT) HOUSI ITIGATION FEE
HAZARDOUS MATERI IeTISCLOSURE
Will theappli...I,,,future building oeupia smmor handle hazurdoes material HEATING UNIT(TO 100.010 BTU)
as defined by the Cupertino Municipal Code, a er 9.12,and the lien0h unit Safety
Code,Section Z5532od) HEATING UNIT(OVER 1(x1,00)BTIJ)
E3 Yes ON. VENTILATION FAN(SINGLE RES ID) PAID
Wi 11 thea applicant or future building cu 11 ptg
pp gte panty Acca Air
Management
801LER-COMPJHPOR 100,000RTU)
emit haznNnus air cmmaminnnts as delincJ by the Bay Arco Air.Quullty Management
DindcYl
❑Yes ❑No BOILCR-COMP(OVCR I00,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.I understand that tithe NEW RESIDENTIAL MF.CH. SQ.FT.
building Does urn eumnOy lmva a mmun6 that it is my tespnnsilinq tat daily th ssaimpam
of the requirements which must he met prior to issuance of a Ceniffcate of Occupancy.
Owner or authorized agent Data AL: ISSUEDBY:
OFFICE