29368 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO, 2 9^ ^ 8
BUILDING DIVISION CATION/PERb1IT PLUMBING-MECHANICAL. L 4J JK hV�XJ
BUILDING'PROJECT'IDENTIF'ICA'f10N
BUILDING ADDRESS: /�y� - SANITARY NO, APPLICATION SUBMITTAL DATI
1 ►ar% r t.,o n -C J4-t 3156
O N 'S TAME: PHONE: CONTRACTOR'S NAME: LIEN
O C NIC CONTROL If
ARCHHECf/ENGINEER: LIC NO: ADDRESS:
CONTACT: /�,�,o� - PHONE: BUILDING PERMIT INFO
lee (Jer �0 0S`9D6/ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB SUCH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE yl batch,storm and I am licensed under provision,of Chapter 9(commencing JOB DESCRIPTION
Od'Z with Section 7")ofDivision 3ofthe Business and Pmfessiore Cde,and my license is
00all y PERMIT ISSUANCE REMIDENTIAI.:
awl= L ane Class and attar. ❑SFDWL El KITCHEN REMODEL'
<Vk� License Clau Lic.p
�<y Dam Contractor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
Dm ARCHITECTS DECLA RATION DMULTl-UNIT DSTRUCFURAL
Z �Z I understand ersnd my plans shall he used public records s MODIFICATION
OZ-, UPTO200AMPS El INTERIOR DCHIMNEYREPAIR
r Lmcnsed PmfessionulOWNE- 2(11-1000AMPS IMPROVEMENT
•�•� J that I a exempt
DECLARATION A ST
C�� I hereby affirm that I hat emmpt font the Connector's License Law for the OVER 11100 AMPS El BATH RF.MODEVREPAIR'b DEMOLITION
3 d V following auson.(Section 7031.5.Business and Professions Code:Any city or countyC D OTHER
Which mutant.a Permit to em swct,alter. ,int rovedemolish,or rt SIGNS ELECTRICAL
qu' p pair any structure
pnonnits,suunce,alsofequim,the.pplicunt for such permit to rile a signed statement SPECIAL CIRCUIT/MISC. APR 16
pN.
that he is licensed# avant to the provisian,of the Conwcmrs Licenu Law(Chapter 9
OHO (commencing with Seninn]000)of0ivision 3ofthe Business and Professions Cattle, TEMP.MEIER OR POLE INST, COMMERCIAL'
Nat he is exempt therefrom and the nasi,Ibr the Began exemption.Any violation of - ❑NEW BLDG/AUDITION V kO DEMOLITION
Serrano 1011 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
Z} t mom than five hundred dollars($50% -]TENANT DFOODSERVICE
C� Ll 1,as owner of the property.or my employees with wages as theirsolecmnpenwtion, SWIMMING POOL ELECTRIC IMPROVEMENT
willdathe"ek,and the stmnure is not mundcdoraRmd far.]a(Sec.70l4,Business ObOTHER
S3 and Professions Code:The Comment's License Low docs not apply In an coma,of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECfR SQ PT.
snle.If,howevee the building or improvement is sold wrou n one yearn(nnnpletimi the - SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pm-
pose of soled. �, // D a.r[.
co Las owner of the property,am.Business
contracting with licensed contractors to TOTAL:: /r//�/
rnnstrvct the projat(See.]614,Business and Professions Code:)The Canwaors Li-
cuseLawdoesnotapplynanownerofpropenywhobuildsnrimpmveatheneon.and QTY, PLUMBING PERMIT FEE 3yG
whncuatrects for tech projects wird uwnwemr(s)IicenuJ pursuant to the Commcmr's OO (f/
License law.exPERMIT ISSUANCE
lam exempt under Sec. ,B&PC for this reason '
Owner VALUATION
WORKER'S COMPENSATION DECLARATION ALTER-DRAIN&VENT-WATER(RA) AL
BACK MOW PROTECT.DENIER S
1 hereby affirm under peoahY of perjury ane of the fallowing declarations:Co
❑Ihave aro Provided
for
maintain 37M of Ce eent 1.Labor ode,for
fin-Worker's ce of the
DRAINS-FLOOR,ROOF ARF.A,COND. STORIES TYPECONSTRUCTION
normo,as provided for mi Section 37 W of the Labor Code,for the performance of the t
work for ad Nisperrtutis issued. FIXTURES-PER TRAP
I have and will are.for Worker's Counts,rethe w rk for hi h required by Sation
3700 of Ne Labor Cde.far he performance of the work for which this permit is issud. GAS-FA.SYS'fEM-I INC.4OUTLETS OCC.GROUP APN
My Curter: pan sit-�pCanytgc�¢POIdy Policy number 4rg,9�'0q GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE ORP[EXEh1PT10N FROM iWORKERS'
COMPENSATION INSURANCE GREASPANDUSTRL WASTE INTERCEPTOR
(Thin section meet not beenmplemJ if thepermit is I'orona hundred dollars BUIhBUILDINGDIVISION FEES
t$W7
or less.) GREASETRAP PLANCHECK FEE a�
I certify that in she performance ofthe Work forwhich this pewit is issued,l shall
not employ an SEWER-SANITARY-STORM EA.200 FT.
p y y Person in any tanner'J uxhe )1�it the Warkcrs'Cumpen- ENERGY FEL
7s wean laws of Celi�foCrg�.Dam ffii 7�•,��j
C)
O A licunt � ��> > WATER HEATER WNENT/ELECfR
pp GRADING FEE
In NOTICETOALIGANT IL after maki this Cmificom of Exemption,you should WATER SYSTENIO"REATING
become subject to the Wurkers Compensation provisions of the Labor Code,you must SOILS FEE
Da fonovith comply with such provisions or this permit shall he deemd revoked. WATER SERVICE
jz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
V 0 l hereby offirm that hem is a cotsnuetion lendingagency for are permoustreof Date Receipt#
w .•. the work for which this permit is issued(See.3097.Civ.C.)
0 f't fender's Name TOTAL:
Lenders Address TOTAL:
fart yt I certify that 1 hove read this application and state that 11.1s,information is BUILDING FEE 114 Vlz
F tq nnrce0lugreemcomply,with all city andcoumy mdinonces and store laws rcbningm QTY, MECHANICAL PERMIT FEE
V z building comwction,and hemby euthonae repmunmtivcs of this city mercer upon the SEISMIC FEE
above-mentioned pmNm,for inspection purpose,. PERMIT ISSUANCE
(We)ugree m save,indemnify and keep hurreless the City of Cupertino against ELECTRIC ME 7
liabilities.jdgments,casts and expenses which may in any way accom against said City ALTER OR ADD TO MECH. PLUMBING FEE 3 yr
in consequence of the granting of this pewit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE e-�
SOURCE REGULATIONS. /73.y1T
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Signature of Applicata Canuactor Data EXHAUST HOOD(W/DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe apPlicant or future building oecupam stmeor handle hazardous munred HEATING UNIT(TO 100,000 BTU)
as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety
Cde,Section 25532(a)7 HEATING UNIT(OVER IW,0IXI BTU)
❑Yes DNo
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building oecepant use equipment or devices which Data Receipt N _
mit hazardous air contaminants as defind by the Bay Area Air Quality Management BOILER-COMP IMP OR 100,000 BTU) O
District? TOT
❑Yes No BOILER-COMP(OVIiR IW,IYJO BTU) .
I have ad the huvtrdnus mutenalsmoments under Chatter 6.95 of the Cali- AIR CONDITIONER
m9 p ISSUANCE DAT
forma Health&Safety Cde, adao 5505,25503 and 25534,1mmd Nat if the NEW RESIDENTIAL MECH. SQ.FT.
building dna mutrently have mmcant,that it i,my resMrnsibility1.mnoaittify the acupmt
of We is whi st be met pdnnoisuuae aft CenjTicgt��cucy/.�
e��••ff b�
Daniel orO or ouN Date TOTAL: ISSUED BY:
OFFICE