29004 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY `
CITY.OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 2 9 O O ag
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL V•! 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNERS NAME: NE: CO RACTORS NAME: LIC NO N/C CONTROL
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RCHITECTENGINEER: _ LIC NO:
r ADDRESS ❑
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oNTACT: PHONE (v BUILDING PERMITINFO
r^ O� �' Zi ❑ Consultant Fees Paid by Applicant(Initial) B1LLDD,G ELECT PLUMB MECH
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LICENSED CONTRACTORS
under p DECLARATION QTY ELECTRIC PERMIT EEE
I M1ereby affirm that 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CCy with Seed.n TIXXBof Divisioo3 of0e Businevs avd Profsaxlon Coda and my licenwis'
�1O r PERMIT ISSUANCE RESIDENTIAL
1yF in full force unJ cffed.n �7 J ❑SFDWL ❑KITCHEN REMODEL
Q V U License CI ass f.)—Lie.k J�
E-zWDate Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
Fpm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT (:)STRUCTURALZ p rzn Z 1 understand my plans shall be used as public records MODIFICATION
OZ— - UP TO 200 AMPS
F 4„1".u0l Licensed Professional ❑INTERIOR ',° [2 CHIMNEY REPAIR
G S.' OWNER-BUILDCR DECLARATION 201-10)(MAMPS IMPROVEMENT
C)C y' I hereby affiro that 1 am exempt from the Contractor's License Law for the OVER II1g1AMP5 ❑BATH REMODEUREPAIR ❑DEMOLITION
�3 LL U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
y which requites a Permit to construct,aher,improve,demolish,or repair any swmum
E"��g prior to its issuance.also requiresthe applievm forsuch pc mainofileasigned smerrom SPECIAL CIRCUITMISC.
�r or that he is licensed pmsuan 1.map versions of the Commerce,License Law(Chapter 9
(commencing with Section 7")of Division.1of the Business and Professions Code)or TEMP.METER OR POLE INST, COMMERCIAL: _
d y m fB that he is exempt therefrom and the hasis for the allege)excmptioa Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
>C 4. Section 701 Ll by any applicant far a Permit subjects the applicant m u civil penalty al' POWER DE ICES
W r�TENANT .❑FOOD SERVICE
f=� not more Nan live hundred dollars(851X). IMPROVEMENT
❑ has owner of Ne properly.or my employees with wages as their tuts compcnsmion, SWIMMING POOL ELECTRIC
p, will dothe work,and the swcmreisnot itnendedoroffered juristic(See 7044,Businen OTHER
it, and Professions Code:The Contractors License law docs nm apply to m owner of OUTLETS-SWITCHES-FIXTURES
�'3 Property who build.,ar improves thereon•and who dee,such work Iumxlf or thnmgh —:WNW
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ ET,
aide.If,howcvee the buildirlimimpmventent i,,.Id withinoncycurof mmplmlon,the SQ.FE FLOOR AREA S/SQ.ET.
poser-builder will love the burden of proving that he did not hand or improve far par- 'JAN 02 1996
x of sale,.. .
h a,owner of the properly,am exclusively contracting with licensed contractors to TOTAL: y 2
consumer the pmjcet(See.TDW.Business and Professions Calc:)The Contractor's m on
Li- CITY
,IT T�/
Li-
cause Law does not apply an owner of proper,who builds or improves there .and QTY. PLUMBING PERMIT FEE COF LUHLHI INO
who contracts for such projects with a contractors)licensed pursuant o the Contmerm's =
License Law. PF,Rh11'1'ISSUANCE
lam exempt undersue, ,B&PCfurthisnaxon -
Owner Uma ALTER-DRAIN&VENT-WATER(E,) VALUATION
WORKER'S COMPENSATION DECLARATION HACK FT.OWPROTECT.DEVICE
I hereby afro under Penalty of perjury one of the following dechr a6.m: OOO�
k I have and will maintain a Certificate of Consenuoself-insum for Workers Conifer.
DRAINS-Fl.00R,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
tion .p 'J J f by S i 3)1X1 f til L bo Cod f r the performince of the
kJ� M1' hiht. permit -issued. FIXTORES-PER TRAP
Q4h�are and will rand a Wnrkors C...ii,crilmim.Insuran.a,ax required by Section `
3700 of the labor Calc.for the perfomtancc of the work for
hich Nis permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
CMy cork 9ynpc _IN Jaau .�A Policy No.ad :(,�-�y� GAS'-EA.SYSTEM-OVER 4(EA)
j CERTIFICATE OF E/X✓EIMPTION FROM WORKERS'
COMPENSAI ION INSURANCE, GREASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Ibis xenon need not be completed il'the permit is for,,.hundred dollars IS lfNq GRF.ASL'T RAP or le"')I PLANCHECK FEE
toy any In.,
Per in the permy mmanrsis the work for subject
bjech tho the Wort is kued.Iers'
h.- SEWER-SANITARY-STORM CA.2W IT.
noiemploy any person in any manncrm asmbecome subjccuothe Worker,'Compcn- ENERGY FF.F;
ZZ satin.laws of California.Dat WATER HEATER W/VENTBiLECTR
Applicant GRADING FEE
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should WATER SYSTEMl1'REATING
M become subj¢r to the Workers Compensation provisions of the labor Code you must SOILS FEE
�r ti• liahwith comply with such pmvisinnsra this pemar,hall be deemed res'okcd. WATER SERVICE
y0
CONSTRUCTION LENLENDING NEW RESIUENTIAI.PLMH, SQ,FT. PAID
lconstructionU O Iheteby of that there is.construction
form
lending agency for the perance of Date ReceiptM
the work for which this permit is issued(Sec.3097:Civ.C.)
U Lenders Name - TOTAL:
O}t W 1<nders Address TOTAL` D•
s� ffl
I certify that 1 have read this applicmion and are Nm the vbase information is BUILDING FEE
fy (i7l correct.l agree to comply with all city i deoumyordinan.msmld,rote laws relmingto QTY. MECHANICAL PERMIT NEE'
U Z building construction.and hereby authorize represenmuscsol'this city toenter upon the - SHISMIC FEE
.Move-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertio nagainst • ELECTRIC FEE
liabilidcs,judgments,costs and expenses which may in any way acemc against said City ALTER OR ADD TO NIECH. PLWIBING FEE
Ow
inconsequence of the graming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLINGUNI'P(OVER 10,000 CFM) CONSTRUCTION TAX
Sigmum,nfApplicaMCamranor Dam EXHAUSTI IOOD(WiTi HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will are aWficam or future building occupant store or handle haamou:material HEATING UNIT GPO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section'l5532m)^ HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No PAID
VF.NTILAI']ON FAN(SINGI.i?kESID) nam ReceiptM
Will)
the applicant m future building occupant use equipment or devices which
t hnzmdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(3HP OR 100JW BTU) TOTAL:
der?
L]yes ❑Na, BOILER-COME(OVER I00,000 BTU)
I have real the hazardous mmcdaLsrequirements under Chapter 6.95crmu Call- AIR CONDITIONER ISSUANCE DATE
board Health&Safety Codc;Seetiamx 25505,2.5533 and 25534,1 understood in.,If the NEW RESIDENTIAL SUCH SQ.FI'.
building does not curemtly have a tenant.Writ it is my responsibility m notify the.wcupant
of the requirements which must IN,met prior to issuance of a Certificate of Occupancy. w .
Owner or amhndaed agent Date TOTAL: ISSUED By _&S
OFFICE