29995 ,APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - \
CITY OF CUPERTINO BUILDING-ELECTRICALPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT - 'PLUMBING-MECHANICAL 29995 n 9 9 5
BUILDING PROJECT IDP,NTIFICA'I'ION J
�ILDING ADDRESS: � SANITARY NO. APPLICATION SUBMITTAL DATE
'v1 �b
OWNI3N'S. ::� PHONE.: CONTRACTON'S LICNO:'
' NIC � CONTROL)
.�ARCHITECTaNGINEER: LIC NO: kDDRESS: ❑
CONTACT: PHONE: ,. - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONIl2ACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 h by alarm that I am heensed under Pm�cions of Chapter9,(commencing J08 DESCRIPTION
'CZ
'Co with Seco 7")of Division 3 of the Business and Profession. PERMITand my license is TI
PERMISSUANCE'
Fly in full tome and ellen. r "OWL' ❑KITCHEN REMODEL
s<UF License Class Lich
6z V APPLIANCES-RF.SIDIiNTIAL ADDIT70N El PLUMBING RE PIPE
yQ 0r Datc r Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURALZ p on Z I nderstand my plans shall be used as public records - PANELS MODIFICATION
OZ—O UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F.re'.Eq-Iy LimnscJ Professinwl . 201-1000AMPS' 1MPROVEMENI'
OWNER-BUILDER DECLARATION
C X2,J - OVER IINOAMPS ❑BATH REMODEUREPAIR El DEMOLITION:
C ad Q 1 hereby affirm that 1 am exempt from the Conmanor's License Law for the
W C LL F following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
y which requires.a p,r t t consumer, It P d fish pa nY:w<wm -
Epp'�OQ priers its.suance,also requiresthapplicant l h pronels The a signedstatement SPECIAL CIRCUIT/MISC. '
21 y'a Nat he is licensed paninim to the p .,min fThe Comment,License Law(Chapter 9
I+I00 (commencing with Section]WO)ofDivision 3of[tic Business and PrefcxsionsCWej or TEMP,METER OR POLE INST. COMMERCIAL:
0.a e C that he is exempt therefrom ani the basis for the.[[aged exemption.Any violins of ❑NEW BLDG/ADI)MON ❑DEMOLITION
�m Section 7031.5 by any applicant for a permit suhjects the applicant to a civil Penalty of POWER DEVICES []TENANT ❑FOODSERVICE
not marc than five hurdrcd dollars($5111).
`ZY IMPROVEMENT -
SQ ❑Lasework,the progeny,or myemployeeswith wages rdforstheir
(Sec.eom.Businesson, SWIMMING POOL ELECTRIC
will Bothe cams,and thrumucturneCont is not intended La does
rsale(ply to an
El OTHER
i 3 m and Professions Code:The improve,
ticmr's Licence law does not apply to an°caner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such rink himself or through
his own ovvcvccimployces.provided f m such mentis old w me nm intended o pletiod for NEW NLSIUENTIACELECTR SQ FII sale.If.howeveq the building of improvement is sold within one year of completion.the SQ.FC FLOOR AREA $ISQ.F1'.
pocr-builder will have the burden of proving that he did not build or improve for par- 2
eof sole,. V 3 03 V
❑ L icio.rnr of the Property,,a.l c hn...and
ti t ci ng C l )licensedroutineurs t
om, nh pc,,,,,pply to a nowner of dl f: nril&o )Th C to ors Li
cancel d supply roan with
ofpropertyh buildsimprovesC coctors QTY PLUMBING PERMIT FEE
whocountersf such pmjtta wiN ucontmct contractors) sal pu n NCC Contractor
License LawPERMITISSUAN -
❑ InmrsacxemptunJarSa. ,H&PCT«Nisrcurou `x
Owner DateALTER-DRAT ,7 WATER RA) VALUATION
WORKER'S COMPENSATION DECLARATION BACKFLOW KROT- 'DF\ [v, Q
1 hereby affirm under penalty of perjury one of the following drelatIf...
I have and will maintain a CeriOcate of Consent ttieelf-insum for Worker's Carer.- DRAINS-FLOG. DOB D_, - STORIES TYPE CONSTRUC'f10N
savor,as provided for by Section 37W of the Labor Code,for the performance of the .mss,
work for which this Permit is i...af FIXTURES-PERTRA ` ,
❑I have and will maintain Workers Compensation lnsumnce,as required M1y Section /A
3]o0 of the La r he performance oIN work for which this permit is issued. GAS-EA.SYSTEM-I INCA LRS OCCGROUP,. ® )g APN
My Worker's Tnsumncecar mor Pnllcy am°herar, - L
/ Carrier ,he,No GAS-EA.SYSTEM-OVER4(HA). I�
CP 1 OFE%EMPIION FROM WORKERS' V
COMPENSATION INSURANCE- GREAS[IINDUSTRI WAS NTGRCEP O o BUIL G ION FEES
(This sec tied not be mmdendifthe)antis is forms,hundred dollars S 100) - - N"/f�'or le,Q GRE.ASE'I RAP PLANCHFCK PeI3//r.
1 certifyiht in the padinno.tnccofth work for which 116,p t.':.mad,[,hall SEWER-SANITARY-STORM OPT. �rT
not employ any Parton in any manner ao as i bee me auct,in the Workers Compes- ENERGY FEE
C) Z station laws of Califomia.Dam WATER HEATER WNFNI' GRADING FEE
Z O Applicant -
H y NOTICE TO APPLICANT.if.ufrcr making Nis Camficma of Exemption,you should WATER SYSTEMTRHA'I'IN
(~ ; become subject m the Worker's Cuntpenermor provisions of the Lubmr Gde,you must SOILS THE
Wforthwith comply with such previsions or this permit shallh JeemM revoked. WATER SERVICE ,
jz CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL PLMB. SQ.F PAID Dae Receipts
U 0 l herebyaRinn the there is a construction lending agency for the performance of ,
the work for which this permit is issued(Sec 304],Civ.G.)
0P. U Lender's Name /mss) TOTAL:
[U Lendae,Address T 1 -1 BUILDING FEE
1 certify that 1 have read this ppl' t d state that the above mormatme is
F.� cmm r i agree t - ply with all chy and emenyommance,andais laws re to ng m QTY MECHANICAL PERMIT FEE
UZ build'rg consuuclim and heraby rmImr,co,,o,,camdor,mI his ritymeme,upon Ne SEISMIC PEE 7
above-mentioned pmpeny for insPectim te,,cs. PERMIT'ISSUANCE ELECTRIC FEE 2 I d
(Way agree to save;indemnify and keep harmless Ne City of Cupertino agaimi
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
PLUMBING FEE
- nxuyucnce of lhr• coming of his Pettit. -
f APPI-ICANT U ' STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING IINII'(I'O IB,IXNI CFM) MECHANICALFEE C
SO] RC IO'S.
10 AIR HANDLING UNIT(OVER 10,000 CFM7 CONSTRUCTIONTAX
Signmurco 'nnVCon¢ncot Ilm, ❑XHAUti'I'HOOD(W/DUCT') HOUSING MITIGATION PEH LJF
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupants mare or handle harsrd°us..coal HEATING UNIT(TO 101.000 BTUI
as def nal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety t
Code.Section 25532(.)7 HEATING UNIT(OVER 100.001I1 BTU)
Yes Fl No
tVENTILATION PAN(SINGLE RES[D) PAID Date Re.qu#
Will the applicant or anra building occupant use equipment nr devices which
•emit hazvdnue air contaminants as dcOnN by the Bay Areaa Air r Qualitity Management BOILER-COMP(3HP OR 100,000 BTU) i TOTAL:
District! BOILER-COOP(OVER 100,IX0 BTU)
❑Yes Fl No ••
I have mail the hvodous matends'requi¢mens under Chapterti95 of the Cali- AIR CONDITIONER ISSUANCE DATE '
forms Health&Safety Cods,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does nm curremly have a tenant,that it is my responsibility m notify the occupant i
of Thu reyulmmen6 which mus be met prior m Issuance of u Curti liente of Oo.,asey.'
Owner or audtunud age. - Datewrzma
il ,SUED BY:
OFFICE