29955 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.FILEL7PRICAL - PERMITNO.
BUILDING DIVISION -.APPLICATION/PERMIT PLUMBING.MECHANICAL 29955
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: r. 7 - SANITARY NO. APPLICATION SUBMITTAL DATE
l vPl OJ�p �j 3-(°
OW 'S NAA1 is PHONr� CONTRAZOR'S NAME. LIC NO:
e 1 C i r 9N/ zc�' c t F3a NIC CONTROL 0
�ARCHI ti NEER: LIC NO: ADDRESS ❑ `/TC`�'�* At Liii,
Viiii1f 8j- t a ! S, ,j u I s 117-0-S /�
CO CT;' N` q/ BUILDING PERMIT INFO
WP/7- �3[3 ❑ Consultant Fees Paid by Applicant(Initial) EL GC PLUMB MUCH
Q Al -
LICENSEDCONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm Nm I-am I ensed under provisions Of Chapter 9(commencing JOB DESCRIPTION
O"'Z with 5 , ]6X)effect.
J 1(h itusi suit f,csiore Cude,and rayl unsc is
OO PERMIT ISSUANCE RESIDENTIAL
In full force.J llcct.
y.W F- - DWL ❑KITCHEN REMODEL
.it License Class Li0.N APPLIANCES-RESIDEN'T'IAL ADDITION ❑PLUMBING RE-PIPE
on Q i Dote Conwmor
'D,n ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ' [I STRUCTURAL -
Z O m Z 1 understand my plans shall be used as public records MODIFICATION
AZ4-0 UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
rF En t:W Licensed Professional 201-1(XX)AMPS IMPROVEMENT -
Y
••1 (IWNER-BUILDER DECLARA'T'ION OVER IINNIAMPS [I BALL REMODI AFFAIRDEMOLITION
K s I.hereby.affum that 1 am exempt train the Contractors License Law for the
3 ED LL F following reason.(Section 7031.5,Business and Professions Gae:Any city or county SIGNS ELECTRICAL ❑OTHER
W which requires u permit m connect,alter,improve,demolish,or repair any structure
O� prior,.its i...ance.al.s.Ier,ires the applicant for such permino file asignedsmomcm SPECIAL CIRCUITM ISC s
y} that heis licensed pursuant pvinionsofthe Conlrtses License Law(Chaprer9
W Cp0 tlro .eIcommencingwith Section.7").fDivision 3ofthe Business and Prnfiv,ions Coat)ar TEMP.METBR OR POLE INST. COMMIERCIAL
tly�(e C IM1m he is cxunpt therefrom and the hasis liar the allegcdexemption.Any violation of NEW BLDG/ADDITION [I DEMOLITION
Section 7031.5 by toy ip,licart for.permit subjects the u,phe rr to a civil penally of POWER DEVICES
t more than frvc hundred dollars(551X6. ❑TENANT ❑FOODSERVICE
FZY nO - IMPROVEMENT
f20 C]Lazowncrnf the propcny,or my cmpinyces with wage.as their sole compensation. SWIMMINGPOOLF,LECTRIC ❑OTHER
F will do the w.k.mnd the structure is not intended oroRered for sale(Sec.]01a.Business
6)-m and Professions Code:The Comeachi License law docs not apply'to an owner of OUTLETS-SWITCHES-FIXTURES
�'3 property who builds or improves,herenn,and who does such work himself or through
his own employees,provided that such improvements are not intended Or Offered Etc NEW RESIDENTIAL ELECTR SQ FT.
sale.ILlowevcq the building orusprovenent is sold within oncycarofecomiction,the SQ.PT PLOOR ARE
owner builder will have the burden of proving that he did not build or improve for par 18 O F 0 ISIS^r�I� �O�S lO�
Arse f I )
I, < f the pmpeny.am exclusivelycontracting with licensed conn m
roost ct the project(Sce,7 1 Business and Profession,Code)The Contractor's Li- �`�N1
2 Z4
cense La does nor apply to fp pony h builds. p thrzon d Ql'Y. PLUMBING PERMIT FEE 7 (—
who tracts lm such pimects with a contractions)licensed pursuant to are Contractor'.i
License L' FERMI I'ISSUANCE -7z
❑1 am excerpt On ,B& C!t ' 1
AI,T13R-DRAIN VF,NT-WA . IEA) VALUATION'
U .
won,- c l S COMPENSATION DECLAR, Ot BACKFLOW OTECT.DEVICE 0-Z -7 T4' JS ^
I heathy off der penalty Of perjury one d he following declarations: J V `�
FIHimeandwill Iain aCeniticmc of Cunsemm self-insum for Worker's Compcn- DRAINS- O ROOF.AREA.COND.
STORKS TYPE CONSTRUCTION( ratip
on,os rovided ction J]Ip of the LvMr Cixlc
or by Se ,for the pufoOnancc of the
work for
have
Ods permit is ark,. m PIXTUR,. -PER" 'El " I
1 have and will nate,for Workers ante oldie w hasrkf for which
an nes, by issued.
My Workerfthe LCC Gde,fonlhsurance cruncofthewlic harder
this permit is issued, GAS-PA.5 TEM-11 LETS OCC GROUP APN
My Worker's Compensation Insurance canter and Policy number ale:
Carrier: Policy No.: GAS-EA. �1'E V[R1
CERTIFICATE OF EXEMPTION MOM WOR KERS'
COMPENSATION INSURANCE 'RE
ND U.T >RCEPTOR BUILDING DIVISION FF:F,S '
(Thi.sctli.n neednolbewmplcted iflc,surnal is lin One modredd.11in,SH)Y) ORBASE'iltAP
or Ir".) PLANCHECK FEE
Icerify that inlheperforrnvnecof the work for which this Perini(is tooted,l shall SEWER-SANITARY-STORK FE
not employ any person in any manner tit as to become subject to the Workeri Cumpem BNERGY FEE r'
ZZ sa(ion loos of California.Date WATER HEATER W/VF,NTH31.ECM p
2 Applicant GRADING FEF.,•' I'
py NOTICE TO APPLICANT:If,after making this Cenific de of Exemption,you should WATER SYSTEMCIREATING
F' ^
become subject nt the Work Coni,ponsation provisions(if Ih Labor Com,ybu muco SOILS FEE
fordhosith enrol,win such l sonh Permit shall beJ d tkcd WAI HE SERVICE I -
5Z CONSTRUCTION LENDING AGENCY - NEN RESIDENTIAL P10B. SQ.FT. PAHn/sf Dae Receipil�
U Thereby vffrm(hetN unarm t 1 d' ghgcncyf rthe performance of L. �(r,., -
Lenders
e work for which this pewit is issuW(Sec.a09],Civ.Cd I
u^ F s 4/IQOTAL:
QName
U fenders t
aI<nder' t
I remy certify that 1 have read This application and.crate that the above information is 1 Hl11LU1NG FEE
.Fat W cmiI gam mcomply wolidl citymid cimmyoidicurne,vnd,fuel.wa mlainglo QTY. MECHANICAL PERMIT .FEE O
U Z building construction.and hereby suthorls representatives of This city to enter main the I SEISMIC FEB,
obove-mentionW property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against 1 L
liabilities,judgments.costs and expenses which may many way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in ^�
asequence Of the granting of this permit. L
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT G`0 I0.00o CFM) 1
SOURCE REGULATIONS. MECHANICAL FEE L
AIR HANDLING UNI'T(OVER 10,000 CFM) CONSTRULTION'1'AS
Si...aceaf AppliciartAmwcmr - Did EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Kill the applicant or future building occupam store or handle hazandous material HEATING UNIT(TO 100.000 BTU) '
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Gds,Section 25532(a)'I ' HEATING UNIT(OVER 100,000 BTU)
❑Yes NO VEN'I']LAI'ION FANS INGLE RESID) PAID
Will d¢aPplican(or from building occoPant use equipment s devices which Uate Receipt N
J�emi,havWoa,air conmminanmaz defined by the Bay Amo Air Quality Managenmot BOILER-COMP(3HPOR IW,BIIO BTU) TOTAL.
r
District, BOILER-COMP(OVER 100.000 BTU)
f C3 U, LINO
I have reeAlhe hvardous m:nen..,requirements under Chapter 595 of the Call- AIRCONDITIONER ISSUANCE DATE.
fomia Health&Safety Code,Sections 255015,•25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.ET. '
building does not currently have a tenant,thus it is my responsibility m notify the occuplm
of the ralWmments which mast be mel prior to remains,of a Cedificale Of Occupancy. T
Owner or authorittd agent Date - T V bt ISSUED By:
OFFICE