29207 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY . 11 '
CITY OF CUPERTINO. 1, - BUILDING-ELECTRICAL PERMIT NO,I
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL - :292,07
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NA P CONTRACI ''ONAME: LIC NO:
Io �
(_to Z NIC CONTROL IT
tq�dkcRCHITECT/ENGINRER: - LIC NO: I ADDRESS:
.o u°11 a UroCaF
CONTACT: - PHONE: BUILDING PERMIT INFO
" ❑ COmmitant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑
LICENSED CONTRACTOR'S DECLARATION E:1 Ell
ELECTRIC PERMIT FEE
1 hereby affirm Net I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
1,000 ZO with Section]I10(1)nf pivision3pf rhe Business and Professions Cotle,and mylicense is PERMIT ISSUANCE RESIDENTIAL,
F .. in fall force and effect. ❑KITCHEN REMODEL
F ❑SFDWL' '
�U Date Cluss Contract.,
n
(J APPLIANC&S-RESIDENTIAL
�a7a Date Comment, � ❑ADDD70N [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION
F,O vi 1 ` )t A i' [I MULTI-UNIT S IFIC
X O�„Z. I undersand my plans shall be records used as public cos ` V`V
OZ _ _ UPT02MAMP5 MODIFICATION
W Licensed Professional
11 INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-IMgAMPS IMPROVEMENT
I hereby affirm That 1 on exempt from the Cmusucma's License Law franc OVER IOMAMPS ❑BATH REMODEL/REPAIR LlDE..h�TION,1
O S U following reason.(Section 7031.5:Business and Professions Cade:Any city or enemy SIGNS ELECTRICAL ❑OTHER J 1. _ • '_ -,
F O yFa qZa which bottomsires it permit m consrotor,alter,improve,demolish er repair any structure _ _ ` 1_ ",ti.i pdomits issuance,also reyuires the applicant for such permino filen signed smtemem SPECIAL CIRCUIT/MISC.
W a tbut he is licensed pursuant to meprovisions of the Canlraclpis License Law(Chapmr9
O (commencing with Section 7")of Division 3 ofthe Businesswel Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
6 Oo OE that he is exempt Therefrom and The basis for the alleged exemption.Any violation of [_1 NEW BLDG/ADDITION [I DEMOLITION
4' Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
yyyy no
more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
60 1,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC„ IMPROVEMENT
will do the weak,and the woretufe is not intended proffered for sale(Sec.7044,Business ❑OTHER
G and Professions Code:The Conbbean s License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.r pmperty who build.,or improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTS, SQ ET.
-
sale.If.however,the building or improvement is sold within one year mcompletiun,the SQ.Na13FI,QO)AREA $/SQ:FT.
owner-builder will have The burden of proving that he did not build or improve for our- M
pose of sale.). I _ -
❑ I,as owner of the property,am exclusively contrasting with licensed contractors to TO O
construct the protect(Site.7044,Business and Professions Code:)no Contractors Li- q��
cense Law does not apply to an owner of property who builds or improves thereon,and QTPL
Y. UMBING PERMIT FE t a� 6
who contracts for such projects with a contractors)licensed pursuant 0 the Contmctprsiti,
License Law. PERMIT ISSUANCE Uf
❑
I em exempt under Sec. ,B&P C fonhix reason
Owner pate ALTER-DRAIN&VENT-WATER(EA) VALUATTON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penaltyof perjury one of the following declarations:
❑Ihave and will maintain a Conficate of Consent to self-inure torworker'.s Cuia'a- DRAINS-FLOOR,ROOF,AREA,COND. STORMS TYPE CONSTRUCTION
cation,as Provided for by Section 37M of the Labor Code,for me performance of the -
werkfar which this petntitisissued, FIXTURES-PER TRAP
1 have and will maintain Worker's Compenution Insurance,as required by Section
37W of to Labor Code,for the Performance of the work for which this permh is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
M olow's Compensation Inumnce carrier end Policy number ape:
Policy N., GAS-EA.SYSTEM-OVER4(EA)' '
CERTIFICATEOF EXEMPTION FROM WORKERS' y
COMPENSATION INSURANCEGREASEIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thlssection coolant lobo mpletedHite permit is fmonehuddred dall.w($]M7 GREASE TRAP
or lonsJ PLANCHECK FEE
Loy ,thmiiitheperfomtance xwo,the as to live
fnr which itis permit iei ,IshallpSn- SEWER-SANITARY-STORM EA.200 PT.
net employ y personin.y manner su a'to bac m subject m the ars'Compen- ENERGY FEE
laws. to WATER HEATER WNENVELECfR
`�!y ppliowt GRADING FEE
TICETO AP (CANT:If,after making this Certificate of Exemption,you should WATER SYSTEM(FREATING a SOILS FEE become subject m the Worker's Compensation provisions of the,Labor Code,you must
LiI forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE -
Q
F� z
CONSTRUCTION LENDING AGENCY NEWRESIDENTIAL PLMB. SQ.FT. PAID
U 0 I hereby affirm that hem is a construction lending agency forte performance of Date Receipt
The work for which this permit is ismed(Sea.3097,Civ.C.)
• 0 U lander',Name / TOTAL:
W Lender's Address ., TOTAL:
a I certify that I have read this application and sate that the above information is BUILDING ME
V) comet.I agree to comply with all city and beauty ordinances and sa.laws relating t. QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize reprosenatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes., PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify cod keep harmless the City or Cupertino egainsl
Iiabilities,judgmenrs,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.P NT AIR HANDLING UNIT TO IO."CEM) MECHANICAL FEE
S CE EG 'ATIONI.
AIR HANDLING UNIT(OVER I0,M)CFM) - CONSTRUCTION TAX
Signame of AppllcanVConaactur Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accepted some.,handle hazardous mmeral HEATING UNIT(M IOOA00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)Y _ HEATING UNIT(OVER 100,000 BTU) - -
❑Yes E]No VENTILATION FAN(SINGLE RESID) PAID
Will the a Iicaw or future buildia t use t or devices which Date Receipt It
pp dby the
sal Air n BOILER-COMETIRE OR 100,000 BTU)
�Or hazalloue air contaminants ate defined by the Bey Area Air Quality Management
Disvict9 ❑Na
❑YesBOILER-COME(OVER 100,000 BTU)
' -
I have read me hazardous materiame
ls requirents under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE . ,
humin Health&Safety Cole,Sections 25505,2533 and 25534.1 understand that if me NEW RESIDENTIAL MECH. SQ.FT.
1 building does not cutaway have a tenant,that it is my responsibility to notify the occupant "
Tim the requirements which must be met prior in issuance of a Cmffln w of Occupancy. "
Owner or authorized agent - Date TOTAL: 'ISSUED BY: ✓ • '�
OFFICE