29302 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIZ' OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 0
e BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7S
&I I(K aP.r
OWNS ' AAM` ^ �� PHONE. CO ACf012'SNA E 4%,9133
RIC CONTROL -
RCHITECT/ENGINEER: LIC NO: AUIIESS9'7 a.valL�� Sr El
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION A ❑
1 hereby affirm that 1 am licensed under Providence of Chapter 9(commencing QTY ELECTRIC PERMIT FEE
pl g JOB DESCRIPTION
O0Z with Section 71)(0)of Division the Business and Professions Code,and mylicome is RESIDENTIAL
00 in full force and effect. PERMIT ISSUANCE
RUZU License Class Lica OSFDWL �SKITCHL'N REMODEL
�6� Dem Contractor APPLIANCES-RESIDENTIAL OADDTTION ❑PLUMBING RE-PIPE
�' ARCIEIECI"S DECLARATION - [:1 MULTI El STRUCTURAL
PANELS
Z O e�? 1 undemand my plans shall o axed ns public records MODIFICATION
OZ Q UPTO200AMPS ❑INTERIOR OCHIMNEYREPAIR
C=iq Licensed Profexsimnal 201IIXIf1AMp5 IMPROVEMENT
OWNER-BUILDER exempt
DE CLARATION OVER 10110 AMPS ❑BATH REMODEVREPAIR [I DEMOLITION
C < I rouse affirm she 1 em exempt from the C Profession,
Co License Low for the
ippi5�O,V following reason(Section]D3 t,5,Business and Professions Cnde:Any city nr county SIGNS ELECTRICAL ❑OTHER
w+�LLO E' which requires a Permit to construct,shot,improve,demolish.or repair any structure
prior to its issuance.also requires the applicant for such Permit to rile a signed ammmrnn SPECIAL CIRCUIT/MISC.
thin he islacroad pursuant to the provisionsofthe Gmnmmors License Law(CopmT9
COO (commencing with Section 7")of Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INST. COMMERCIAL:
G cy y C that he is exempt Nerefmm and the basis fee the alleged exemption.Any skeleton.of O NEW BLDG/ADDITION ❑DEMOLITION
Pe W Section 7031.5 uER DEVICES by any applicant for a Permit subjects theapplicane a civil penalty of POW
y nm mine than five hundred dollars El TENANT El FOOD SERVICE
< I,as owner mthe norm IMPROVEMENT
❑ property, my wide (See.compensation, SWIMMING POOL ELECTRIC ❑OTHER
G will dothewons and rhe he Corcisnmi Liccow Law offered
of apply to an,Business
3$ and Nty who
Cade:The Cons tharemer License Law saes not apply to if owner of , OUTLETS-SWITCHPS-Fl%TURES /
property who builds or improves thereon,and who does such work himself or through If
his own employees,provided she such improvements are not intended or mRnred for NEW RESID[iN171AL F.LECfR SQ FI'.
sale.If,however,the building or improvement is sold within one year ofcompledon.the SQ.PT.FlO ARF.Y D S/SQ.FT..
mer-builder will have are burden of proving that he did nae build or improve for our. L MM
pose of scovit TOTAL: � JV
❑ h the r of t(Sec. np um sines cardely ciertmeProoso ere C=:iccns Contra actors m FEB 6 199 a
constructLathe project(Sec.]lido,Rosiness rM property
who
Cafe:)noContractorsnthecmrs and
u Lawdoes not apply toanowner ofpropeny wecareddurs imprmecCereun,and QTY. PLUMBING PERMIT FEE
' who omuacts for such projects withecmnuanor(s)IicensN pursuenuo We Cnmracmis ``
License law. PERM IT ISSUANCE SRY CITY
3 Uf VVYCIAIIN
❑ L am exempt under Sec. ,B&P C for this reason
Ower Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under Penalty of perjury one of she following declamtiom: I7 V
O lheveand will maintain eCcnificate of Consent to selGinwrefor Workers Comprn- DRAINS-FLOOR.ROOF,AREA,COND.
sation,as provided for by Section 37W of she Labor Cole,for she performance of the STORIES TYPE CONSTRUCTION
work far winch this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workcrs Compensation Inxumnce,ss
❑ perm ion respond Section
My ofthe Worker's
gfar the
suranccPerformance r f the and
(number are permitisissued. GAS-FA.SYSTEM IINC.d OfITLEfS -.
M Worker's Compensation Insurance carrier and Polis OCC.GROUP APN
My pe Policy are
Centrist. Policy GAS-EA.SYSTEM-OVER 4 IPA)
O
CERfIFlCCOMPEN EXEMPTION IRAN WORKERS'
'
COMPENSATION Gft1iASF/INDUSTRI.WASTE INTERCEPTOR B1111A1NG DIVISION FEES
(This section need not be completed if the pemdt is forces hundred dollars(SIM) GREAMTRAP
or loo.) PLANCHECK FEE
I certifydol inlhe performance of the work fofw h this pmmit is issued,lx hall SEWER'-SANITARY-STORM EA.200 FT.
not employ any m in any manngP{ t be e�jhjano We Workers Cooper- ENERGY FEE
7.. and Laws o( I omia.Date A `� 7 WATER HEAT[R W/VENTIELECI'R
O Apt on
-_s+lI come GRADING FEE
OTICE TO APPLICANTalf,after making this Cenlfieate of EFcardson,you should WATER SYSTEM7REATING
come eubjece eo she WorkerMm
Worker's Compensation provisions of the Lur Cale,you uss SOILS FEE y
forthwith comply withauch provisions or this permit shall he deemed resolved,Q WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
U O I hereby affirm that there is a construction lending agency for the perfemeareceof Date RweipN
Ne work for which this permit is issued(Sec.3097,Civ.C.)
CrU Londoes Name TOTAL:
{kl Lender's Address TOTAL: Lot
1 certify that 1 have read this application and auto that the move information is BUILDING FEE Zoo
faA correct,I agree so comply with all city and county ordinances and date laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,unit hereby statement representatives(if this city m enter upon the SEISMIC FEE
ove-mentioned property for inspection purposes. PERMIT ISSUANCE:
(We)agree to save,indemnify and keep hamdess the City of Cupertino against ELECTRIC FEE
liabilities,judgencnt,s,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the gmmeng of this permit, PLUMBING FEE
APP INT UNDERST S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(PO 10,000 CFM)
MECHANICAL FEE
5 0.CE EGULATION.. ,��/�
AIR HANDLING UNIT(OVER 10,000 CITE) CONSTRUCTION TAX
Signature of Apd araachr - Um EXHAUST HOOD(WMUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Well the applicantorfuture building occupant stoatm handle hazardous ms¢nal HEATING UNIT(TO Haff"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety -
CoJe,Section 25532(a)'t HEATING UNIT(OVER I W,OI1fI BTU)
L]Year ❑Nm VENTILATION FAN(SINGLE RESID) PAID �G96
Data Receipt l'
Will the applicant or future building occupant use cyui mor devices which BOILER-COMPOHP OR 100,000 BTU)
it M1azaNm ycommunicate.mr nmcommunicate.mfinA.nts deed by the Bay AAmit Queliry Manegemem TOTAL:
WcC
❑Yes F7 No BOILER-COMP(OVER 100,000 BTU)
1 have read the ha molous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FT.
building does not canteen,have a occurs.that it is my rcspnnsibility to notify the occupant of the eyuimments which most be met prior to issuance of a Certificate of Oxcupamy.
Owner or authodacd agent Date TOTAL: ' ISIUED.Y. — `
OFFICE