28859 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -
BUILDING-F.LF.CTRICAI. - •PERMIT NO. /� /� ^ r
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-ELCIIANICAL / X X `19
BUILDING PROJECT IDENTIFICATION L�J VVV VVV
BUILDINGADDRESS; SANDARYNO. APPLICATION SUBMITTALI3ATF
L
R' N E: PHONE: CO T R'SN IC NQ
_ 77 N/C CONTROLk
•AR ITECLIENGINEER: LIC O: [SS ❑
CONTACT PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aRrm that 1 am licensed ander provinw.of Chaffer 9(commencing JOB DESCRIPTION
y"yIZ. with Section 70(0 f Division 3 ofthe Business road ProfessionsCode.and my license is RESIDENTIAL,
F00 in full force and Tuan. PERMIT ISSUANCE —_ '
W .OSFDWL ❑KITCHEN REMODEL
�U License Class o
Data—Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�Q '
E,pna ARCHITECTse DECLARATION PANELS ❑MULT6UNIT ❑STRUCTURAL
Ozvv�/ 1 unJersmnJ my plans shell be mW as public records MODIFICATION
.".1p � - lIPT02W AMPS ❑INTERIOR [I CHIMNEY REPAIR �
r,4k5 Licensed Pmfesstonal 201-1000AMN IMPROVEMENT
•i OWNER-BUILDER DECLARATID OVER IOW AMPS [I BATH REMODEUREPAIR F1 DEMOLITION
yy04 1 heeby affirm duet L am exempt from the Cont or's License arm far the
560 O following reason.(Section 7031.5.Business and Pro ons Cade:Any cit or countySIGNS ELECTRICAL
'❑OTHER
d irWO�. which requires a permit to construct,alter,imp ,demolish,or repair an swcturc
Q, prion its ieamnce,nlsorequiresmaripplic orxuch permitm flwsignn statement SPECIAL CIRCUIT/MISC.
yThat he is licemed pursuant to the ns of the Cgnuannh License Law apder9
<f (commencingw of Division 3 ofthe Business and Profession Code)or TEMP.METER OR POLE INST. COMMERCIAL:
Y c K Nat he'is a to themfmm and the basis for the alleged exemption.Any v lotion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y• S«tion] LS by any applicant fora permiuubjens Ne applicennoocivil nahyof POWER DEVICES EITENANT ❑FOOD SERVICE
not mo than five hundred dollars($50l IMPROVEMENT
6� �I,as of the propeny,or my employees with wages as their sole coral oration, SWIMMING POOL ELECTRIC ❑OTHER
will da ework,anJ theswctum is not intended oroffemd for sale(So,7044.Bus' csx
G and Pr essions Code:The Contractors Licens w does tont apply m an�of OUTLETS-SWITCHES-FIXTURES
propen who buiWx or improves dherenn,and w r ces such walk hi s f rough
his o employees,pmvidW on i impro am not in
d to, NEW RESIDENTIAL ELECTS SQ FT.
W,.lf, wev<r,the building or impro s eyearo n c SQ.Fr.FLOOR AREA &SQ.FT.
owner- ilder will hove the burden of p A at he did IT imp ve pur. y� B
.of ale.). `su
❑1,m caner of the open < as comm g th n d ntctor's a TOTAL: _
anew N<projttt( «. s std femmdd,W,i. stharco,and 1 O
censeL wdceanma m t own re mpc who uuilJs prim was thereon,and QTY PLUMBING PERMIT FEE OCTV 1995
who oo imam for such ms we,
rts)llcenscdpurs mina Contractor's s7
Linens Law. PERMIT ISSUANCE: CIlY Ur
pie exempt under Se .B&PCfor Wsrcnson LUrtklDaln
ALTER-DRAIN&VENT-WATER WA) VALUATION
Owne
Data
WORKER'S COMPENSATIO ECLARATION BACK FLOW PROTECT.DEVICE
rL
ffirm under penalty ofperju me ofthe following declarations:
Ill maintain aCmificateo ansenna self-insurefar WurkeYx Compen- DRAINS-FLOOR,ROOF.AREA,CONI. ' STORIES TYPE CONSTRUCTION
smioed for by Section 3]( life Labor Code,for the performance ol'the
workhis permit is issue FIXTURES-PER TRAP
❑1 ill maintain W ars Compensation Insurance,as required by S«tion
3701r Coda,f eperfammnceofthework forwhichmis permit isissuW. GAS-EA.SYSTEM-1 INC.4 OU]LETS OCC.GROUP APN
My ton Insu <canicr and Policy
Cam Palicyoli GAS-EA.SYSTEM-OVER 4(EA)
CERTIFIC OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissation read of be completed if the pewit is forum,hundred dollars($1 o GREASE TRAP
or IessJ, PLANCHECK FEE
leartifythatindhe ace f work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.200 FT.
not employ any pe n me I t become subjecuo the Workers Compen- ENERGY FEE
Z
seoion laws of do .D WATER HEATER WIVENT/ELECTR
0 GRADING FEE
7 O APPlicant
NOTICE ,C W.I er making tut enifcate of Exemption,you should WATER SYSTP.MRREATING SOILS FF.F.
aaccount jest to t Worker's Compensation Provisions of the Taunt Cade,you most
{11 fa nit comply withsuch provision,or this permit bull he decmodrevoked. WATER SERVICE
CONSTRUCTION LENDING AGENCYNEW RESIDENT IAL of SQ.FT. PAID
U work iheuair,.by arm theUh<rc isaco (Sea.3097.
agency fnnhe pcdormance of Dam Receipt
the k for which this perm (S
it is issued IS«.3097.Civ.s,C.)
U*ULanders Name TOTAL:
Lenders Address L'
a 1 certify that I have read this application and smm that the above information is BUILDING FEE
LO) carrier.I agree to comply with all city and county on inamms,and state laws relating to QTY MECHANICAL PERMIT FEE
U building emswm
mioand hereby amharium,reuhia
n...ivesid' ,hym enlerupan the SEISMICFEE
above-mentioned propany for inspection Panics". PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
laid,Iuesj'it
gmenta expenseswh' may in anyway«ame against said City ALTERORADDTOMECH. PLUMBING FEE
I.
caasequa¢e cgmnti of this n.
' APPLICA' UNDER ' NDS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL FEE
SOUR REGUL ' NS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUMIONTAX
dg IicanOConanmor Dam EXHAUSTUGODONMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume building occupant some or handle hazardous metttial HEATING UNIT(TO 100,000 BTU)
To defined by she Cupertino Municipal Cute,Chapter 9.12,mad the Health and Safety
Code,Seuian 255320)] HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Na -' PAID
VENTILATION FAN(SINGLE RESIO) Dade accept is
Will the applicant or future,building occupeno use equipment or devices which BOILER-COMP Off OR. 100,000 BTU)emit hasardous air consaminams as defined by the A.Air Quality Management TOTAL:
Dimict? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Na
I have eadur hawdmu material uimme us under Chapfer6V5ofmx Cmi- AIRCONDITIONER ISSUANCE ATE
forma HealthCede,Sttua 305,25533 end 25574.I undcrstend shad if the NEW RESIDENTIAL MECH. SQ.FT.
buiIch s unendy hav nut,that it is my responsibility to nafify the occupant -
nf ncnds whic nuissuance afa cute ofJddial
r aathudud agcm Date TOTAL: ISSUED BY:
OFFICE