29095 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 9 JO9 9
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
GWR' NAME:
PHONE NTRACTOR'S NAME: LIC NO
1 �
_ O'+s LAW - 'I� 0 fid, NIC CONTROL# '
ARCHITECTIENGIIs °R: LIC ADDRESS: C ❑
f!fj� arm
CONTACT: P ONE: BUILDING PERMIT INFO
/_ ❑
Consultant Fees Paid by Applicant(Initial) - B� ELECT PLUMB . MECH
LICENSED CONTRACTOR'S DECLARATION— - QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 um licensed under pro,mims of Chepter.9(commencing JOB'DESCRIPTION
C fLZ with Se I 700EWO.vi.' n3ofthelloonewuncil' fession Cope,morrylicemeis RESIDENTIAL
O O PERMIT ISSUANCE
W in fullfoseand cRect. WL ❑KITCHEN REMODEL
tFUj nano ass Lis. APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
y Z Dote Contractor
49
1 Z- w 'HITECTS DECLAR PANELS ❑MULTI-UNIT ❑STRUCTURAL
OZvv�� 1 understand my ans shall be used u public records MODIFICATION
%d� UPTO200AMPS ❑INTERIOR C3 CHIMNEY REPAIR
,0.'1-� Licensed Professional - 201-IWOAMPS' IMPROVEMENT � t
tea^ OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR ODEMOLITION
N1 hereby effort nm ex
thaaempt from the Cmntrveme.License Law far the
S U following mown:(Section 703 t,5.Business and Profesnions Code:Any city or county SIGNS ELECTRICAL ❑OTHER _
LVO which taryires a permit to common.alar,improve,demolish,or repair any structure
prior to its issuance,also requires the applicam for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant o are Provisions ofthe Connaaoes License Law(Chapter 9
(commencing with Section 7")of Division 3 ofthe Bmineaa and Professions Cade)or TEMP.METER OR POLE COMMERCIAL:
Lk�o eE that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION El DEMOLITION
yxi5 4• Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
Yl�rn ❑TENANT ❑FOODSERVICE
Oof mare than fve'an dollars($SW). IMPROVEMENT
Lae owner of the prapcny,or my employees with wages as their sole compensation, SWIMMINGPOOL CT t
will Jo the work and the vwcturc is not imended moffercJ for sale(Sec.0044,Business ]OTHER.
and Professions Code:The Commcwrs License Law does am apply to on owner of OUTLETS-SWITCH - URES
pnsp runty who builds or aided t s thereon,end who does such ince biro if or Nnmgh n
his own employeese building that such improvements am on intended or plleerW fur NEW RESIDENTIAL ELE i SQ FT.
sde.ILhowever,the building or improvement is sold within one year of completion.use SQ.PT.FLOOR AREA 5/SQ.FT.
caner-builder will have the burden of proving that he did net build or improve for put- C1 %�6 rr�
pare of sale.). s 1
I,as owner of the property,am exclusively contracting with licensed cantmcwn to
construct the project(Sec.7IH4,Business and Professions Code)The Convectors Li-
cense Law does not apply to an owner of property who builds or impmves therton,and QTY. PLUMBING PERMIT FEE �r
who containers for such projects with a contenemr(s)licensed pursuant to the Commcwrs
License Law. PERMIT ISSUANCE
❑lam exempt under Sec. ,B&I'Cfordsormusan'
Owntt DoleALTER-DRAIN& - TER( VALUATION
#''�� ♦
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE E
ffirm
Ihereby aunder penalty of Perjury one of the following declarations: L `
I] IhiveendwillmaintuinSCcnificateof Consenuosel6imsumfor Worker's Compen- DRAINS-FLOOR,ROOH EA, STORIESisA, p�TYPE CONSTRUCTION
wtimn,as provided far by Section 3]00 of the Lebo Codc,for the p ....voce of the ® {A
ark for which this permit is issued. FIXTURES-PER TRAP
I]1 have and will maintain War kne,,Comismsetom Insumnce,as requiml by Section -
3]OO of the labor Code,fur the performance of the work forwhich this pemdr is issued GAS-EA.SYSTEM-I TNCAOUTLETS OCC, p APN
My Workels mpensatinn Insumnce carrier and Policyn bar ac: - e n
order.
PolicyN., GAS-EA.SYS'IEMOVER 4(EA) 4��j- .a�6
ATE OF EXEMPTION FROM FROM RKE S' Vr f ..
COMPENSATION INSURANCE GREASERNDUSTRL WASTE INTERCEPTOR BUILDING'DN/SJ .ES
This section need not becompleted ifthe permit is for one hundred dollen S IW) GRE45L'TRAP
or less.) PLANCHF.CK
Iceafy that in the berfornnnce of the .,it for which this permit it issued,l shall SEWER-SANITARY-STORM EA.20X1 Fr.
not employ any person in any manner so as to become subject the Workers'Campen- ENERGY FEE 1"
Z sation laws of Califamia.Date WATER HEATER WNENTM ECTR
7�7 0 Applicant GRADING FEE aa �
F7 h NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
become suhjano the Workers Compenwion provisions o(Ne tabor Cade,you must
forthwith comply wird mch provisions or this permit shall he deemed revoked. WATER SERVICE -
aQ
U z CONSTRUCTION LENDINOAGENCY NEW RESIUEN]]A1,PLMB. SQ.FL PATO . Date cciptN
U I herebyich his
pe mit i is u c d(See.0n lending agency bathe perfnrmantt of
the work for which tM1is permit is issue)(Sec.71197,Civ.CJ
0 Lender's Name L'
Lenders Address
Ly, 1 certify thm 1 have read this application and state that above information in BUILDING FEE I CL lg
i..i V) correct,1 agrx to comply with all city and county ordinances eM state laws rtlating nr QTY. MECHANICAL PERMIT FEE
UK building conswmion.end hereby authonu rtprescmaives ofthiscity to en¢rupon the SEISMIC A6 -
above-mentioned property lm inspection purposes. - PERMIT ISSUANCE
(We)agree w save,indemnify and keep harmless the City of Cupenum against ELECTR FEE
liebilities.judgmcros,coxa and evpcnses which may inany vay.cuieagomil,aid City ALTER OR ADD TO MECH.
in consequence of the graving of this permit. PLUMB E
APPI(CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,001 CIM) MECH AL BE
SOU CE REGULATION
4 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
real - t Data EXHAUST HOLD OVMUCT) HOUSING MITIGATION FEE 1 'ria
HAZARDOUS MATERIALS DISCLOSURE
Will thevp,Iicamorfuwre building occubamewrear handle hamrdaus mound HEATING UNIT TO 100,000 BTU)
as definM by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)^ HEATING UNIT(OVER 100,000 BTU) -
a.
❑Yes, ❑No VENTILATION FAN(SINGLE RESID) PAID
Will Ne applicam or future building occupant use equipment or devices which Data Receipt p
t haurdous air contaminants ea defined by the Bay Ates Air Quality Management BOILER-COMP(JHP OR IOO,tXYJ BTU) TOTAL:
District?
I]Yes ON. BOILER-COMP(OVER 100.000 BTU)
I have read the harallous mounds reptiremetns under Chapter(s95 of one Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not curently have a tenant,that it is my responsibility to notify the occupant sg�
of the requirements which must he met prior to issuance of a Certificate of Occupancy. - �V//
Owner or authorized agent Dano �l ISSUED BY:
OFFICE