29785 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUI.DING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERDIIT PLUMBING-MECHANICAL 29785
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAY
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
NIC CONTROL#
ARCHITECTIENL
GINEER: IC NO. ADDRESS:
�>v(C> l:spx . > 13 . (6(6 V Arj
CONTACT: PHONE: BUILDING PERMIT INFO
1_.✓r/V t Q 1—i T"�� ElConsultant Fees Paid by Applicant(Initial) BILLDC, ELECT PLUMB MECH
—) r`�'� I��Y`% I[]l r_11 Ifs
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed miner provisions of chapter 9(commencing JOB DESCRIPTION
WoZ th Sectiom 70kXftmf DivrQmt 3mite Business and Professions Ctde,und my license is RESIDENTIAL'
F O nrlull force and ell'L PERMIT ISSUANCE
5,F 9 '711"16`( C1 FOWL ❑KITCHEN REMODEL
aUU Licence Inss Lick APPLIANCES-RESIDENTIAL. •/d'('A
rPzw_u Dam�Conmmmr DDITION ❑PLUMBINGRE-PIPE
I,-D,n ARCHITECTS DECLARATION PANELS OMULTI-UNIT ❑STRUCTURAL
Z O w Z 1 understood my plansshall be used as public record
O Z^O UP TO 200 AMPS - MODIFICATION
F 0,1 qty Lmenscd Prnfcssumzl C3 INTERIOR O CHIMNEY REPAIR
X OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
C 6 1 hereby affirm that 1 am exempt from the Convenors License Law for the OVER 100YAMPS 0 BATH REMODEIJREPAIR 0 DEMOLITION
O4 U Billowing reason.(Sellout 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL
[]OTHER
3 c N which requires a pemtit to construct,alley,impe..ve,llamas sh.or repair any,traclme
E-� ac Puerto its Issumice.almrequiresthe applicant fnrcuah permiu,file o ii,pedemteoem SPECIAL CIRCUITMIISC.
that he is licensed Forward a the provisions of the Connector's License Law(Chapter 9
0.'00 (commencing with Section 7N10)of Division 3 of the Business and Professions CoM)or TEMP MFTF,R UR POLE(NST COMM R IA
d e rhe he is exempt therefmor and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicam fora pemtit subjects the...he:w m a civil penally Of POWER DEVICES 0 NEW BLDG/ADDITION 0 DEMOLITION
Fp Z an not mom Nan five hundred dollars(5500). []TENANT 0 FOOD SERVICE
CI SWIMMING owner Of the progeny,nr myemployces with wagesanheir sole compensaion, SWIMMING POOL ELECTRIC IMPROVEMENT
will dolhework,and thesvucture is not inteadedorof&red forsale(Se 7. ,Business ❑OTHER
W 3 ac and Professions Crile:The Conmmmr'.s License Law does not apply ns an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who builds or improves thereon,and who docs.such work hiar,df or thou,M1
his own employees.Provided that such improvements am not intended or offered for NEW RESIDENT( L ELF.CTR SQ ET.
sale.If.however.the building or improvement is sold within one yea of completion.the SO.FIT=AR� IISQter-builder will nava the burden Of proving that he did not farBY or improve for par-
you of sale.).
1.as owner of the pmperty,am exclusively contracting with licensed contmnon,nomxtrver the project(Sec.7(00,Businens and Pmfessiona Cade#The Conuacme,Li-
cense Law does not apply to on owner of property who builds or improves Nerwn.add
QTY. PLUMB PER IT FEE
who conducts for such Pmjcell with a wntmemOO lscemed pursuant to the Comr lcoma
License law.
❑ I am exempt under Sec. ,B&P C for thicreason PERMIT ISSUAN
Owner Dae ALTER-DRAIN&VE T- (EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT D VICE �, r Q �•
I hereby affirm under penalty of perjury one of the following declarations: b
I have and will maintain a Certificate ofConvenuoself-ml.mfa Worker's Compxm DRAINS-FLOOR,ROOF,AREA.COND,
since,as Provided far by Section 3700 mf the Labor Code,for the performance of the STORIES 'TYPE CONSTRUC'YPTs
work for which this permit is issued. FIXTURES-PER TRAP
3A 1 base add will maintain Wor oex Compensation Inmnc
rae,ac required by Section
3700of Oc labor CWe,for the px1mormnce of the work for which this permit is issued. GAS-EA.SYSTEMSrker's .4 OU TLETS OCC GROUP MINMy WoCmusensolna
no lvancnum
e carrier and Policy number are: \
Cartier. Policy Na: GAS-EA.SYSTEMOVE 4
CERTIFICATE OF EXEMPTION FROM WORKERS' -f
COMPENSATION INSURANCE OREASFJINDUST A E[WE: CE OR
(This limon need not hewmpleled II'the Permit is fortune hundred dollars(SI KE BUILDING DIVISION F qsS
or less.) GREASE TRAP s-` ��' PLANCHECK FEE I Q
ley'any Nein Ne performance of Nc workfit me object
this topermitWi is issued.I SEWER-SANITARY-STOR\.A.
nen employ any Person in any mannas m as m become subject no the W'mken'Compen- - ENERGY EEE I uI1.
,$ action taws nl Culiforniu.Dam
� WATER HPAfEN W/VENT/ELECI'R
O NOTICE
GRADING FEE
z y NOTICETO APPLICANT:If,afar making this Ccrtificac of Labor o d you should WATER SYSTEM/IREATING
a — became subject y the Workers Coons he tis acrd hal of the Labor Cale,you mus' SOILS FEE
Ct1 .. forthwith comply with such provisions or this permit shall be dttmed invoked. WgTF,k SERVICE
d. AI
CONSTRUCTION LENDING AGENCY NEW RFSIDENTIALPLMB. SQ.FT. PAID V
U I herebyoffirmthanhereisuconstruction lending agency bn the perlormanae of 1 to kccciprp
0 F-' the work lin which this permit is issued(See.3097,Co,C.) .
Lenders Nature,
WIznde/s Address TO TOTAL.
FLI I unify that 1 have real chis applleminn and.time Ihm rbc aMwa infommtimn is BUILDI Flo
fn corect.l agree to cOMPly with all city and county ordinances and stale laws mlming to QTY. MECHANICAL PERMIT FEE
U Z building conermctina,and hconymodamize represenutivesofthi,city mOdefapon the SEISMIC FE
ubuve-mentioned pmpeny for impecdon Purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC F ' O
Iiabiiities,judgmentx.costs and expenses which may in any way acerae against said City ALTE0.OR ADD TO MECH.
in mscumove of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING 11N1'P(TO 10.0(10 CFN)
SOURCE REGULATIONS. / MECHANICAL ME r
X J AIR HANDLING UNIT(OVER 10.000 CFMY CONSTRUCfIONTAX
S' rut of Applicu Contractor ane EXHAUST IIOODIW/DUCT')
HA9ARDOUS A9 y RIALS DISCLOSURE HOUSING MITIGATION FEE
W'll the pplicann or future bul(�ng occupant store or handle hazardous material HEATING UNI'f(To 100.000 BTU) / 1;
as d 1 ed by the Cuperino Municipal Crile,Chapter 9.12,and the Health and Safety
Code,(Section 25532(0)1 HEATING UNIT(OVER 100.000 BTI[]
Byes 0No qq(l(1Icc q p�
VENUATION FAN(SINGLE RESIDQ 8Y 3 1"I`IO PAID —3 /6 21ol
�40
Will Ne applicam or futum building Occupant use equipment or devices which .- Date Receipt#
nnithuaNuus air amcmimmms as defined by the Bay Area Air Quality Management BOILER (3HP OR I(X),(X10 BTI[]
Disoriel?
❑Yes ro BOILER-COMPOVER 100.000,BTU) T Vf IrUI Liltucv TOTAL:
I have read the meadows materials requirement under Chapter 695 mf the Cali- AIR CONDITIONER
;buildfing
ra Health&Safety Clale.Secaens 25505.25533 and 25534.1 undersand that if the ISSUANCE DATE
does not curremly have a tenant,that it is my respensibility to notify use occupant NEW RESIDENTIAL MECH. SQ.ET.
e rtquirementswich must Be n Fdmm issuance,ofa Cenificomof Occup cy
ill
net mouth reed agent lone TO
ISSUEDBY.
�� OFFICE