29766 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29766
1/X�g^/N
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING-M, L�9 / {l..la I6
BUILDING PROJEC"I'IDENTIFICATION'
BUILDING ADDRESS: aAegc u SANITARY NO. APPLICATION SUBMITTAL DAD
, �Cal., �1� t�C.J
OWNERS NAhI E: eA sJ �', PHONE: CONTRACTOR'S NAME.E: LIC NO:
Z I^— /t(p4�pyf N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: Zoo gj/Mr. ❑
_
CONTACT: r s Sp nfy PHONE: L BUILDING PERMIT INFO
eM
es 427 /-0qu ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Yry 0 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provision:of Chapter 9(commencing JOB DESCRIPTION
OW02 thS,Oion AXXB of Division 3oftheBasin...und Pride..min Gxlc,and my liacnscis RESIDENTIAL
i- nt full force and cBccr PERMIT ISSUANCE �_
FQF-UU Liccnu Clms Lic.N ❑SFDWL [I KITCHEN REMODEL
tufa Dmc Dr Cotnmmm lt,C� APYLIANCFS-RF3IDEMIAI- []ADDITION El PLUMBING RE-PIPE
AKCHITECI'g DT:CLAHATION ❑MUI:rl-UNIT ❑STRUCTURAL
F-mw IundaelunA mY plat RCHI ECI-Slm bl RAUOh
PANELS
Z O rq zj nn CHIMNMODIFCATION
OZ�O Uti-10001MPS ❑INTERIOR .CHIMNEY REPAIR
FNFu: Licensed professional ?01-HXU AMPS IMPROVEMENT
OWNER-BUILDIiR DECLARATION OVER II11X)AMI'S ❑BATH RE DEUREPAIR ❑D1iMOLITIQN
d'w Q I berth,affirm thus I am exempt I'mm the Comruemds Liume Law for the
W6 :fLU followingremon.(Section 7031.5,Business and Prolessions Gyle:Any city..oumY SIGNS ELECTRICAL ❑OTfiER �$pIfLLL f -l;not
F-=O lipe which requires is penis,to c...met.alter,improve,demolish,or repair any structure 1A i n-[�ast r
J prior to its issuance,also requites the applicant for such Permit file a signed statement
N SPECIAL.CIRCUI S
that he is liccnsttl purvuunnnshc provisions rel the Cnmraniir'n himnm Law(Chupmr9
IW MC, (commencing with Section 7000)of Doeieion3Of the Business and Pmfemimn Gxle)or TEMRMETERORI .E T. COMMERCIAL:
a d
0= that lie is exempt therefrom and the basis for the alleged eacmption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
�^y
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POW17R DEVICES, ❑TFNANT ❑FOODSERVICE
ZDlin more than five hundred dollars(S50p,
❑ Lu,.owner ol'she pmpcny,ur my mnployws with wugm nsthcirnnle compensanum, SWIMMING OL ELE'TRIC IMPROVEMENT
F- will dvmework,mdthenructure is not imm�dealm.ffiend formis(Sev.JBf4,Bminees [_1 OTHER
at:
3? and Professions Code:The Cmunicmra License L.aw dies sol apply m an owner of OUTLET -SWITCHES-FIXTURES
pmpcny who huilda or improves thmcon,and who does such work himselfor through
his own employees,provided that ranch improvements am not in4mdul Or oirced 10, NEW RIiSIDENTIAL ELECIR SQ EL
sale.ll;however.the building or mprovenunt is cold within One year ofcompletion,the SQ.FT.FLOOR AREA SISQ.ITT.
er-builder will have the burden of proving that be did not build or improve for par-
poe of sale.).
O 1,as owner Of the pmpcny,sun exclusively contracting with licensed contmetnrn m TOTAL: P Ff(k ' D
nxun ct the project(Sm.9194,business
and Pmfes m On1T.C....—"..Li-
nm Law does not apply to an ownet of progeny who builds or improves thereon.and Q'rY. PLUMBING P MIT FEE
who ensurers for such projects wish a comsed
racom s)licenpursuant to the Comactols MAY 15 1996
Licenm Law. PERMIT'ISSUANCE
Ism exempt oullm Stu. ,B&V C fur in,rca,m
Owner Dam ALTER-DRAIN&VE. - ATEfiz 1 LILY r s,VrrVALUATION
WORKERS COMPENSATION DECLARA'110N BACK FLOW PROTECT DEVICE 1(OT1'"T�[an 1 / V �.y_
I herehyoffrni under penalty of perjury one m the following declaraiona: I / VU
❑ .rker's Compere- DRAINS-FLUOR,ROO AREA.CONU. STORIES TYPE CONSTRUCTION
nation,as provided for by Sectiom 37M of the Labor Code.for the performance of the
k for which this petmir is issued. FT%TURF,S-P TRA
�p--11 have and will maintain Worker's Compensation Insurance,.s raryired by Session
3TOB of the LaMc Cody f the perlimauce of the work for which this permit is issued. GAS-EA.SYS 7 1ETS OCC.GROUP APN
My Workers Compo sae sun{{carricrund Policy nt,115,a
Cartier. -� •�r� Policy No. GAS-EA.SYST f )6 4(;A)
CI:R'I'IFICATH OF EXEMPTION FROM WORKERS' // /J(,
COMPENSATION INSURANCE. '! // GREASUINDUS'I' AS'U3 IN'D7RCEPTOH
(Ibis section need not be completed it the permit is Reone hundrN dollars(SIM) BUILDING DIVISION FEES
Or less) GRF RAP
PLANCHECK FEE
Ioyanythmoum pednomm,, of as to he work
Per11h,W.kc,yued,I that[
Open- SEWER-SANITARY-STORM EA.2W PI'.
Or,employ any person in any manna no ns m hwomn snhjcct ni the Warkcrs'Contprn- ENERGY NEE
Z satlon Laws of Coliliimia.Duro WATER HATER W/OENT/ELECTR
z Applicant GRADING FEE
y NOTICE TO APPLICANT:IL afta,making thin Cedifcae Of Exemption,you should WATER SYSTEM/TREATING
a > berome subject to she Workers Cort,mation pron.,o m rime Labor Code,you nmst SOILS PEE
D.) forthwith comply with such provisions or thin permit shall be deemed revoked. WATER SERVICE,
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
V I far whip thi lbuuhert is.rd(Svmion len ding agency fonts perfnmienceof Dam Receipt
LL F., Newark for which thispermit is idnucd(Seu.3097,Co,,C.)
0r's Name TOTAL:
Umbe
} W 1<nderAddress TOTAL
I :
ccnifY that 1 M1vvc real this applicninn and slime that the above information is BUILDING FEF.
F tai] c ren.l agree m,consply with all city and county Ordinances unit nice to ..s:eingm Q'I'Y. MECHANICAL PERMIT FEE
L) Z builds ng commuction.and hereby audmri,e mpmsentutivevnlthis city thenar ugmthc SEISMIC FEE
uMve cusadoned property for inspection purposes.
(W'e)agreem save,indemnify and loss,harmlcm the City of Cultism."against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and cn,u,es which may in any way same...ina said Cit' ALTER OR ADD'11)MECH.
inconecrocus,of me granting of this pertnit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.010 CFM)
SOURCE REGULATIONS. MECHANICAL Mli
AIR HANDLING UN '(O E 0 CFI,/.
CONS]TRUCTION TAX
Signature ofAlanicum Conoetor Date EXHAUS'I'HOOD( HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle haxalloue mmerial HEATING UNIT(TO 11, BTU)
as derided by the Cupertino Municipal Cndc.Chapter 9,12,and the health and Safety
Code,Suction 25592(.)? HEATING UNIT F0VFV 100,000 BTU)
C]Yen PAID
VEVI'II FAN(SINGLE RESID)
Will Neopplicum or furoe buildingnt...c ccewnhi
Date
trout hmnrdous air eunwmanu m dfined thy lieBay Ate,Air Coat,M.n.gaem' BOILER-COMP(31111 OR 100,X)0 BTU) Receipt N
TOT L:
Ginnie,?
' dyes ON.
BOILER-COMP(OVER 100,00(1 RTU)
I have scud pie hvunlooty nu li nals mrylrnmenin node,Chapus h.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
forma Health&Selety Code.Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.FT.
building does nos currently have a cmem,that it is my respunaibility�m notify the occupant
of the requirereems which must be mer prim ui iasdana of a Cemfie!m of ups cy.
OwneOumthnnxu cut - Date TOTAL: ISSDBY:
OFFICE