29152 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29152
INII.DIN(:IsROJECI'IDF.N'riFICA'1'ION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTALDATE
2/04.2- w�-z,A (211
OWNER'S NA E: PHONI±: CONIRACTOR'S NAME: LIC NO:
2 - 76y5� /¢AI4 P/ nvq CS6 zo Z/jV-j,)2, NIC CONTROL#.,
RCHITFUMNGINEER: LIC NO, ADDRESS: ,/ /� ' �/ ❑
' �sZ �-FYEYYIO-H/ /vim t S.Y
CONTACT,. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ LSI
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT I•FE
O Z I hereby eifum Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Sation 7fNR1)of Division 7 of Ne Business and Rofessinns Cale,and my license is RESIDENTIAL:
FSO in full forteand ellen. PERMIT ISSUANCE. 'O SFDWL ❑KITCHEN REMODEL
PUW1 License Class Contractor
APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
IFn S a Dam TS DECLARATION
-
ANCIIITECI-g DECLARATION - ❑MULTI-WNIT
El STRUCTURAL
PANELS
Z O to Z I uakrstoml my plans shall be used contrail.mconis MODIFICATION
OZ�O _ - U1170200AMPS 0INTERIOR El CHIMNEY REPAIR
1-.tr1`4 I�s Licensed Professional - 201-1 gxI AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
y Q 1 hereby affirm thin 1 um exempt front the Contractor's License Law for NOVER IOBIAMPS e [I BATH REMODEUREPAIR C3 DEMOLITION
x a 6 U following reason.(Section 7031.5,Business and Professions Cade:Any city m county SIGNS ELECTRICAL ❑OTHER
ul O which requires a permit to common,alter,improve,demolish,or repair any stmeture
prior to its issuance,also requires the applicant for such Permit o file a visited statement SPECIAL CIRCUI VMISC.
} that he is licensed pursuant o the pmvisions of the Contractor's License Law(Chapmr9
.�� (commencing with Section 7do0h.fDi,If1m3of Ne Businessand Preowed...Cade), TEMP.METER OR POLE INST. COMMERCIAL
6 ky M that he is exempt therefrom and(lie basis for the alleged exemption.Any violation of 0 NEW BLDGIADDITION ❑DEMOLITION
a�
Section 7031.5 byany applicant far a pemtilmbjects(he opplicanunacivil penalty of POWER DEVICES
y not mum than Eve hundred dollars($500)
[]TENANT ❑FOODSERVICE
n6 O 1,to owner of the property,or my employees with wages as their sole compensation, SWIMMI NO POOL ELEC'I'EIC IMPROVEMENT
will do the work,and the structure is not intended orofferN for ark,(Sec.7044,Business ❑OTHER
ii �_ and Professions Code:The Cenmamr's License Law does not apply to an owner of OUTLEFD
(TURES
property who huilds or improves thereon,and who it.such work himself or through
his own employers,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT,
ade.If.however he building mimprtveucal issald within may.of completion,the SQ.Fr.FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving that he did not build or improve far par. ®�� -
of sale.).
C] 1property,
I,if owner of the property,um exclusively contracting with licensed commnom m TOTAL:
construct the project(Sec.9144,Business and Professions Code:)The Contractor.Li- ['
cense Law does not apply to an owner of property who builds or magnesia thereon,and QTY. PLUMBING PERMIT PEE CIJy Ut 1�
whontra
occtsfmsuch promanm(s)limnW
jes with scantr + perform (h
bre Committees License law. PERMIT ISSUANCE LU~`L
���11�
❑l em exempt ander Ser ,9&P C fonhis reman
Owner Date ALTER-DRAIN&VIiMr-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby action under penalty of�e jury one of the following deductions;
El I have and will maintain a Certificate of Comenuo self-imue,for Workers Comlxn. DRAINS-FLOOR,ROOF,AREA.COND.
Nagar,as provided fm by Statim 37M of the Labor Code,fonbe performance of the STORIES TYPE CONSTRUCTION
weak far which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,to required by Section
3700 of the Labor Code,for the pMarmaoce of the work for which this PertNl is issued. GAS-RA.SYSTEM-I INC.4 OUTLE'S
My.Workers Compensation I avumnce carrier and Policy nM. OCC.GROUP qPN
Cartier-. Policy Nn: GAS-FA,SYSTEM-OVER4(
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASRJINDUSTRLWASTE INT. RM OR BUILDING DIVISION EliE.S
(This section need rot he completed ifthe Permit is for enehundred dellats($100)
Our less.) GRHASE TRAP PI.ANCHECK FEE
I certify that indepedideranceuf Ne work hadueb this permit is issue,l shall SEWER-SANITA - 'O .A.200 FT.
not employ any person in any manner so m m become subject to the Workers'Cooper- ENERGY FEE
zZ Nation Laws of Coliforms.Dam
O Applicant NATER FATE /ELF.LTR GRADING FEE
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATERS . E BEATING
abecame subject to the Worker'.Compensation provisions a nil,labor Cale,you must - SOILS FEE .
forthwith comply with such positions or this permmtsheli be deemed revoked. WATER SERVICE
Q Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
LJ work
rwhich that there permits isaanslmNon lending agency(onhe performance of Date Receipt
r�
the work for which this permit is issued(Sec.3097,Civ.CJ
Q
L)W LenLenders Name TOTAL:
ders Adress d - TOTAL:
� a larifythat lhuve read this application and some that the above infonnatinn is BUILDING FEE '
m cotreel.l agmen comply with all city and emicayor jounces and state law.existing to QTY, MECHANICAL PERMIT FEE
building commuction,and hereby authnriee repmsenm(ivesofLis,hy turner upon the SEISMIC FEL±
above-roa doped pope"fm inspection pugwses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hornless the City of Cupertino sgaiost ELECTRIC FEE
l iubilitie,judgmen(s.criminal expcnus which may/many way aarueaguindiaid City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
S URCE REGULATIONS. MECHANICAL PEP.
O. / y /���� /Z��� AIR HANDLING UNIT(OVER 10,000C IM)
`A9Gl'fl t� s�JCr/ !!LLCONSTRUCTION TAX
Si¢ntiure ofAppliceduContm nr Date BXHAUSTHOOD(WIDUCt7
T HAZARDOUS MATERIALS DISCLOSURE _Kck
1401151NG MITIGATION PEE
Will the applicant or future buildingacupunt storemhni lelmounkuireadi ial HEATING UNIT(TO 100,000 BTU) Cie
as defined by the Cupenino Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Section 25532(«)? HEATING UNIT(OVER 100,0610 BTU)
❑Yes ❑Nn
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dae - Receipt if
esti(hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100,000BTU)
District? TOTAL:
❑Yes 7 N BOILER-COMP(OVER 100,000 BTU)
1 have read the hdefolom materials AIR CONDITIONER
req 15533 an under Chapter rsta of Ne CA. ISSUANCE D
forma Healthgdoes&Safety Cede Salmons 25505,235)3 and 25534.1 n unity the
that if the NEW RESIDENTIAL MECH. SQ.FT
building dcexnot
tscurrently have amne,pNath isua ce of a Certifimnotifythepancy no
of the reyuircmeme which mi be met prior m issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
OFFICE