29236 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CILY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
IBUILDING DIVISION APPLICATIONIPERMIT PLUMBING-aIECHANICAL 29236
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
VNE v�f /�_ C Tk NAML'' LIC NO:C
_.T 7jS1S Ts�CL7�f_rT N/C CONTROL#
%RCAITEC71yENGINEER: LIC NO: ADDRESS:
PHONE: Consultant Fees Paid by Applicant(Initial) LDG BUILDING PERMNFO
ELECT UMBMEC
LICENSED CONTRACIOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat I am licensed under provisions of Chapter 9lcom usard g JO D CR ION
woZ with Section](]W)ofDivisionJofthe Business anJ Prnfessiors Code,and my license ie ESIDENTIAL
FLL- ' full foreemel cff 2 77.p Z PF,RMRISSUANCF.
'= ❑SFUWL ❑KITCHEN REMODEL.
6 0 6
U U License Jass Lic.a
hGL Datea�F N ��—Contractor APPLIANCES-RESIDENTIAL _ El PLUMBING RE-PIPIT
ARCHITEC'1';S DECLARATION El MUCH-UNIT ❑STRUCTURAL
F.D. PANELS
Z O N Z 1 undersand my plans be used m public recoils MODIFICATION .
OZ—o UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F.HW Licensed Professional 201-IOWAMPS IMPROVEMENT
=lgj OWNER BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAI ❑ E ITION
yy 6 I h by ff that t 1 pt f the C t t L L f r the
YC�p�,U follow g n (S t ]011.5 Bu. dP f.: CJ A y city county SIGNS ELECTRICAL - ❑OTHER
F�a.� which reaches_ liciritt toconstruct,alter, toprove,demolisli.or repoi,-any structure
prior oc'.suanre.alsooduires the applicant for such Tormil To file asigned statement SPECIAL CIRCUIT/MISC.
yOur he is licensed pucuant to the provisions of the Commerce,License Law(Chapter 9 '
�IYpO (,.sentencing with Sector.]OWJof Di,rhm 3oflhe Boorm.sznd Pmfcssions C"dc)or TEMR METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmLL
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
LLl—rn []TENANT ❑FOOD SERVICE
�yQnot more than five hundred delta,,($500). - #a� IMPROVEMENT
❑ I,asowotrofthe propmy;nrmycmpinyccxwith wage usthuirxolccompenvnion. SWIMMINGPOOLELECTR
(... will do the work,and the structure is not intended oroffuted for sale(See7N4,Business .W 11 OTHER
3 m and Pofessionx Code: The Connector's License law,does her apply to an owner of OUTLETS-SW ITC IE -FIXTURES p A ! n
property who builds or improves thereon,and who does such work himself or though
his own employees,provided That such improvements are not intended or offered for NEW RFSIDENTI SQ FT.
sale.IL however,the building or improvement is sold within one year of Completion,the SQ.FT.pF_N0 EA � SQ.FT
owner-builder will have the burden of proving that he did not build or improve for pur- MMYYUU FFYY!! X2f MJ
Trieste ofsale.).owOT _
❑.1,as ner of tire ppany,vm exclmively contracting with licensed ennmenon o
onamct Ncpri ort(See70G .BosocvnandPmfe,ims;Code:)The Cumr"emra 1,l- C�TYuf"LUNE UNO -
nsclawdoes not apply man owner nfpmpcny who builds or Improveancfre"n,and QTY. PLUMBING P MI FEE
who cm
oae¢for such iih tracord
pm)ecta wa conts)licensed pursuant to The Con ss"'O s
License law. PERMIT ISSUANCEJo1e,
am exempt under Sec. ,B K P C for this reason
ALTER-DRAIN.F VE, ER ILA)
gLUAT10N
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEC . NIC:
1 hereby anion under penalty of of piano,mm the following declarations. ,
vve and will mu at ineCettifemeof Consent,.self-insure for Workers Compete pRAtNS-FIDON,ROOF,A OND. STOk1E5 TYPE CONSTRUCTION
station,as provided for by Section 37W of the labor Cade,for the performance of the
work for is hick this permit is issued. FIXTURES-PER TRAP X
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W ofjkN'e�labor Code,for the terfommnre nf,he work for which This permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC,GROUP APN
CannerM1 s - in. Insumna camero ..:e2n://l /O �i
N1 7I1 GAN-EA.
CI?kl CATS OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE.INTERCEP1OR
❑UILDING UI VISION T,
(Thissution need not be completed ifthc permit is Tomos hundred dollars(gTWO GREASE TRAP
or Ie.azJ_ PLANCHECK FEE
Ic ify Nat inthe pcRurmancc ophe work forwhich Nispemtit isissued,Ishan SEWER-SANITARY-STORM EA.2W FT.
of em y any perwn many mannei so as to ficoses mbjen m Ne Workeri Compcn- ENERGY! E
ZZ s iso ws ifnrn tc WATER HEATER WNENT/ELECTR
C) A icadt l GRADING 17EE
.N. O CF.TO APP.ICANT:IL after making this Cid ificam of Exemption,you should -WgTER SVSTIiM/I'RL'ATING
a M1cco a subject m the Worker's Compensation provisions of the lathor Code,you mull SOILS FEIi
forthwith comply with such provisions or this permit shall Its,deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT PAID
U O I hereby affirm Nat there is a emudoalon lending agency for the permornance of Dae Reed,,#
the work for which this permit is issued(Sec.3(N],Civ.C.)
C) ULeadees Name TOTAL:
V Ltndcr'.v Addresx - TOTAL:
certify that 1 have read this appllcaumn and state that the above information is BUILDING THE
F fA connect I agree o comply On all city and county ominanre,and s,am laws relating m QTY. MECHANICAL PERMIT FEE
V z buidingeonsnuction.and hereby authorise mpresentravesofthis city toenteruponthe SEISMIC FEE
aMsre-mentioned pmpeny forimpeaton mrgne, �gaPERMIT ISSUANCE r O
(We)agree m save,indemnify and keep harmu,,the City of Canadian.ainst ELECTRIC FEE is
liabilities,judgments,c...,and expenses which may in any way notice ngainto said City ALTER OR ADD TO MECH. yPLUMBING FEB
D
nccquence of the Nc ming of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR BANDUNG UNI'T(TO 10,000 CFM) MECHANICAL FEE -
SOURC EGUI TIONS,
AIR HANDLING UNIT(OVER FLOW)CFM) CONSTRUCTION TAX 40- 44v
Z
ralurc of Applicant/Commuctor Date EXHAUST HOOD(W)DUCT)
HAF.ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Willthe applicant nr future building uttupuntsomm handle bctmdcus material HEATING UNIT(TO IW.000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
,diftdc,Secli"n 25572(")1 —I - HEATING UNIT(OVER 1 W.(aM B'TO)
YcsO
CJ VENTILATION PAN(SINGLE.RESID) PAID
s will thea locant or future building t use mcnt or devices which Pam R«sip p
Ygsecupan equip BOILER-COSIPQUP OR 106.000 BTU)u hazardous ort contaminants as defined by the Bay Area Air Quality Management TOTAL:
tom?LJ yes BOILER-COMP(OVER IW.000BTU)
y[I Na
1 have read the huxumlCCVIJJns mmaiuls m is under CNt t� G95 of the Cvli� AIR CONDITIONER IS CE DATE
forvire no
- buil Healthy Sum Code.Sections 1.th.t.25539 and SSh lit,
todcrspmd Net ifort NEW RPSIUIIN'I'IAL MECH. SQ.FT.
buil ' gd sn tts is rel haveate 6Nm'n is myresponsibility onmT the«cuWm
o u is w ie s be tet t 11 _c¢p[I ClI t fJetg V` -
Ownerormahorized agent /W1•V� LOII(/O_DatateYT TOTAL: i O ISSUED BY,
\ OFFICE -
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