29174 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITI'6F CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING.MECHANICAL
NUILDING PROJECT IDENTIFICATION 29174
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I D 3 8 Tei 1 A kal, C-
OWNER'S NAME: I' ONE: CONTRACTOR'IN E: LIC NO'.
N S V n " G I NIC CONTROL#
RCHREC( NGINEER: LIC NO: AO)
RES ElO.� z s A 4.1A
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Pccs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ N ❑
LICENSED I . dundeCONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE -
I hemby a1Brin mal 1 lmenam unser pmxiaima of Chapter 9lcommendng JOB DESCRIPTION
w000 with Sve1i.r17 ])mf eW3— fthc Nosiness and l4nfasinm Gxle,and mpliccn.0 is RESIDENTIAL:
Y W F m full tamarind of ve ) PERMIT ISSUANCE
�.UU Liceme Class Lic.a 8 CSFDWL [I KITCHEN REMODEL
,nam Dam Convector APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
_pm ARCHITECTSL CI ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z=Z I understood my plans shall he used as publicremrds MODIFICATION
UPTO WAMPS ❑ ❑
INTERIOR CHIMNEY REPAIR
Licensed ProPossional 201-IMIAMPS IMPROVEMENT
Y� Oat I am
DECLARATION Contractors
ON
U 1 hereby affirm that I am exempl from IM1e Comramor's License Law for Ne OVER IIXq AMPS C BATH RE O Aaaaaa PAIR DEMOLITION
6 following reason.(Section]031.5,Business and Professions Code:An n W count ❑OTHER
'31y which y ct Y SIGNS ELECTRICAL
C reisca a pemdt m comtrucp aper,improve.demolish,or repair ed awmtrre
to that heto..licensed
pursuantl.
to res Novisio s ofthet for Counnosuch rte Licefilse signed statement SPECIAL CIRCUIT/MISC.
(co(commencing
pursuan on 7 N)provisionanf the Gorondou s License Lames Code)
500 (cat he
is xempthominantadno basis for n(NeegeBusiness Professions Code)or TEMP. EfEROR POLE INS COMMERCIAL:
y m e' Nn io is exempt therefrom and Ne basis for the alleged exemption,nto Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W—H Semon]031.5 by any applicantfara permit subjens Ne applicant rra civil penapy of POW EVIGES
Z y not more Than file hundred dollars 6500). ❑TENANT FOOD SERVICE
Sa 1.as owner of are IMPROVEMENT
❑ properYor my with wages esthei(Ses.compensation, SWIM OL ELECTRIC COTHER
WF wJl do be work,end the torture is nm intended or offered tarsale(Sa.]OU,Business
3 m and Professions Code:The Contractors etors License Law does napply men owner of OUTLETS- ES-FIX'TUR
Properly who builds or improves thermn,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ
axle.If.however,the building or improvement is sold within one year#(completion,the SQ.FT.FLOOR AREA y/SQ.FT.
owner-budder will have me burden of parsing Nor he did not build or improve for ptrr-
pase or sale.). ' F
C L m owner of the parpeny,an exclusively contracting with licensed contracmrs m TOTAL: ry ryl
arcommel the profes(Sec.T04Y,Business and Professions CadeO The Contractor's Li-
cenu few does not apply to an owner of 4
PP Y property who builds or improves daemon,and QTY.`f PLUMBING PERMIT'' FEE r�
whocontractsLaw.for such pmiecu wiNecomrenor(s)Iirenutl pursuant rn the Contractors - �J 79�
Wttnse Law. PERMIT ISSUANCE �•
❑Tem exempl underSw. ,B&PCfor Nis reason [.•�I'v
Owner Dam ALTER-DRAIN&VENT-WATER(EA) t r'._.VALUATION
WORKER'S COMPENSATION DECLARATION �'drCkJ
1 hereby atlbm under Penaltyof BACK FLOW PROTECT.DEVICE
perjuryencofthefollowing Worker's
shave and will forty Se Ccrdpwm of the sent Labor
oda.for for Workers Compcn- DRAWS-FLOOR,ROOF AREA,COND. STORIES TYPECONSTRUCTION
737M
irk,a provided for mi Section 3]00 of the 4brr Cade,for Ne performance of the
rk for which this permit is issued. FIXTURES-PER TRAP �y
1 hate and will maintain Workers Compenstion&for whi h required by SesienRyWakof elabor Codg6rthe performanceofnd work for which Nis penNlis issued. GAS-EA.SYSTEM-1 INC.40I1TLETS OCC.GROUP APN
yWorkeraCg� pens#ionIn certierand Policy number art'rdeC Q � PolicyNo.: UlUkakil 1{R7 GAS-EA.SYSTEM-OVER4(EA)
CERTI IC OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This action need nm be completed ifthe Parodi is(Drone hundred dollars(S I W) �' � , ;� , BUILDING DIVISIONless.) GREASE TRAP PLANCHECK FEE
Icenify that in Neperformanttnfthe work for which this pe mat is issued,Ishall SEWER-SANRARY-STORM EA.200 FT.
nor employ any fa coon in any manner so as m become subject m the Workers'Co.,.- ENERGKMTAL E
,'� sation laws of Califomia.Date
Z O Applicant WATER HEATER W/VENT/ELECfR
OR
EE
ryl NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM,TREAnNG
s'# Become subject to me Workers Compensation provisions of are Labor Code,you most
Lkl`� forthwith comply with such provisions or this permit shall Be deemed revoked. WATER SERVICE
0. La
Uz th.,di CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB.
V. the
I for by which this
that Nemissuedecti0lending agency for theper(ormmce of Data Receipt#
La work for which this pertnir is issued Sec.309],Civ,C.)
I--�
Landes Name TOTAL:
Lende I Address y I certify Na 1 have read Nis application end sw¢thot tM1e#rove information is FEEh comes.I agree m comply with all say and county Ordinances and sum laws relating to QTY, MECHANICAL PERMITbuilding conswmion.and hereby aumorize represennimc of this city m enter upon theE
above-mentioned property for inspection imare,ex.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE As
liabilities,judgments.costs and expenses which may to any way arcane against said City ALTER OR ADD TO MECH.
in consequence of the gretning of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
U14AIJOA In. ��`,( AIR HANDLING UNIT(OVER 10.000 CENT CONSTRUCTION TAX
B mm of AppocanwCommelor m EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupeo,unte r handle havrNous maurial HEATING UNIT(TO 1010M BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532u1^ 1 HEATING UNIT(OVER 100.001 BTU)
❑Yes CNo
VENTILATION PAN ISINGLE RESID) PAID
Will then applicant or frame building Dae Receipt#
PP il by the Bay Area
Air
Maagemet BOILER-COMP OHP OR 100.0'10 BTU)
mil hazardous am contaminants as defined by the Bey Arco Air Qmlity Management
islrlcr^ TOTAL:
' ❑Yes 71 No BOILER-COMP(OVER 100.(IIM)0N)
1 have mad the hazardous materials requirements under Chapter 6.95 of Ne Cali. AIR CONDITIONER ISSUANCE DATE
[il'ur,does
e Health&Safety Code.Seaiom 25505,8533 evil 2553a.1 understand tha if INC NEN'RESIDENTIAL MECH. SQ.FT.
dnns currently have a tenant.Nal it.,my responsibility to noddy Nc Occupant
the requirements which must Be mel prorm issuance ofaCti ificme ofOccupancy.ner or uwhomzed#gem Dam
\ ISSUED BY:
OFFICE