29041 rtY D,sr Uf•Iv1Nl IWN Vill f"M KLU LINOS•USI=UMLL F'L I YIN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMITNO. /� q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL -/Q O/I 1
BUILDING PROJECT IDENTIY'ICATI(1N L J -f
BUI IN ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Z Z2cr, // -/3-Ayr
OWNER'S NAME: PHONE: CRACTOR'S NAMB: - LIC NO:
R ifAI T2 L NIC CONTROL#
z
ARCHITlD7UENGINEER: LIC NO: ADDRESS: ❑
N/46 e4k'6 10Ra SUnA/ vALEC
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Feet/Paid by Applicant(Initial) BLDG ELECT PLUM MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
. I hereby affirm Nat Iran licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Y40Z with Section 7")ofDivision 3 of,he Business and ProfessionsCede.and my licensers RESIDENTIAL,
IW i PERMIT ISSUANCE �.. L.
yr License
effect. ❑ShDWL El KITCHEN REMODEL
�UU License Clsss LIC.M APPLIANCES-RESIDENTIAL []ADDITION C/s /PLUMBING RE-PIPE
EDate Contractor
Fly ARCHITECTS DECLARATION PANES El MULTI-UNIT ❑STRUCUML
O
CZ y� I undersmed my plans shall be used vs public mN
cos MODIFICATION
:J UPT0200AMPS L1 INTERIOR ❑CHIMNEY REPAIR
I:4�4I Licensed Professional 201-1003AMP5 IMPROVEMENT
•....4Il OWNER-BUILDER DECLARATION OVER IIXIO AMPS ❑BATH REMODEUREPAIR ❑DE ITION
OW U 1 hereby affirm that I oto exempt fon atrucmrs License Law for the 1 ER AL �' �,•
3 d following peas....(Section]NLS.Busines' rd Pro I s Codc:Any coy m uoty SIGNS ELECTRICAL F�J� p ..ems.
u•ya which requires v permit m c...tmc,elle improve,demo) m repair any swemre L ON �/VATE/efsla.rGa�_
F.LL.y.4 prior to its issuance,also requires the app antforsuchpeomi0 lee signed statement SPECIAL CIRCUIT/MISC. .eOPrRry'
} Nat he is license pursuant to the proms' naofthe Contractoo§Lic Law(Chapiers)
GC (commencing with Section Man of Di slon3nf11be Buainessand Pro ion.sCere)or TEMP.METER OR POLE INST. OMC MERCIAL
IIF n y that he is exempt therefrom and the sis for the alleged exemption.An iolution of _ ❑NEW BLDG/ADDITION ❑DEMOLITION
LttSemon]031.5 by any applicant for permit subjects the applicant to v civil nalty of POWER DEVICES
-Ra ❑TENANT ❑FOOD SERVICE
z} notmoroman ftfth pone dollars employees
mpl IMPROVEMENT
Q ❑Lothework,andtmptractu yot meneesolthwaga as their sole compin inn, SWIMMING POOL ELECTRIC
Q'will Pmfia work,ande:The Cu iatots License Lawdoesmsale(51,.]041;owner
ss - ❑OTHER
and Professions Code:The C Iracmra'Licit w Luo dues not op to If owner of OUTLETS-SWITCHES-FIXTURES
R' his w.who builds fo im a Neuron,enJ who docs such wvI 1 or through
his awn emimm.0h,pmvi that such impm enm arc n�'qt de oro red for NEW RESIDENTIAL ELECRt SQ FT. b
owner-builder
will
ngorimprovemm�t is ithinohcg4r m einn,the SQ.FII FLOOR AREA SISQ.PT.
.wnervbuilder will ha the,other of pfoving •did nm wild pimp ve(mpur-
'we of agile.). f�
❑1,as owner a Atop"',sm exclusive utraa((71RAg WBh licensed .toner....to _ TOTAL:
...drat the tj,,t(Sec.9044,Budnev-n roµcssllaS e:)The mossermsLi-
nsoLaw I net.Aptly torn ownent arcsx hohuiTTds ar imp.. e,dareo ,and QTY. PLUMBING PERMIT FEE
whocon tefico me madpursuant the Contractors 00Lieense law. \\__ PERMIT ISSUANCE W
❑ lam exempt a er Sec B P C forthis taaon
Owner D e ALTER-DRAIN&VENT-WATER(EA) VALUATION
WOR 'S COMPENSATION DECLARATfON BACK FLOW PROTECT.DEVICE 0o 00
I hereby from uncle nahy of perjury one of the 17.119iliall declantions: 7V V
I have and will maintain o nificateof Consenttosclf.ins re for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
smion,as provided for by Se
3900.E the labor Cee, r the performance of the
work for which this pemdt is I,. - FIXTURES-PER TRAP
I have and will maintai Wor .mpenution Insu nue,as required by Section -
3900ofthe ode, rthep on ceofthewmk mwhichthiapemakimmed. GAS-EA.SYSTEM-IINCAOUTLETS OCCGROUP - APN
My Worker' ra rad PnT ndmlxrJrc:
Pot GAS-EA.SYSTEM-OVER 4(EA)
Cartier.
C IFICATF.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thn,,ectiot nee not hccompteted if the perm,la furore hundom dollars lS 1 No GREASETRAP
or less.)' PLANCHECK FEE
Boy My Person
in man,oramaer otom. lork far xt.nne bje this perthe Wcslssue,l ahall.- SEWER-SANITARY-STORM FA.200 FT.
not....ploy any person in any manner m oa to become mbject m the Wnrker%Compen- ENERGY FEE
0 smion laws of Califnnit.Date WATER IIEATF.R W/VENT/ELECTR
Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Workers Compensation provisions of the Li lour Code,you must SOUS FEE
fonhwith comply with such provisions or this Permit shall bedeemedrcvoked. WATI3R SERVICE
Q
STRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
U 0 Ihereby e(B ,zgTt/�' ertt atnci�lendim Mw,f.,.hxpermunm,eor Data Receipt#
Ila r4 the work fm ahi I+em �asu-rd(S p -
0 Landers Name TOTAL:
Lenders AdNeaa TOTAL:
ns I=Y Ora l hat/ pea this M,tm.mm mW state that the above information is BUILDING FEE
U(A cmreel.lagreemcomply i all city and county ordinances and state laws Misting m QTY. MECHANICAL PERMIT FEE
U buildin6 conswction,and hereby uuthorim represenmtiva of this city¢+enter upon the SEISMIC FEE
above-mentioned properly for inspection putpnses. PERMIT ISSUANCE
(We)agree m save,indemnify and keep Made.the City of Cupcnino again.. ELECTRIC FEE
liabilitinjudgmema,costs and expenses which may in MY way accrue againatsaid City ALTERORADDTOMECH.
in consequence of the granting ofthis pemtit. PLUMBING FEE •S
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1101 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature mApplicant/Comracror Dam EXHAUST HOOD(W/DUCT) - HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building occupant store orhandle hanummus material HEATING UNIT TO 1011"BTU)
sa defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safety
Code,Section 25532(4)? - HEAfIg
TING UNIT 1WD BTU)
C]Yes air VENTILATION FAN(SINGLE RFSID) PAID T/ u 17/6
In Receipt#
Will Ne applicant m fumrc building nectitandthe B y A equipment m devices which
emit hazardous air contaminants as defined by the Boy Area Air Quality Management BOILER-COMP(3HPOR 100,000BTU) OTAL:
District? /' BOILER-COMP(OVER 100,0X1(1 BTU)
C)yes C NH
AIR CONDITIONER
I have mad the h ode,Se me¢ritls requirements under Chapter understand
of rite Cali- L'11 I Ur V�SSUANC&D'AT
fomin f n Safety Coda Sections 255115,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. 1 �p
b' C not currently have utenanL that it is my res p,In Ceirycate.to fOccupancy. i
of umexamit ich mus a ,pri. t suana ofa Certificate of Occupancy.
0 t mese rued agent - Date TOTAL: ISSUED DY: a
OFFICE ,