29673 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29673
BUILDING PROJECT IDF.NTIFICATION
BUILDINGADDRESS: SANITARY NAPPLICATION SUBMITTAL DATE
a
OW RS 2 7- rm
'g � `�(�NE: LTO ' NAME: f- lljO: 3 NIC CONTROL#
RCHITECT/FNGINEER: rLIC NO: DRE. /t ✓( ❑
69 044SPS
CONTACT. PHONE: a/V/ BUILDING PERMITINFO
❑ Consultant Fee.Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
`r ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affrm Nat Iran IicenseJ under pnrvininnx of Chapter 9(commencing, JOB DESCRIPTION
Qax
� iNm$ae Cllas]IXX) f Diii3l htlLIC.i# d Pfc,uma C[We`
u ylieenseis
RESIDENTIAL,
Wrfull tomeand effect PERMIT ISSUANCE ❑ DWL
in � ❑KITCHEN REMODEL
LiceAPPLIANCTS-RFSIDENTA. ❑ADDITION. F ❑PLUMBINGRE-PIPE
(�(--..fin' D �CH�LTS ECLA ON PANICS GMftjjIlTI-UNIT ( y OSTRUCfURAL
Z8 l understand my ,an shall be used as publi a /E MODIFICATION
0 pp TO 2W AMPS �INTERIt� 9 ❑CHIMNEYREPAIR
�ayu1 Licensed Pmfessian 201-1000AMPS "/,IM '9 ,.•
C •.•11 ' OWNER-BUILDER DE LARATION OVER IOW AMPS QBATH,REMODEVREPAfH/O DEMOLITION
d'W st I hereby affirm that 1 am exempt from the Cmitremors License Law for me V`r_^
iqyx5 6 V following reason,(Section 703 1.5,Business and Professions Code:Any airy or county SIGNS ELECTRICAL ❑OTHER
0
i++3which requires is permit to construct.alter,improve,demolish,or repair any structure, syff�(/
� prior 0 its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provisions ofthe Commnor's License Law(Chapter 9
00 (co an.with Section.—,.I Division 3 ofthe Business and Professions Code)or TEMP.METER OR EI COMMERCIAL:
o eC Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑N W BLDG/ADDITION ❑DEMOLITION
II• Section]031.5 by any applicant far o permit subjects Ne applicant m e civil penalty of POWER DEVICES
I„ iN+ not mom Nan five hundred dollars($500). 1 RO [I FOOD SERVICE
la�a' pl,ae owner of the property.or mycmploYeeawiNwogesas their sot<compcnsation, SWIMMING P(lO1.ELECIRIEMENTC
,L35s � wdl dmhework,ande:The turelsnats Livens urofwdoess notapply 1H4,Business ❑OTHER
land Professions Cnde:The Conwmor's Liceme Lnw Jnes not apply m vn owner d UTLETS-SWITCHES-FIXTUH ��
n' r pmpeny who huilds ad improves thnaom,and who docs such work himself ar thmugb
his awn employees,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
sale.If.however.the building or improvement Made!within one year a(compinion,Ne - a�- SQ.F�T.FLOOR AREA FT.
coureor-builder will have Ne burden of proving Nat he did not build lar improve for par- I ga{.�
pas,of sale.). '`I1Tl/
❑1,as owner mf the property,am exclusively contracting with licensed contractors to
construct the project(See.7044,Business and Professions Cider The Unioncmr'a Li- -
cams,Law does not apply to an owner of property-who huilds or improves thcremn,and QTY. PLUMBING PERMIT FEE '
who contracts for such projects with a cortico(s)licensed pursuant to the Canwemr'c
License Low. PERMIT ISSUANCE
Olametrourn eln Sec. ,B&P C for this reason
Owner Data
ALTER-DRAIN&VENT-WATER(EA) VALUATION
a #issue i,WORKER'S COM PENSATION UECLARATIIN BACK FLOW PROTECT.DEVICE � �Js s
1 hereby affirmunder Penalty or
to perjury one of the fnllawingdedantiom:
❑Ihave and for by etion 37M of the Laud sole.for
for Workers Camper- DRAINS-FLOOR,Rt]OP,AREA.COND. .STORIES TYPE CONSTRUCTION
workas provided for by Section 3]W of the ISMr Cale,for Ne Performance of the
work for which this pinna is issued FIXTURES-PER TRAP
I have and will ode,fon Worker's Compensation rkfar which
h require.)by Section
My of the Calm Gde.fanhsurance cancer and Folic farlnumberh Nis permit is issued, GAS-EA.SYSTEM-I INC.40U'I'hETS OCC,GROUP APN
Ca Worker's Compensation Insurance earlierandPolicy number are
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 41t!A)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
obis section ri not W completed ifthe permit is for one hundred dollvs(SIW) GREASETRAP
or less) PLANCHECK FEE
I certify Nut in the performance ofthe work for which this permit in Issued,Ishall NEWER-SANI'T'ARY-STORMPA.2WFT.-
net employ any prison in any may...o as m tuci me subject 1.the Worker'C.rii ENERGY FEE
2,Z starer lawsof California.Data WATER HEATER WNENTIELECTR
� Applicant GRADING FEE '
ti NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption ynu should WATER SYSTEM?SEATING -
a become subject an the Worker's Compensation provisions of the Labor Carle,you must SOILS FEE
forthwith comply with such provisions or this shall be deemed revoked. WATER SERVICE
0
CONSTRII NLENDlNGAGENCY NEW RESIDEiN'I'IAI.PIMB. SQ,FT. PAID
O � -
1 hereby affirm that them
construction erc is a consction lending agency fur the performance of Date Receipt
U. Ne walk for which this permit is issued(Sec.3097.Civ.C.)
0 E•' LeMers Name TOTAL:
LJ Lenders ANlress - TOTAL:
BUILDING FEE
F+ 1 certify that I have ithJ this application amt dstateine that Ne above information ming is
fq coweL lagree mcomply
andwith all city and county sencin ncesand cityto alual othe QTY. MECIIANICAL PERMIT PEE O
' V ,� building conswction,and hereby authorize representatives a(tbis city to corer upon the SEISMIC FEE
43
above-mentioned property for inspection purposes. ` PERMIT ISSUANCE
(We) zoom save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs add expenses which may in any way true against said City ALTERORADDTOMECH. t
in consequence ofthe g.ti,of t is permit PLUMBING FEE
SAPPLICANT
OURCE GULATIONS ND A .L CfJWLY W HALL NON-POINT AIR HANDLING UNIT(TO 10.0X0(1 CFM) MECHANICAL PEE
O
(/
2- Z, 9 AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTIONTAX
itsi of AppliciumpUmwdor Uam { EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store mhandle hazadous arterial HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9:12,and the Health and Safety
Cada Section 25532(x)? - 'HEATING UNIT(OVER I00,000 BTU) '
-
QYess , FIN. PAID e
VENTILATION PAN(SINGLE RESID) .Date Receipt#
W.II the applicant or future building occupant use equipment or devices which
t emit hazadnm it contaminants as defined by the Bay And Air Quality Management BOILER-COMP(3HP OR IWABO BTU) TOTAL:
C District? BOILER-COMP(OVER Ionond BTU)
❑Yes ,MNo
AIR CONDITIONER
1 have reml Ne hazardous S tions 2 5 requirements under Chapter fi95 of the Cali- - ISSUANCE UA
folia Health&Safety Code,have
25505.25533 and]5534.1 understand Nat if Ne NEW RESIDENTIAL MECH. SQ.FT.
Wilding does ercmtendY have a m met
Nato ismy.a of.Cardinale
notify Nepancy. t
of the requirtnrnts which must M met prior to issmnee of a Cerdfinm of Occupancy.
Owner or amhnrized#gem Dine ISSUED BY �v`•- aa •
OFFICE