29575 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-RLEC`PRICAL PERMIT NO.-
BUILDING DIVISION APPLICXrION/PERMIT 'PLUML,PLUMBING ti29575
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/r0/SS
NER'S NA E: (N '�` ON' THACTOR'SNA LIC NO:
NIC CO ROLA
H(ECT/ NGINEER: IC NO A 1-S:M WO ❑
i
G)NTACI': H(1NIi: BUILDING PERMIT INFO
,e•{ �}J'�-/ �+ � El Consultant Fees Paid by Applicant(Initial) wC IiLF,CT PLUMB MECH
4`1 6elOAn 41M,41W'30110
LICENSED CON'FRACr OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
o�z with Section —RESIDENTIAL
WOO PERMIT ISSUANCE
F w in full force and effect. •� WL ❑KITCHEN REMODEL
aUU License Class Lic.p APPLIANCES-RF'_SIUFNTIAL DUIT'ION ❑PLUMBING BE PIPE
G a Date Contractor
�Om ARCHITECTS DECLARATION PANELS 0MULT6UNIT ❑STRUCI'URAI.
Z n Z I understand my plws,bull be used as puhlic records MODIFICATION
0Z_ UPT0200AMPS
a ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Poressimol 201-I0100AMPS IMPROVEMENT
�J
OWNER-BUILDER DECLARATION OVER IMIOAMPS ❑BATH REMODEUREPAIR ❑DEh10LIT10N
C d 1 hereby affinm that 1 ons exempt from the Contractor's License Law for the L O a U following mown.(Section 703 L5.Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
'�3 m h which requires a permit to construct.alrer,improve,demolish,or¢pair any structure
Fq-,�.0¢ Prior t0 its issuance,also requires the applicant far such permit to fie asigned statement SPECIAL CIRCUIT/MISC.
2`�} that he is licensed pursuant o the provisionn of the Contractors License Law(Chapr,9
Wy�� (commencing won Sectimn]W0)nf Division Softhe Business and Professions Cmie)nr TEMP. OR POLE INST. COMMERCIAL:
6 q o K that he is exempt domfmm and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
i� trN.
Section]Oils byany applicant for a permit sobj.a.,the applicant o a civil pcnaltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
not mom than five hundred dollars(SSW).
f-ZY I OVEMENT
=6 0I,as owncrof the Pmpen,or my employres with rages as their she compensation. SWIMMING POOL ELECTRIC
T F C ,R bi die work,i nd the suuctme is rel imendcd moffcrtd fr...le(See 7044,Business HER
W or and Prdes,inn,Code'Ihe Cnnascots Licence Law docs not apply lo un owner of OUTLETS-SWITCHES-FIXTURES47 1
property who builds or improves thereon,and who dons such work himself of through
his own employees Provided that such impro'corms are not intended m oRcred fm NEW RESIDENTIAL ELECFR SQ FT.
sale.If,however,the buildi ng or improvement is sold isithinanc year of completion.the i2`v1 SQ.FT Ff.00R AREA lYLSQ.FT.
mer-builder will have the burden of proving that he did ons build nrintpmve Torpor- 6 1�y rs�j x0.f1D
pmseuf.ale.). � -� b L Z, V
❑I.as cowar,of the property,ons csrhmisely contracting with licensed commeto n to TOTAL: I['
mnstruct the project(Sec,704Y Business and Professions Casm:)rie Contmetnrs Li- •+ �`� +J-� (`
seLawdxsnotapplyman owncrof property who builds or iniproem,hcremn,and QTY. PLUMBING PERMIT
who contracts for such projects with a contmctims)licensed pursuant o the Contractors
License Law, PERMIT ISSUANCE
Icon exempt under See ,B&P C fonhis reason
Owner Date ALTER-BRAIN&VENT-WATER(EA) 1 'VALUATION
• WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
1 hereby affnn mWcr pcmdly of penury arc of the fallowing declarations:
FlIhaveond will mainminn Cenilicate ofComenuo,elf-insurt fir Worker's Cooper- DRAINS-FLOOR,BOOK.AREA,COND. STORIES-.. TYPE CONST RUCTION
sation,as provided for by Section 37W of the Lahr Cede,for the performance of the `
work for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Cnnspensmimn Insurance,.,required by Section
390(u(tbe labor Code,forthe perRairanceofthe work for which thopermit isissued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OC s OUI"orj '' Q APN
My Without Compensation Insurance carrier and Policy number on: lD
Currier: Policy
so: GAS-EA.SYSTEM OVER 4(EA)
Cfiml IFICATEOF EXENIPI ION FROM WORKERS' s'I't Vt' Lllr... .
COMPENSM ION INSURANCE GREASE/INDUSTRL WASTI;INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifthe permit is formic hundred dollars(SIIXB GREASI7TRAP
nr lens.) YfANCHfiCK FEE C4
Iccnifytbm intheperformam¢of Nework 4nwhich thispermit isinwed,I shell SEWER-SANITARY-STORM CA.210 IT.
not employ any person in any manner w as to become subject o the W'mIscri Compen- ENERGY FEE r ZQ
Z sation laws of California.Date WATER HEATER WNEM1TIELECIR
C
Applicant - GRADING FEE
NOTICE TO APPLICANT:IL after making this Ccurficnte of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker's Compensation provisions of the lalwr Code,you must SOILS M.P.
431 ry forthwith comply with such prnvisicasor this Permit shall be deemed revoked. WATER SERVICE
0
n• CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.M. PAID
Dine RreeiptN
U 0 I hereby affirm that there is a construction lending agency, Performancefor the Performance of `
F the work)a,which mhis permit is issued(Sm.NYD,Civ.C.)
QLenders Name =^ TOTAL:
} W Larders Address TOTAL:11J 1•
CL. 1 certify that 1 have real this application and state that the above information is BUILDING FEE
ice.N conch.l agree to comply with all city and county ordinances and state laws riming to QTY. MECHANICAL PERMIT FEE
U Z building combustion,and hereby authorize representatives of this city to enter umn'he SEISMIC IgiG ,i��
ohove-mmtioned property for inspection ptopa". PERMIT'ISSUANCGELECTRIC FEE 1 `SIl10 0
(We)agree m save,indemnify and keep harmless the City of Cupcnom against
liabilities.judgments,costs and expense,which may in any way aecmeagain,st said City ALTER OR ADD'TO MECH. ^
in consequence of the granting of this permit. PLUMBING FEF. 1
APPLCANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-POINT AIR HANDLING UNIT(TO 10.(100CFMl
O P. F.GULAT NS. MECHANICAL FEC
S
AIR HANDLING UNIT(OVER IIh000CFM) CONSTRUCTION'1'AX
Signature ofApplicanUCo for ate EXHAUST HOOD IW/DUCI) HOUSING MITIGATION FEB
IIAZ IDOUS MAI HEALS DISCLOSUR.
Wi llthe applicant or future mildingoampont,ture0r handle hazardous macrial HEAPING UNIT(TO 1011,1X10 R.IG)
as defined by the Cupertino Municipal Calc.Chapmr 9.12.and the Health end Safety
Code,Simon.25532(ap HEATING UNIT(OVER 100.000 BTU)
❑Yes Fl No VENTILATION PAN(SINGLE RES1D1 PAID
Will thea applicant or future building t use t or devices which Date Receipt R
PP gby the
ea Air n BOILER-COMP DRP OR IRL000 BTU)
emit hazardous air contaminants a,defined by the Hay Arca Air Quality Management TOIAL:
Lbuildingd�nm
BOILER-COMP(OVER 100,ng)B'fU)
, ON.
read the hazardous materials re is under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE E
g25533a p
&Safety Cede,Sections 25hat i 25533 and 25534.1 to notify
Ron Illhe NEW RESIDENTIAL MliCll. SQ.FT.
not m whit y hive a tenant.that it is ua responsibility to notify the ucheYmems which moa be tact prior to issuunre mfa Ccnificac mfOccupancythorial age Ilam TOTAL: .W ISSUED BY:
OFFICE
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