29092 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPE'RTINO BUILDING-ELECTRICAL " - PERMIT NO. L1JJ^ ^ O 9 2
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.'
BUILDING PROJECT IDENTI
J�GILDING ADDRESS: L-OT I SANITARY NO. APVPLICATION
1SUBMITTAL DATE
44
WIDE MF.: PHONE:
CONTRACTOR'SN ME: - U
p y1 011 ,� N/C CONTROL#
ARCH 'ECT/E GI EE LIC NO: qD RESS. �O/ "0
. . t ,
CONTACT: - ONE: - 1 1. BUILDING PERMIT INFO
Z ❑ Consultant Fees Paid by Applicant(Initial), @Lpp TLE T PLUMB MECH
% IT.dCf �
.KENS DCONI'RACTOR'S DECL A DN ,QTY. ELECTRIC PERMIT FEE
I hereby i ffnm that Iran Bcemswv
aer pre.mouser chapter 9(enmmeneing IDTIA700 DESCRIPTION
E%Z whhsem'on 0000)of Divisio f the Insoles,and Prnfes"mr,Cod,rad my licameI,
Fky0_ infill force andeffect • PERMIT ISSUANCE FDWL ❑KITCHEN REMODEL
�UZU License lass Lia#
CES-RESIDENTIAL
FQW Date Contractor ADDIETIIOONN El PLUMBING RE-PIPE
CT:S DECLARATION PANELS
N,❑rn A ❑MULTI-UNIT ❑STRUCTURAL
L
yph� lunderstundnryplens shallbeasedaspareords MODIFICATION
blioc
O Z 4 UP TO 200 AMTS
.�.E"W Licensed Professional El INTERIOR ❑CHIMNEY REPAIR
giti "I OWNER-BUILDER DECLARATION .•, 201-1000AMPS IMPROVEMENT
'I hereby affirm that 1 am exempt four the Contractor's License Law for the OVER 10011AMPS ,El BATH REMODELIREPAIR C1 DEMOLITION
?q5 O U following reason.(Section 7031.5,Business and professions Code:Any city or county SIGN9 ELECTRICAL ❑OTHER
which requires a permit to construct,alter,improve,demolish,or repair any structure _
q w prior[ O.tasu c Ise rec,dre,thri,plicaarn lr,ucb permtt file.,,randmirtanner, SPECIAL CIRCUIT/MISC.
pq y
that heislicensed p te tt the provisions fthe Corrosions L L (Chapter9
qC) (commencing withy ti 7000)of Division 3(if the Business andProfessions Code)or TEMP.METER OR POLE.TNST. COMMERCIAL' '
0.GL m OL that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ' El DEMOLITION
IrX1 {ye Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 'POWER DEVICES []TENANT FOOD SERVICE
F' qzz not more than five hundred dollars($500} IMPROVEMENT
❑ . SWIMMING POOL ELECTRIC
I,as owneroftbe properly,or my employees with wages as their sole compensatioq
Qa will do the work,nnd the suumarc isms,imandedoroffered tontine(Sao 7044,Business ❑OTHER
aad'Profasions Code:The Convector's License Law deal not apply ,,an owner of OUTLETS-SWITCHES-FIXTURES
a'3�' property who builds or improves thereon,and who does such work himself or through - -
his own employers,provided that such improvements are not intended or olkered for NEW RESIDENTIAL ELECTR S '
sele.If,howaver.the building or improvement is sold within one year ofermpletion,the �� - SQ.FEFLOOR AREA , $/SQ.ET.
owner-builder will have the burden of proving that he did not build m improve for pm- - ���LLL,,, /�
pose of sale.). 2Q^ 3 8 O
❑ has owner of the property,em exclusively contracting with licensed contractors to 1 /� CJ
construct the pored(Sec.9044,Business and Professions C(de:).The Contractor's Li- - ��1 I `
cense Lew dees not apply to an owner of,property who builds or improves thereon,and QTY PLUMBING PERMIT PGE l7
whocomracts fersuch projects with a contentious)licensed pn arculto the Contractor's - -
License Lure. PERMIT ISSUANCE
❑I am exempt under Sec. ,B A,P C for this reason - 'I
ALTER-DRAIN&VENT-WATER -A), VALUATION
Owner Date -
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVIC /11
. - y1
- Iheredy or firm under Cenra o[perjvey one of @d Ynllnwing devinratione
07 I have and will muinmina Certitficate of Conscnt to self-insure for Worker's Cmnpen- D AINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
i.on,as provided for by Section 37W of the Labor Code,for the performance of the - "
work for which this permit is issued. FIXTURES-PER TRAP -
❑ I have and will Ominmin Worker's Compensation Insurance,as required by Section - - -
37M of the Labor Code,for the performance of the work for which this panic t is issued. -EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Comps sit io nceccoier and Policy boar +
Cama:�nv Policy No.:�1J11/7K GAS- .•YSTIM-OVER4(EA)
C ]FIC .OF SATIONIONFRO K `
lb
COMPENSATION INSURANCE ASGIND .TRI WASTE INTERCEPTOR BUILDING DIVISION MM,S
(TM1lsewtlon need nm becompldedifthrpermitiv forme hundred dollars($Ilg) SETRAP ;+
or less) PLANCHECK FEE ,
Loy say that
rwriin rerformanythamnceo the a,1.Fokforwhich this permit lsro,'C ]she, SP. 'AN ITARY-STORM .200 FT.
not employ any aim r n any manner so as m becomo sobject m the Workers'Compen- �- ENERGY PEE `
„ Z stood
mcum sof Celifornin.Data WATER .RW/VENT/MECfR rUU'�N I GRADING FEE
y NOTICE TO APPLICANT.If,after making this CartiOcato of Exemption,you should WATER SYSTEM/TREATING
f-I become subjacuo the Worker's Compensation pr..Wooser the Labor Coda,you most SOILS FEE
forthwith comply with such provisions or this permit shot]be deemedmvoked.
WATER SERVICE ,
Q
�7. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Er. PAID
(hereby afTrm that ieaconstmedon lending agency for the Performance of Recant _A
the work for whichthis permit is issued(Ser.3097,Civ.C.) W
Q U Lender's Name
- - TOTAL:
{Ta
LandersAddress "
1 certify that 1 have read this application and show that the above information is - BUILD] E ILA 62
t0./, armed.]agree to comply withal]city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE ^ b
U building construction,and hereby authorize representatives ofthis city to enter upon the SETS L BOO
aM1nve-(We) nod properly for inspection keep ha PERMIT ISSUANCE I� /_•-�
(We)agree to save,indemnify and keep harmless the City or Cupertino against E RIC FE
liabilities;judgments,costs and expenses which may in any way acerae against said CityALTERORADDTO MECH.
sequence nfill granting of this permit. P BING E
APP.]CANT UNllBRSTANDS AND WILL COMPLY WITH ALL NON-PONT. AIR HANDLING UNIT(TO 10,000 CESS 1[\
SO .RWULATIONS, MECHANIC LFEE. Lo`
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRU TAX
Si .- p 1 for m EXHAUST HOOD(W/DUCT) � - HOUSING MITIGAT FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO IW,OW BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety ,
Code,Sodom 25532(x)'! •.f HEATING UNIT(OVER IM 000 BTU)
Ely as i, ❑No ,
" VENTILATION FAN(SINGLE RESID) PAID Date Receipt#
WIIItheappticamir fumes building by the Btuseea AirQuordeviceswhich BOILER-COMP DGP OR 100,000 BTU)
nit hazardous air wntnmivan¢as definod by the Bay Arca Air Quality Management
�istrleR ' - . BOILER-COMP(OVF,R 100,000BTU) .. TOTAL:
„
Fl W, No -
Ihave mud the has d te' t t nder Chr,,Nr 695 ofth Cal- AIR CONDITIONER
- ISSUANCE DATE,
Serum Health&Safety Cod Sect 25505 25531 J 25534 1 understand that f the NEW RESIDENT MECH. SQ,FT.
building drus nom,which
ha,a t t th t t y re p b'rtifl a ffOve occupant
. fNe requirements which muss he met priors tsuthreats Cen Eca¢ofOwupnncy ;
Owner or anlorized agent - Date - '
ISSUED BY:
,. 'OFFICE