29650 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 2 9 6 5 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL VJ {V�
BUILDING PROJECT'IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
(0 3
OWNS 'SESAME: PH N': CO AC/JpNy�N201d �r� n I.IC NO:
E L 'e ' / /Nf/Yf ON� /(/iG• NIC CONTROL M
( ARCHI'MCNEN NEER: )IN •9i APUR $$ v 6t.LL SL 6a ❑ $oyv
CO���N111TACT: PHONE: BUILDING PERMIT'INFO
�� IJ;,r
D U� �as,S-���� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
%1 L? 5-- L— Cd'
LICENSED CONTRAC O S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby M.that I am licensed under pmvisimns mf Chapter 9(commencing JOB DESCRIPTION
-WOO with SectID
ion 0lBof Division J ofthe Business and Professions Code.and my Iwameis RESIDENTIAL,
Ftp infull Ruceandeffect. PERMIT ISSUANCE
QFUZV License class s,' 9f• y� ❑SFDWL KITCHEN REMODEL
N6� Date Coatimmr C N APPLIANCES-RESIDENTIAL I^ ❑ADDITION ❑PLUMBING RE-PIPE
F,pr>a ARCHITECTS DECLARAI ON •CN PANELS C1 MULTI-UNIT C1 STRUCTURAL
O2 q 1 understand my plans shall M1e used as public records MODIFICATION
UPT0200AMPS [-I INTERIOR [I CHIMNEY REPAIR
Ft3 '-14 Lmerscd Pmfussmod 201-100)AMPS IMPROVEMENT
vQkit rl OWNER-BUILDER DECLARATION
% 1 hereby uflirm that 1 am exempt yrom rhe CCountLicense Law for the OVER WMAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
following reason.(Section]031.5,Businessomit Professions Code:Any cantor.,only SIGNS ELECTRICAL []OTHER
F which requires a permit to construct•alter,improve,demolish,or repair any swetum
prkam innisance,elso requiresth,.,licout frsrxuch partial o file.signed statement SPECIAL CLRCUIT/MISC.
c�} that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
�C�O (cmmmeruing with Secti9n]f100)ofDivisinnJ nfthe Business and Rofessi...Code)or TEMP.METER OR POLE INST. COMMERCIAL:
6 6 n E Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y
Section 70113 by anyapplicant forapermit subjects the applicant too civil perod"of POWER DEVICES
p,
not more than five hundred dollars($50P.
❑TENANT ❑FOODSERVICE
G ❑1,as ownerofthe progeny,many employees with wages as theirsolecompensation, SWIMMING POOL ELECTRIC IMPROV MENT
will do the work,and the structure is not intended muttered for sale(See,7(94,Business ❑ E
Wa and 1'mfeWons Code:The Contmcme,License Law does not apply m an owner.1 UTLETS-SWITCHES-FIXTURES0.
property wlm builds ter improves thereon,unA who Arc xuch work himself or tivnugb
his own employees,provided that such Impmvemmnts are not intended or offered for NEW RESIDENTIAL.F.LECTR SQ FT.
aide.lL however,he building or improvement is sold within one year ofcompletion,the SQ. LO ARBA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve fur pur-
pose of Rule.), ^�
❑ 1,as owner of the property,am exclusively cmetructing with licensed contrarian or .0
construct the project(Sec.7814,Business and Professions Code,The Contradori Li
wc pm
e Law does not apply to owner of pony who builds or improves thermmn.and QTY. PLUMBING PERMIT FEE
bocmntmcts(nnuch projects with acomrumr(s)licensed pursuant to the Convenors �n96
1.rclaw.
I am
❑ ate exm
attempt under S . ,B&PCfar tre..re....his an JUN ,t°
PERMIT ISSUANCE 9
Owner Date ALTER-DRAIN&VENT-WATER(EA) Cily UI- GUIVL1IuATIQpjp
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE � L'J,�U
I hereby ditto made penaltynl'perim,one of the following dmlmodurs:
❑ Ihuve and will mainwina Cenificutc ofCnnsennn self-insurefor .Worker's Cmngzm DRAINS-FLOOR,ROORAREA,COND STORIES 'TYPE CONSTRUCTION
cation,as provided for by Section 37N)ol'tIm Labor Code,for Nc Performance of the
..,it 1'or which this permit is issued. FIXTURES-PER TRAP
❑ I have and will nuimuin Worker's Compensation Insurmtee,u required by Section
31MofIle Lahti CCcode,for the performance of the work for which Ni ;;,it i9issuad. GAS-FA.SYSTEM.I INC.4 OUTLETS GCC.GROUP APSE
C.merMy �ktt .Imp .mmol etmnce 'a1cy No.;�uddr���r� •� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFIC TE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUIL IVIS NFT:1'S
(This section need not be completed if the permit is for one hundred dol Ian DE its)) GREASE.TRAP (A..
or less.) PLANCHECKFEE 9Zg/J
lit,mythmo the performance.any
work forwhichobject
permitrkers'Conquer.I shall SEWER-SANITARY-STORM[IA.Nat FT. �J
nm employ any person in ony moaner tet ns 1u Ixnmie auhjen m the Worker.'Conquer. ENERGY FEE
Oz eaten LtwcnfCallfomia.Date WATER HEATHS WIVENT/ELECTR
0 Apph, 11 GRADING F
y NOTICE I0 APPLICANT.If,after making this Cerilicate of Exemption,you should WATER SYSTEM/TREAHNG
aheamm subj.,tot he WmrkerR Compensation provisions of the labor Code,you must SOILS FEf
forthwith comply withsuch Provisions or this permalhall be deemed revoked. WATER SERVICE
CONSTRUCTIONLENDINGcOAGENCY NEW RESIDF.Nf1A1.PLMfl. SQ,FT. PAID
VQ I forwhichinnt pe there isand(Sect3W7.Cis.agency for the performenceof D RaciptN
P. .y the work for which this permit is issued[Sec.909],Civ.C.)
0 (~ Lendrev Name TOTAL:
L) Lenders Address
0. 1 certify that 1 have read this applicalinn and state that the above information is BUII.DIN FEE o /1
+ L7I) s correct.l agree to comply with all city and county rrdinances and state lawmind,I,) QTY. MECHANICALPERMIT FEE
U A building cmnRtmgiont and hereby uuthorire rcpmwmmtivex of this city to enter urym the SEISMI FEE
nhnve-mentimod property for inspection pmposos' PERMIT ISSUANCE
(We)ngrce to save,inm�i
dmly and keep bunnies,the City of Cupertino against ELE IC FEC
habil ities,judgments,costs and expenses which cony in any way accrue against said City ALTER OR ADD TO MECH. - PLU BING FEE
inconsequent
fill gran ting ofthia permit.
APPLICAN NDERSTANDS All WILL COMPLY WITH ALL NO AIR HANDLING UNIT fTO IB00(1 CFM)
Scon;C ' CATIONS. r aa MECHANI FEE
RA4� ,y - • / AIR HANDLING UNIT(OVER IB,(Ifl(1 CFM) CONSTRUCiI TAX
Siarum of ApplicanVConvactor Date EXHAUSTHOOD(W/DUCO HOUSING MITIG ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupnnt store or handle hamrdous material HEATING UNIT 00100,(08 RME
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health used Safety
Cole,Section 25512OC HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Data Receipt q
emit huvnnlnus air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP OHP OR 100,000 BI'U)
DikrictI1 TOTAL:
❑Ya Ditto BOILER-COMP(OVER I(O.hNI BTO)
I h.ve road the hacuNoos mamdals AIR CONDITIONER ISSUAN iDATE
requirements under Chapter 6.95 of the Cali-
handsHealth&Safely Code,Sations 8505,25533 and 23534.1 undersmnd that lithe NC RESIDENTIAL MECH. SQ.FT.
bulldingmdtxs ncurrently have a edam,that it is my respnreibilay to nofify the acu nem
of the requirements which most he me no,to issuoncc of a Crnifew.of 0uupancy.
Ownerorauthnvcd.,ot Date
SSUED BY:
OFFICE