29922 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IBUILDING-ELECTRICAL. - PERMIT NO, 29922
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BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL L�9 9 L L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
2►Gas nLau(/�re �� ^Dc . �u/ -erh✓1a<1 , CSW- � s(oi 57-/ C
OWNER'S NAM-a✓i1/1 CILA PH aSS-gw(lf G�,RG II1lNA ITV CSI 1..0YI Jl LIC NO: Y��
f1/- N/C CON']EOL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: �f4 ❑
I s ;na Way, S.T. 9SI I Y
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 an licensed under provisions 0f Chapter 9(commencing JOB DESCRIPTION
COZ with Section]000)of Division 3 ofthe Business and Professions Cade,and my license is RESIDENTIAL'
Wore, in full force and effect. PERMIT ISSUANCE - I
GUU License Class hie# ❑SMWL ❑KITCHEN REMODEL.
y G W Dam Contractor APPLIANCES-RFSIDENTIAC ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
F"z land ea.ad myplsoo,hall heated aspablic records PANELS MODIFICATION
OZ4� UPT021q AMPS ❑INTERIORHIMNEY REPAIR
F 4.F-,; Licensed Professional 201-1000AMPS PROVEMENT
cy OWNER-BUILDER DECLARATION
"Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000AMPS BATH REMODEUREPAIR ❑DEMOLITION
¢136{y vI'a following mason.(Section]031.5.Business and Professions Cri Any city or county SIGNS IiLE.CTRICAL OTHER
O which requires a permit to construct.alter,improve,demolish,of repair any structure
F.
C prior to its issuance,also requires he applicant for.such permit o file a signed statement SPECIAL CIRCUIT/MISC.
f es•, that he is licensed pumtt
uvno the provisions of the Contractors License Law(Chapter 9
W�00 (eommembir,with Section 7000)of Division 3ofthe Business and P..fic,ont QNB)or TIME METER OR POLE INST. COMMERCIAL
6 e C that he is exempt therefrom and the basis for the alleged exemption.Any violation at ❑NEW NLUG/AUDITION ❑DEMOLITION
W2, Section]031.5 by any applicant for a permit subjects the applicant to a Civil penalty of POWER DEVICES
ul—rn ❑TENANT ❑FOOD SERVICE
not room than five hundred y,,syatH)). IMPROVEMENT
fS0 ❑lLothe montane PmEsmthe comptur,myon intended with as for
c04.Busi ip.ess SWIMMING POOL.ELECTRIC
p- will do the work,and the he Com it nm intended Cut,chat, safe to an Business ❑OTHER
❑a. m and ens who
Core:The oyes there. License taw Jots not apply to if owner of OUTLETS-SWITCHES-FIA-TURES
6'3 propeny whes.,ilds pr improves[hereon,and who does,such work himself or through
his own employeese provided that such improvements vre not in.,of m offered for NEW NESIDEN'TIAL ELECTR SQ let.
salelLboweaemthe buildingoden of pement itmlhewithinitbuildr improve
the SQ.FT.FLOOR AREA SISQ.FT.
er-0 ds.) will M1we the Norden of proving that he did not build or impnrvc far par. -
pose os,Owne - ,
❑1,as owner of the propeny,,B exclusively contracting with:)T1m Ccunuumms m TOTAL:
answer the Project(Sec.]1414,Business and 14nfessiom Code:)'D1c Contractor's Li-
nseLaw doesnot apply toanowner ofproperty who huiIds oriinpmvesthereon.and QTY. PLUMBING PERMIT FEE
Li-
cense
e.ntmns for such projects with a combr a)licensed pdrsarm I.the Com tutor
License law. s PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of the ItIDon declarations: I I W s
�]Ihave and will maintain a Cenificate of Consent toself-iname for Worker's Compete DRAINS-MOOR.ROOF AREA.COND. STORIES TYPE CONSTRUCTION
worn,us pmvidhi for by Section 3]W of me labor Cale,far the perfomtance of the
work farand this maintapermit is okJ. PIXTUNES-PER TRAP
F1 have and will in Worker's Compensation Insurance,which his res M1y Section
My orkerla.or GNefonhsuranccancer and Pomk(numare pemtit isisauad. GAS-G.SYSI'GM-1 INCS OUTLETS OCC GROUP AI'N
My Worker's Compensminn Insurance comer and Policy number ore:
Cariee Pnlia,NO.: GAS-EA.SYSTEM-OVIiR4(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRLWA. EINTERCEPTOR
BUILDING DIVISION FEES
['This Oatian need mf be completed if mepanat is if,,Onchundred dollar,IS half.r less) GREASIi TRAP PLANCHECK FEE
I reufythm in the pedarmmar.fine work for which mit pcmdt is issued.Ishall SEWER-SANITARY-STORM EA.200 FT
oat employ any person in any automat so ns u0 become sahjecno the Workcrd Compete ENERGY FEE
',Z sari..Laws of California.Date WATER HEYprit WNENTMLECTR
z O Applicant GRADING FEE
z y NOTICE TO APPLICAM':If,after making thin Certificate of Exemption,you should WATER SYSTEM BEATING a 501.8 EEG.7 became.subject w the Worker's Cmmpmq
cnsetion provisions of the Luba Cuda,you m
fOMwith comply withzuch powitiorte mthiv permitshvll screamed revoked. WATER SERVICE
G0 Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.ET. 'PAID pato - Rccci t#
1 hereby efbrm that[scre is a nmswetion lending agency for[M1c perlJnnance of T
the work for which this permit is issued(Sec.3091.Civ.C.)
u' U Lenders Name C, TOTAL:
O V Lender's Address TOTAL.
} WI sanity that I have read this a I t d stats that me above information is BUILDING TEE
r t3. Y pa dcounty building and
with allordinances and sm[e laws refiling he QTY. MECHANICAL PERMIT FEE
L) z building amnmminn,and lumeby awhorize npresemWiven.f this city r,0 enter upon the SEISMIC FEE
above-mentioned propeny for inspection purgai PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRI f E V
liabilities,judgments,costs and expenses which may in any way nreme against said City ALTER OR ADD TO M P.CI I. PLUMBBS�FEE
in consequence of me granting of this permit. .l
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR GUL 194NS' M[CHAN 11 FF.F.
��/%/2� •/y/ AIR HANDLING UNIT(OVER 10.000CFM)FX�� � �'� CONSTRUCHON TAX
Signam 'pplicanVContmcmr Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATF.RIAI S DISCLOSURB
'ill the applicant or future building Occupant store or handle haardnus material HEAPING UNIT(TO 100,000 BTU)
_ as defined by the Cupertino Municipal Cale,Chapter 9.L2.and the Health and Safety
,. Coda.Section 25532(a)P HEATING UNIT(OVER 100.000 B'TO) ,
E]Yet []No VENTILATION PAN(SINGLE RESID) PAID
Data Receipt Of
Will the applicant or future building twerpoin use equipment or devices which
�ctutI td onto I. defined by theBay Area A' Q lily Managcmmnt BOILER-COMP[3HPUR U10,00011TH) TO'T'AL. .
Dismal BOILER-COMP(OVER IWA(IO BTU)
❑Yes E]No
I have sad the.matrass ttiutedals rryuiremcros uiMer Chapter 6.95 of Cut- AIR CONDITIONER ISSUANCE DATE
Lesson Health&Safety Code,Sections 25505,25533 and 25531.1 understand that if the NEN'RESIDENTIAL MECH. SQ.ET.
building does not currently have a mint,that it Is my resrymsihilay to notify the Occupant
of me requirements which must be File[Pare o issuance(if it Cenlllcare of Occupancy.
Owner or authorized agent Data TOTAL: ISSUED BY: + `
OFFICE