29594 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO
• RUILDING-ELEC7FRICAL PERMIT NO.
r1uhBNc-MEcunNlcn-BUILDING DIVISION APPLICATION/PERMIT 29594,594r
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRFSS: } Oak llY - SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'SN ME: /Iw^ {S(� C RACE 'S NAME: - 1 U ��
Y , CI 3a
SEC CONTROLM
ARCH ECT/ENGINEF.R: :IC NO: DJ)RF.jSI/1 C I � Li
CONTACT: PHONE . flssCC�.'•��yy11 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT Lp UM1y$ MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ Lia(r_ �(
1 hereby mina mat I am licensed under provisions of Chapter 9 brommeneing JOB DESCRIPTION
D0Z with Section 7000)of Division 3 of the Buslnesa dlmfessiom Csal and my license iz
00 PFiRMIT ISSUANCE RESIDENTIAL'
F fullfarceandefieN�f�
CLEF ", k:.� 4 0SPOWL D KITCHEN REMODEL
yU License Lic.p APPLIANCCS-RESIUIiNT1AL
ZW Damn-�f'�Contractor ❑ADDITION ❑PLUMBING RE-PIPE
p,pm ASCI{ITECTS DECLARATIO PANELS ❑MULTI-UNIT OSTRUCTURAL
OZmZ I understand my plans shall be used as public records MODIFICATION
� UP'10200 AMPS
D [I INTERIOR D CHIMNEY REPAIR
I'^4t:W Licensed Professional - 201-I1M10 AMPS - IMPROVF.h1ENT
4qX J OWNER-BUILDER DECLARATION n OVER]big)AMPS DBATH BE REPAIRnns 0DEMvie,OLITION
OwlC Q .I hereby affirm thin 1 mm exempt from be ConOaktors License law far the
V 3¢.F following ressom(Section]031.5,Business and Professions Code:Amv city or county SIGNS ELECTRICAL. �� DOTHER
y which requires a permit t.consnmc,,alter,improve,demolish,ar repair any swaurt
rl—
���' prior to is Issuance,ulsonspareslheapplicaut for such permit to fleasigned statement SPECIAL CIRCUIT/MISC.
E p.
that he is licensed pursuant in the provisionsof the Comacmrs License Law(Chapter9
u�]aap0q (commencing vim See ian70)lDivision 3 of the Business and Professions Code)or TEMP METER OR POLE INST.
a COMMERCIAL:' -
kc 4 that he i. exempt therefrom and the basis f the alleged d pl .Any violation of D D&OI BLDG/ADDITION D DOLITION
4• S,,fim 7011,5 M1y ....Imiumlor pe tl hjcc fic,plicarlI wd Ityol POWF,R DEVICES
W^m AN - ❑FOODSERVICE
rZy norm manf hundredd llar,($500) EhIENT
ESQ ❑I,asow f the property,or my employees with val as their solecompensation, SWIMMINGPOOLELECTRIC
F.,
will do due work,and the%fracture is not intended matteredfor sal (Sec.70i•1 Business OT
w'-'m o utl Profess ons Cams Th
Costs: Comrasnms License taw taxm m a napply an owner of OUTLETS-SWITCHES-FIXTURES
4'3 prnpeny who builds or imptav s thereon,and who does such work hirmielf or through
his awn employers,provided shot such imp rnveton ms an,not intended oroRered for NEN'RESIDENTIAL ELECTS SQ FT.
sale.If.however,the building or improvement is sold within one year of complminn,Ea SQ.IT.FLOOR AREA $/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for put-
❑L as owner the E castof (See
E elusively contracting Curbth licensed contractors m O
mswct the project(Scc.]0a4,Nosiness andProfessions Codep'The Conm:mmr's Li- '
use Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such Projects with a contractors)licensed punuam to he Comencmrs ftp A`I .1
License law. PERMIT ISSUANCE S 'IIP1r �fT(]�
❑I am excanp,under Sec. ,B&P C for,this reason JJ
Owner Date ALTER-DRAIN&VENT-WATER(EA) vtt f Ur• L�ureTION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT..DEVICE V
1 hereby affirm under penalty of perjury one of lic following declarations:
❑I have and will maintain a Crmificate Uf Consenuo self-insure for Worker's Compen. DRAINS-FLOOR,ROOF.AREA. ND: STORIES TYPE CONSTRUCTION
eauon,as provided far by Section 37M of she tabor Code,far the......mance of me
work for which his amou..-coated. FMURES-PER TRAP
lWv I have J will maintain Workers Compensation Insurance, 9 - d by Sectio"
3](0 fore Tabor Cede,fn the perminumcenfine work for wti h,hi parrion,is issued. GAS-EA.SYSTEM.I INC.J OU'T'LETS
Mywamky' C tanlu 'rand Paicyn OCC GROUP AVN
Cartier: �RVn a-te a -PolicyNa: GAS-EA.SYSTEM-OVER 4(EA)
CERIIFlCATE OP EXEMFI'ION FROM WORKERS'_
COMPENSATION INSURANCE GREASE/TNDUSTRL WASTE INTERCEPTOR
BUILDING,DIVISION FEES
(Thisaection need not be completed iRM pcmuit is ter one hundred dollars GREn$ETRAP
err Ions) rs l$10PLANCHECK FEE
Tcertify that nthe o work for sparentisissuedlsha0
not employ ay person in mymannerso as to became subject to the Worken'Compcn- SEWER-SANITARY-STORM 3 .200FK
ENERGY FET:
O Z action Laws or California.Date WATER HEATER WIVENT/ELECTR
Z l] Applicant GRADING FEE
y NOTICE TO APPLICANT.If,Ufa,making this Cenflu me of Exemption,you should WATER SYSTEM/TREATING
a , became subject to the Workers Compensation provisions of the Labor Code.you must - SOILS FEE
W farthwim comply with such provisions or this pemtin that be deemed revoked. WATER SERVICE
7Q PAID
Z CONhen is a IONLENDING AGENCY NEW H&SIDL•NTIALPLMB. SQ,FT Date RecreateX
Vp I for by whin thi thusthenisaed(Sectio"len ding agency for me pe..urmana of -
the work for which this permit is issued(See.309].Civ.CJ
Q Ulender's Name TOTAL
Lender's Address -' AL.
1 ref if that 1 have mea this a n d sate that the above information is BUILDING PETi
Y Pa ice ion an -
rA cnmingconstrmco,and with all ntyand county ordinances iandbis state lawsrelatingutomte QTy, MECHANICAL PERMIT PEC
V Z adevingmnonest construction, horchy aathmize Canis. iivca of this city roamer upon the SEISMIC FEE
above-(WdamM pmpeny for inspection t kne,females,
PERMIT ISSUANCE
(We)ogree to save,indemnify mtl keep hannl<ax me Cu,of Cucenin.pgaimt ELF.CIRIC FEB
lisbilines,judgments.costs and expenses which may in any way accrue against said City ALT ER OR ADD TO MECH.
I.consequence of the granting sif this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 111,000 CFM)
MECHANICAL FEE` CLT \ (46
/ elk-K.1✓\ S-1 1��1to AIR HANDLING UNI'f(OVEkI(I,l1WCPM7-
CONSTRUCTIONTAX
Signambe of Applictu naacm Date EXHAUSTHOOD(w/DUCT) HOUSING MOGATION FEE
I ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha lc hme.do.,material T HEATING UNIT(TO 100,0))BTU)
as defned by me Cupertino Municipal Cede Chapter 9.12.and the Health and Safety
Code.Section 25532m)? - HRATING UNIT(OVER T W(M10 RTU) .
0Yec ON. VENTILAT ION FAN(SINGLE RESID) PAID
Wilt mea applicant Or future buildin t use t or devices which
Data Receipt X
PP dby nor
ea Air Qu BOILER-COMPOHPOR 100,000BTU)
mit hmardous air contaminants as defined by me Bay Area Air Quality Management
Fl Yes 0Nn BOILER-COMP(OVIiR I(XI,IXI)BTU)
I have mad the haardous materials tegemerem s under Cleeptir 6.95 of the Cali- AIR CONDITIONER I ISSUANCE DATE
- aomia Healthbs&'Scary Core,have
Secti...,buti is my d 255ba I J d that if me NEW ftf?SIORNT1nL MECH. SQ.IT.
building Safety
hoe union,mm t' ) .pu25534,1notify me rc,if ina
he
District?
f the restatements which must be tprior t - of Crnf fO.uperry.
Owner or amhnrized agent Uum ISSUED BY: y T�
OFFICE