29957 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. ^ ..a
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL I5 1/
BUILDING PROJECT IDEM'IFICATION
ILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATI
l 9Sbl� r13O.-C4rM
R'SN E:
PHONE ;O ACT R'SNA E: LIC NO.
NIC CONTROLp
A CHITECTIENGINEER; LIC NO: AUI ESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
-❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ J�' ❑
LICENSED CONTRACTOR R'S DECLARATION QTY ELECTRIC PERMIT FEE -
I hereby affirm that I am licensed under provisions of Chapter 9(commencing � JOB DESCRIPTION
C�DOZ wilh Sectioal00D.I'Division 3afthe BusineaenJ Pmftaoima Cade,andmylicenmis PERMIT ISSUANCE RESIDENTIAL,
W r in full force and effect. 0 SFDW L C KITCHEN REMODEL
aUU License Class Co
Date ' C ntractor APPLIANCES-RESIDENTIAL CADDITION ❑PLUMBING RE-PIPE
g,
W DECLARATION
O v0.i
ARCHITECTS
' DECLARATION ❑MULTI-UNIT []MODIFICATION PANELS
Z O vv�� 1 undcratond.,,Ins shall h used ss public records - MODIFICATION
OZ:d- UPTO 200 AMPS C1 INTERIOR []CHIMNEY REPAIR
r13� Licensed Pfafessianal 201-MMAMPS IMPROVEMENT
��a OWNER-BUILDER DECLARATION ON OVER IIIOOAMPS 0 BATH REMODELIREPAIR [I DEMOLITION
C W 1Mherchy aRnn Thal 1 mm exempt from thee Comm<ors License Law for Ne
�11 V following rtman.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
LL I" which requires a permit to construct,alter,improve,demolish,or repair any structure '
r.�C su
prior to its isanco.at.rtq.t.theapplicam for such pemniun Blea signal statement SPECIAL CIRCUIT/MISC.
<� that he is licensed pursuant to Ne provisions of the Combat License Law(Chapter 9
CO (commencing with Section 7000)or Division 3 of the Business and Professions Case)or TEMP.METER OR POLE INST.
6 c eG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ` C NEW BLDG/ADDITION []DEMOLITION
n
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES
..y TENANT []FOODSERVICE
y>. not mOra than five hundred&It=(§5W). IMPROVEMENT
< C Las owner of Ne pmputy,ser my employees with wages as Neir ante mmpemation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended affiliated for sale(Sec.IIIiC,Business []OTHER
and Professions Cade:The Contractor's Lt..Lawes w donot apply to an owner of OUTLETS-SWITCHES-FIXTURES
6'Z^ property who builds or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.IL however,the building or improvement is sold within one yemofcompladam.We SQ.PRFLOORAREA $/SQ.FT1
owner-builder will have the burden of proving that he did not build or improve for Pur.
poseofaaleJ. - -
1,as property, ns
owner of the property,am exclusively contracting sum liceed conuacmra o TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li- 4� 41(4 h Pj
cense Law does nut apply to an owner of properly who builds or improves thereon,and QTY, PLUMBING PERMIT FEE u
who co malts farsuall ects projwith a conmunds)licensed pursuant to the Commetnfs III
License Law. AY 3O lq
El am exempt under Sec. ,B&P C fonbis rtason PERMIT ISSUANCE.
IIJs D n ALTER-DRAIN&VENT-WATER(EA) /,"f,t VALUATIO
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE A VLt 41r/❑YkJ _
I hereby affirm under Penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure for Workers Campeau. DRAINS-FLOOR,ROOF,AREA.COND.
sauon,es provided for by Section 37M of the Lahr Code,for ate perfamemcc of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PERTRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700of use Labor Code,for the performbaceof the work for which this permit is iaauW. GAS-RA.SYSTEM-]INC.4 OUTLETS
OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number oR:
Carder. Policy Na.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASEIINDUSTRL WASTE INTERCEPTOR -
BUILDING DIVISION FEES
(This section need nosh cmmplewlifthc pcnnit is foronehunJrc4 dollars($100) GREASETRAP
or leas] PLANCHECK FEE
f certify Net in the performmeaciftha work 6rwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 Pf.
not employ any Person in any manner so as m becume subject to the Workers Compen- ENERGY FEE
ZZ radon Laws of California.Dam WATER HEATER W/VENT/HLFCTR
O Applicant GRADING FEE
sr ti NOTICE TO APPLICANT:If,after making this Ca fi,am of Exemption,you should WATER SYSTEM/fREATTNG
became subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
Til RUNwith comply with suchprovishms or this permit shall h deemed revoked. WATER SERVICE
G. Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
Date Receipt# '
L)0 I far which
armit isvcfinrtmc.ion lending agency for performance of
the wars for which this permit is issued(Sec.3097.Co.C.)
0 UJ Lenders Name TOTAL'
M. I Asa 1<nder' NTrcTOTAL: -
certify that 1 have read this application and state that the above information is BUILDING FEE
lZ) mrtecLlvgrcemcamply with all city and county nrdinvnm send oma laws rclatingm QTY. MECHANICAL PERMIT FEE
L) builiingcursmuclum,and herebyuuthdre represerldivesofthirdly m ebtelf,en the SEISMIC FEE
shove-mentimmil plurality for inspection purposes. PERMIT ISSUANCE
(We)agru m save,indemnify and kttp harmless Ne City of Cupertino against ELECTRIC FEF. '-
liabilitic%judgments.castsandexpeaseswhich may many wayaceraeagrimel said City ALTER OR ADDTO MECH. PLUMBING FEE
to unsequence of fallacious of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CFM) MECHANICAL ME
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.004)CFM) CONSTRUCTION TAX -
Signature of ApplicanUContractor - Dale EXHAUSTHOOD(WMUCG HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupant store or handle hurinsious material HEATING UNIT(TO I(p.0(M/BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553200? t HEATING UNIT(OVER 100.(100 BTU)
[]Yes ❑N VENTILATION PAN(SINGLE RESID) PAID
. Date Receipt p
Will the applicant or future building occupant use equipment or devices which BOILERCOMP(3HP OR 100,00)BTU)
emit hazardous air conmminanm -
as defined by the Bay Arca Air Quality Management TOTAL:
Distri2t?
❑Yes ❑No BOILER-COMP(OVER IW.OMBTU)
I have mad the hurnNous meadcls requirtmenm under Chapter 6.95 of The Cali- AIR CONDITIONER ISSUANCE DATE
famla Half&Sofery Code,Sections 25505,25533 am125534.1 understand that if sea NEW RESIDENTIAL MECH. SQ.FL
building does not currently have a mount,thud it is my oopamibility tu notify Ne occupant _
of the raquirements which most he met Prior to issuance of a Ceri finea of Occupancy.
Owner or amhadred agent Dam . TOTAL: ISSUED BY:
OFFICE