29817 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 29817
BUILDINGADDRMS: SANITARY NO. APPLICATION SUBMITTAL DAI
/
ivs -IWS� Gv �f-3�-9
7OW R'SSNAME:rcasiiivoo �Ce�al ���I C TRACcs 'iffOR'SNAME: / ��LIC NNO� NIC CONfROLa
Lf
4RCHIIFCT/" GINEER: LIC NO: AD"" z O� L t ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELEC'T PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRI ION
I-OCwith Sation]000)of Division3oRhc Business and Profasaians ClWa anJm 1
ymec,eia PERMIT ISSUANCE RESIDENTIAL,
W in full forec and eflict.
aVU License Class Lie.p ❑SFDWL (3 KITCHEN REMODEL
rF�a Dmc Cmimaor APPLIANCES-RESIDENTIAL []ADDITION F;ALUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
F.Otn MULTI-UNIT ❑STRUCTURAL
ZO-Z 1undemand my plans sM1all M+usv]as public retools MODIFICATION
O Zia UPT02(NI Ab1P5 ❑INTERIOR ❑CHIMNEY REPAIR
1-�F"; Licensed Professional 201.1000AMPS IMPROVEMENT'
aa OWNER-BUILDER c.c.DER on me Contractors
OVER["AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
CY
C Q I hereby affirm that 1 em exempt(mm the C.mrecmrx Licence law for the
R1'3 06 U following reason(Section 7031.5.Business and Pndesslons Cyte:Any city or enemySIGNS ELIiCTRICAL ❑OTHER
LL In which requires a permit to construct,alter,improve,Jentalish,or repair any sweture
1p"i�; prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL Cl RCUITIMISC.
HTEMPA y 0 that he is licensed pursuant to We provisions of the Counselor's License Law(Chapter 9
131�p (a'mmencingwiih Secdon7M))of Division3ofthe BusincssmdProfessions G.le)or
.METER OR POLE INST. COMMERCIAL,;
d p,o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W y
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICESEs ❑TENANT ❑FOODSERVICE,
=Qt mon,than five hundred dollars($500).
❑ I.as owner of the proptrty.or my employees with wages a dwirwdecompensation, SWIMMING POOL ELECTRIC IMPROVEMENT
WF' will do JtewmLerddmstructureisnm imendedmitfferedformle(See 70,14,Business OTHER
m and Professior,Colic:The Contractor's License Law docs out apply or an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who Jces such work himself or through — Fl!�_V_
his own employees.provided that such improvements aro not mottled or offered for NEW RESIDENTIAL ELECTS
,site.11;however.the builJiug nrimpr.vcmcm is sold withibnne year of completion,the S¢{•1'FLOORAREA SISQ.F..
owner-builder will have the burden of proving Nat he did not build or improve for pur. 71/OJ_ .
post of sale.).
❑1,as owner of the property,am exclusively contracting with liecnxd contractors to IOTA01
construct the project(Sec.71114,Business and Professions Coda)The Contractor's Li-
cense Law Jens net apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a convacmgs)licensed pursuant m the Contractor's
[I land d Law' PERMIT ISSUANCE S, Q
I exempt under Sec. ,B&PC 6u Nam
is rtn
ALI 17R-DRAIN&VENT-WATER(EAI
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO rECT.DEVICE
Ihand%olE maintain
pcnallyaf perjuryent ne self
-ins mfor Wookemiom
❑ Ihave aodwie main by eCion 3700 of the Lahr Code,for therw.rkerace of the
DRAINS-F100R,ROOBARCA,GOND. ,✓�U STORIES TYPE CONSTRUCTIO
workI as, Provided far by Section J711U of the Lnbnr Cada for the perfonn.nce of tha
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's weeof the w Insurance,as hiiP r by Senion
J]IMl of the Labor Gale,little peubmmnceuf the work for which this Permit is issued GAS-EA.SYSTEM-1 INC.4OUTLETS
My Wmk``u�.0 r�y�en,mrlmumr� artier mW Policy numpeYT?
p{c -��p OCC.GROUT' APN
Carrier, o'V '1"'s�-.A Policy No.: U4Y 7Oq /'•2 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPF"NSA'I'ION INSURANCE GREASMSIDUSTRI.WASTE INTERCEPTOR
(This section need not he completed time permit is forer a hundred della,,(SH)m BUILDING DIVISION FEES
m less.) GREASE TRAP PLANCHECK HE
1certify that in theanymnner of the work for whichthis permit Lsissued,)shall
not
ationLwany Person in any manner so asmbecome subject the Workcn'C.mlen- SEWER-SANITARY-STORM flA.2flo FT.
,Z nationanws of California.Dam
ENERGY FEE
z0 Applicant - v WATEk HEATER WNENI'/ELECTR. GRADING HE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYST=PLMB. SQ.
a ; become subject m the Worker's Compensation pmvis,am,of the Labor Code,you nm,iSOILS FEE
forthwith comply with such previsions or this parol)shall be deemed revoked. WATER SERV
0. Q
� Z CONSTRUCTION LENDING AGENCY NEW RESIDEPAID
V C) I hereby affirm Nat them is a consimelion lending agency for the paformonce ofDate Receiptis
1, Fthe work for which this permit is issued(Sec,3097.Civ.C.)
Lenders NameO W LendersAddress aTOTAL:1 certify that I have mad this application and vale Jwt the above infommtion isBUILDING FEE
In ammo.)agree 1.rnmply with ell city and counry ordinances and stem laws relatin1. QTyMFEEz building construction,and hereby authorize representatives of this city to enter upon theSEISMIC FEE
ante-msium ed property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino u.ainst=(WfDUCT)
ANCE
6ELECTRIC FEE
inefilies.oncesdherosts and expense- hmay in any way acme against sail CityDDTOMECIL
mc.nsequence.f he me N oft ' Pe L PLUMBING FEB
APPLICAN' Uli 1'AND AN WILL COMPLY WITH ALL NON-POINTNG UNIT ITO III"CFM)
SOUGUL NS MECHANICAL PF.F.
ING UNIT(OVER Ill,"CFNI) CONSTRUCTION TAX
Si amrt of Applicant/ r DmeDOD(W/DUCT)
HA9Ak0005 MATERIALS DISCLOSUREHOUSING MITIGATION FEE
Will the applicant.,future building eceupantsturem handle hazardous materialIT DID 10.000 BTU)
as defined by the Cupealnn MunicipalCode,Chapter 9.12,..,it the Health and Safety
Code.Section 25532(.)? BEATING UNIT(OVER I0L000 BTU) e
El yes Fl No
VENTILATION FAN(SINGLE RESID) PAID
Will the aPplicanl or future building occupant use equipment or devices which Dam `Receipt N
•emit hazardous air eonmmi.ats as defined by the Bay Area Air Quality Management BOILER-COMP CHIP OR 100,(IW BTUI APR "I�b ti: e
Ldmsnm
s ❑No BOILER-COMP(OVER 100.000 BTU)
nand the hmmdous mamrials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER&Sufcty Cert.Sections 255115,25533 and 25534.1 undersmnd that if meells �iSSUANCE DATE
nm currently have a mesal,than it is my responsibility to notify the occupantNF.W RF'SIDENTIAL MECH. $Q.fT.erms which must be ten prior to iwmnce of a Coni Rcate of Occupancy /�{rimr!.gem Dam TOTAL: ISS (�
• OFFICE