29705APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
0
BUILDING PR(IJEC'1' IDENTIFICATION
BUILDING ADDRE$$;
Z 7 ,t c 2�sT C
SANITARY NO.
APPLICAIIONSUBMITTALDATE
6
OWNER'S NAME' PH NE
s C .A.
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C ACTOR'S WAME LIC NO:
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NIC
❑
CONTROL))
�%RCHI ITC UHNGINEER: JC NO:
AImIRESS:�O
CONTACT: PHONE:
BUILDING PERMIT INFO
[QTS sl`a" II t�/ Z_
J
❑ Consultant Fees Paid by Applicant (Initial)
BLpG� ELECT PLUMB ME❑CH
(X5_,l/�`
IJCENSED CONTRAC TOWS DECLARATION
I hachy drhm, mat I am licensed under provisions of Chapter 9 (commencing
QTY. ELECCRICPERMIT FEE
JOB DESCRIPTION
with Seainn]EMX))of sion3ol the Basines.c end l'mfessions Coda, and mylicenu is
in full force and eReff, TO I/Q 7�
'
PERMIT ISSUANCE
RESIDENTIAL,
❑SFDWL ❑ KITCHEN REMODEL
APPLIANCES - RESIDENTIAL
DateClaes _/�L_ Lic.p r
Date Contrwtor
C1 ADDITION ❑ PLUMBING RE -PIPE
El MULTI -UNIT []STRUCTURAL
MODIFICATION
ARCIIITF; DECLARATION
1 undersmnJ my plans shall b: u,n used as public record.
PANELS
UP T0201 AMPS
[I INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMEINT
Licensed Professional
2014000AMPS
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contrwrors License Law for me
following reason. (Section 7031.5. Business and Professions Cade: Any city or county
KATH REMODEUREPAIR ❑DEMOLITION
❑OTHER
OVER 1000 AMPS
SIGNS ELECTRICAL
which requires u permit ns r tomeL nicer, improve, demolish, or repair any sm.mx
SPECIAL CIRCUITIMISC.
priorm its issuance, also requires the applicant linsach lurinit to file a signed ammmem
Oat he is licensed pursuant o the provi.omis of the Commuter's License Low (Chapter 9
mommencingwith Section 7")of Division 3 ofthe Busincoand Professions CoOdar
than he is exempt therefrom and the themis for me alleged cimnin ion. Any violation of
TEMP. METHR OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
POWER DEVICES
❑TENANT ❑ FWD SERVICE
not more than five hundred dollars ESSEX)).
�1, as Owner of the property. or my employees with wages as their sale compensation,
will do 1M1c work, trod the swdure is nal intended muttered for sale (Sec. ](40. Business
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
and Professions Cede: The Commnur's License law does not apply in an owner of
NEW RESIDENTIAL ELECfR SQ FT.
property who builds Or improves thereon, and who does such work himself or through
his we employees, provided that such imprvvemems are not intended or offered for
sale. If. however. the building or improvement is sold within one yew ofahmplction,the
SQ. FEFLOORAREA
$/SQ, ET.
builder will have the buNen of proving that he did Out build nr Improve for pun
1OL,ale.).
pedo
exclusily nmlmeting with licensed uhmmdm nrs
the property, .,it ve
1, as owner nl ro
TOTAL:
construct the project (Sec. 7(A1. Business and Profession Code:) The Conwcmr's Li.
emu law docs not apply m en owner of property who builds or impmvcs thereon, and
QTY PLUMBING PERMIT FEE
who contracts for such projects with a contractors) licensed pursuantto the Contractors
PERMIT ISSUANCE Mull
License Law.
F I am exempt under Sec. .B& P C for thisrea,on
ALTER -DRAIN & VEN9'- WAI ER (EA)
Owner Date
WORKER'S COMPENSATION DECLARATION
VALUATION
O�
BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
l
Ihmcanal will chairmin. CertificamufConuh,, self -insure for Worker, Co.,.-
cation, as provided for by Section 3700 of the Labor Code, for me performance of the
DRAINS- FLOOR, ROOF. AR G. COND.
STORIES
TYPE CONSTRUCTION
w r which this permit is issued
FIXTURES -PER TRAP
1 have and will maintain Worker's Compensution Insurance, as required by Section
3700 ofm. labor Code, far the perfotmsimecof me work for which this permit is i,sued.
GAS -EA. SYSTEM -1 INC. Y OUTLETS
OCC. GROUP
APN
MyW a sC mpJy.huo ns ran ccamCrand Policy
Gurria tsG+Y.l'-�—PohcyNo,olic -]
GAS - EA. SYSTEM -OVER J(EA)
GREASPIINDUSTRL WASTE INTERCEPTER
Ch GIFCATEOFF"EMPTION MOM WORKER $'
COMPENSATION INSURANCE
r -
BUILDING DIVI51(lN IFES
('thisx woon need not he conhpleand ifhhe permit is GU One hundred dollars I$I W)
nr less.)
GREASE'I'RAP
PLANCHECK FE'
SEWER - SANITARY - STORM EA. 200 FT.
I certify that in the permarrom e, ofine work for which this permit is issued, I shut 1
net employ any peam in any manner so as to become sabjectm On Workers Co.,.-
ry
ENERGY FEE ! 6
WATER HEATER WNEN'DELECTR
FGIITV
cation Laws of California. Date
Applicant
NOTICE TO APPLICANT: IT otter making mssovisio %at of Exempted, you should
beahme auhjecE to the Workers Compcns provision Of the Labor Cede, you mux
WATER SYS 'I'EM/fREATING
GRADING UT.
w
SOILS FEE
WATER SERVICE.
en,
forthwith nhmply with such provisions Or this permit shall be devoted revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that is a construction lending agency for the performance of
NEW RESIDENTIAL FILMS. SQ. FL
PAID
Data Receipt))
the work for which this permit is issued (Sec. 3097, Co, C.)
h
Leaders Name
TOTAL:
Leader', Address
is
BUILDING FCC
1 ccnify that 1 have read this application unit state that me abhor infmmmion
correct i agree to comply with all city and county ordinances and state laws relating to
building consction, and hereby aumonce representatives of this city m enter upon me
w
QTY, MECHANICAL PERMIT FEE
SEISMIC FEC
PERMIT ISSUANCE
above-mentioned property for inspection purposes.
(We) agree to.cove, indemnify and keep harmless the City of Cupertino against
ELECTRIC FEE
ALTER OR ADD TO MECIL-
PLUMBING I'IAi
liahilitiea,judginenls, costs and expense, which may sonny wary accrue egmno, iil City
E this ctmi
in consequence of the granting Opt
AIR HANDLING UNITOO 10,00 CFM)
APP T UNDERSTAN SAND WILL COMPLY WITH ALL NON -POINT
�Rf , REGULATIO
MECHANICAL FCL'
AIR HANDLING UNIT (OVER 1ILM CFM)
CONSTRUCTION TAX
(� —2(
EXHAUST FOOD(WIDUCI)
HOUSING ME I'IGA9'[ON FEE
g..to,. of APpic,mVCianrwot, Marc
HAZARDOUS MATERIALS DISCLOSURE
HEATING ONI'r(TO 100,001 B'TO)
Will the applicant or future building decupair slum orhandle hamNmix material
as defined by the Cupertino Municipal Cod, Chapter 9.12, and the IImIm and Safety
Code. Santo 25532001 —/
❑4.n V^0'
HEATING UNIT (OVER U0,010 BTU)
PAID
Dore Receipt a
VENTILATION FAN (SINGLE RESIDE
BOILER- COME FEHP OR 100AM BTU)
Will then licant Or fair,. holding t use e - t Or devices which
pp dby he .Airwn
Lit h:¢aNnus oir canlaminants as JeQned by me I{ay Arca Air Quality Management
DivnchPY'hf,/
Yes
'1 (1TAL'
pO1LP.R-COMP(OVER IIX1,0X1 BTU)
AIR CONDITIONER
I have mad the hwwJous materials requirements under Chapter 6.95 of the Cali-
ISSUANCE. DATE
NEW RESIDENTIAL MECH. SQ. FT.
hands Health & Sofcry Code , Sections 25505, 25533 and 25534. I endemmrd that if the
I di tsvncnt h mreno ii,fliwakn - rlrtfhrrintilytnchrcupra,
of a eIt eol.cenifiam�eef"10,p an
�y
ISSUED BY
TOTAL:
ser or amkhnsJ agent Data
OFFICE