29246 (2) APPLICANT TO FILL IN INFORMATION WITNIN RED LINES-USE BALL POINT PEN ONLY
'CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29246
BUILDING PROJECTIDENTIFICATION -
BUILDINGADDRCSS: /� SANITARY NO. APPLICATION SUBMITTAL DATE
/ aB 1/ 91yy y . r''7
O .R'S NAME: - PHONE: CON TRACTOR'S NAME: LIC NO:
Tv� �2 NIC CONTROL
RCHITECTIENGINPER: LIC NO: AD�ftPSS: ❑
CONTACT:, - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG E$ PLUMB MECH
. . - ,
LICENSED I a CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing )OB DESCRIPTION
X00 with Section 7")ofDividnn 3 of the Business and ProfcssionsCada and my license is RESIDENTIAL:
WZ in full force and effect. PIiRMIT ISSUANCE
�Vi•- Li cense Class Lic.p - ❑SFDWL El KITCHEN REMODEL
�< Date Commcmr APPLIANCES-RESIDENTIAL �ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURAL
ZQyZ l understand my plans,hull be mud as public records PANELS MODIFICATION '
OZ0�' UPTD200AMPS
Licensed Professional a ❑INTERIOR El CHIMNEY REPAIR
201-IIXppMPS IMPROVEMENT
Oat I am exempt
U LDERmptfr DECLARATION OVER I"AMPS ASWH REMODEUREPAIR ❑DEMOLITION
GG 1 hereby affirm the 1 1. exempt from the Cessions os License Law for the
X a d V following rcuun.(Section]03 LA Business and Profession Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
4477 O which rWussunpermit re conswct,aheq improve,demolish,fie a sig any structure _
priormslits ccaoame,rsu requires the hovisio ant for softhesuchpermiuofles Law(ed hapte9 SPECIAL CIRCUIT IS .
} that mending ad!with
pSectionnthcpronsi,iof the Contractor's License Loons Coda)or
(commencing with Section]IXXB of Divisinn3of the Business and Professions Cale)or TEMP.MBTER ORP COMMERCIAL:
a c K shut he is exempt therefrom and me basis fur the alleged exemption.Any violation of L1 NEW BLDG/ADDITION ❑DEMOLITION
Section 703).5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
oe 46 []TENANT ❑FOOD SERVICE
I„>p„ not more than rive hundred dnllOm($500). \ IMPROVEMENT
a6 wi Las me work,
the memuy,nr myemploydes with weeds as their sole compensation, SWIMMING POOL EL Cf IOa
G will dothework ands:no Cmumenot se,Lnded ense Law
' ❑OTHER
and Professions Cale:The Cnnwctors License Law Aocs urn apply as an owner of OUTLETS-SWITCHGS-PIXTUR
a' .. property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such int,tw,mems am not intended or offered for - NEW RESIDENTIAL ELCCTR SQ PT.
sale.If,however,the building or improvement is sold withinone year of complains,the SQ.FT.FLOOR AREA $)SQ.FT.
cr-builder will have the burden of proving that he did not build or improve far pur- pN��1 p
o sit otsale.). - r -
n owner of the property,ran exclusively contracting with licensed contractors to
19 conswct the project(Sec.7044.Business and Processions Code:)The Con r ctor's Li. �N
cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE ' K
whocontmcts for such pnjuats with a cmmuctons)licensalpursunnt tothe Convector's
I
101o, 190
License Law.- PERMIT ISSUANCE 098
❑lanae niter Sec. ,B&PCT nhis resstm LUN.'
ALTER-DRAIN&.VENT-WATER(EA) VAI; JON
vert Date
WORKER'S COMP 'ATION DECLARATION BACK FLOW PROTECT.DEVICE n .gMis�
1 erebyalfrm underpcunty ofperjury one ofthe following declarations:
Vsbaveandwilliam in"in aCcnifceeofConsem mutGinsure for Woder's Cnmpen- DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
cation,m provided for by Semion 3701 of the Labor Cale,for the peHbr airce of the
work for which this .it is l.uaed. FIXTURES-PER TRAP 4
❑1 have and will maintain Worker's Compemation Insurance,as required by Section '
37W of Ne Labor Cale,for the performance of Ne work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier. Policy Na.: GAS-EA.SYSTEM-OVER 4(P,A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASFJINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FF,ES
(ThissecOon neral not he complecd if the penins is fur one hundred dollars(5100) GREASE TRAP
or less.) PLANCHECK FEE '
leenify that in theperfomtance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
am employ any person in nay manner so as to become subject to the WorkerF Compen- ENERGY FEE r
zZ sation Laws of Califomia.Date WATER HEATER WNENT/ELECI'R
2 Applicant GRADING FEE
fq NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTF.MfIREATING
a biome subject to Ne Worker's Compensaiior(provisions n(the Lubar Code,you must SOILS FEE
{2J forthwith damply with such provisions or Nis permit shall be devoted revoked. WATER SERVICE - -
Q
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,IT. PAID
V 0 lhor which
this
the thea is.construction3 97.0 gagency ha the performance of Data - Receiptp
LLU Nadu',Nrwhich ibis permit is famed lSec.1090,Civ.CJ
Q (~ Leaches Name _ TOTAL:
>s W LendeYs Address -
I certify that 1 have rend this application and state that the above information is , BUILDING FEE I
comct.Ias=to comply with all city and county ordinances and suite laws renting to QTY, MECHANICAL PERMIT FEE
V building conssrvction.and hereby 0mhoriu rcpreuntatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection puria us.
(We)agrtt m save.indemnify it keep Intrudes,the City of Cupertino ugain,r PERMIT ISSUANCE ELECTRIC FEE
Iiabilitin.judgmenu,cosuend expense.,which may in any way accmc against said City ALTER OR ADD TO MECH.
PLUMBING FEE
in conuquentt of the granting of Nis permit.,
APPLIC UNDHRSTANDS AND ILL COMP LY WITH ALL NON-POINT AIR HANDLING UNIT(TO IT000CFM)
$OU GUUTIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
azure of Applicant/Contrifl5k kine EXHAUST HOOD OMMUCD
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum building occupant store or handle haarolm,mmerial HEATING UNIT 0D 101000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cad,Section 25532(0)? HEATING UNIT(OVER 100,000 BTU)
❑Ya ❑No VENTILATION FAN(SINGLE RESID) 56 PAID
Data - Receipt M
Will the applicant or future building occupant use equipment or devices which
emit bazmdom air conmminants as defined by the Bay Area At,Quality Manogemem BOILER-COMP(3HP OR 100,00(1 BTU)
Distrin? TOTAL:
-
El Yes FNo BOILER-COMP(OVER 100.00OBTU)
I have read die hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 amt 25534.1 understand mat if the NEW RESIDENTIAL MECH. SQ.Fp
building does not currently have a tenant,that is is my responsibility to notify Ne occupant
of the requirements which must be met prior to issuance of a Cenific n,of Occupancy.
Owner or emhmiud ascot Date L4l- ISSUED .
OFFICE