29446 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 2 9 4 of rat
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 54J 44Va
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRII � � SANITARY NO. APPLICATION SUBMITTAL DATE
f*o
OWM1'ER'SN MH: PHONE a CONTR 'S Mh 1"6
NIC ON'fkOl,b
LIMP—
RCHITECDENGINEER: LIC NO: ADDRESS: R(-- ❑
' CONTACT: PHONE: I
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ - ❑
LICENSED CONd,edunOR;SDECLARATION QTY. ELECTRIC PERMIT FEE
1 he.70 cobs that 1 rat Ifthe B.ander.dProla,ors Cdda. 9 lmylicens eg JOB DESCRIPTION
{rO d'Z with Sforce ndeffec DivisinnJnfthe Bu.,inessanJ Prolbesions Cshde.and my license it RESIDENTIAL:
FOO
infull effect. PERMIT ISSUANCE
IA^ ❑SFDWI. ❑KITCHEN REMODEL
�UU License Clues Lich APPLIANCES-RESIDENTIAL DADDITION ❑PLUMBINGRE-PIPE
Qn. Dam Throne L
t,�w ARCHITECTS DECLARATION PANELS ❑MULThUNIT El STRUCTURAL
ZOnZ I understand my plans shut]be used as public records MODIFICATION
OZ UP T02B0 AMPS C1 INTERIOR [I CHIMNEY REPAIR
1-HItm Licensed Professional 201-100OAMPS IMPROVEMENT
�ya� OWNER-BUILDER DECLARATION OVER INMAMPS Q BATH REMODEUREPAIR ❑DEMOLITION
C' I hcrcby off nn that I um emmpt tram the DECLARATION
License Luw for the
2060 following reason.(Section 9031.5.Business add Professions Cole:Any city or county SIGNS ELECTRICAL ❑OTHER
3 LL y which reyuits a Permit m construct,alter,improve,demolish,or repair any structure
rimmu,iswina,alsorequlres the..plica,ha,ta,h pencita,fil...to cd statement SPECIAL CIRCUI17MISC.
Fly that he is licensed punuanno the provisions ofthe Contrador's License Law(Chapter 9
IN� (commencing with Section 7000)of Division 3 of the Business and Professions Cackler TEMP.MET ER OR POLE INST.
COMMERCIAL
2 ca that he isexempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ElDEMOLITION
My Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
mo mom than five hundred dollars(S500).
F Z i IMPROVEMENT'
-=6 Ol,as owner of the progeny,or my employes with wages as their sok compensation, SWIMMING RX ELECTRIC
�yG windo lbewnrk,aralmesructurc is not iatendednrtdfcfed forsele(Sce9W4.Businc,x OTHER
3 and Professions Cods.The Contractor's License La.thereon. ,
redoes not apply m.n owner of OUTLITS-SWI'T'CHES-Fl%TGRES
property who builds or improves eon.and who does such work himvelf or through
his Own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however.the building or improvement is sold within one year ofcompletion,the SQ.IT.FLOOR AREA VSQ.FP,
owner-builder will have the burden of proving that he did not build or improve for pur-
,seofsale.). �� If
F1Lax owner Of the progeny,am exclusively contracting wird Ilcco,od,proems to TOTAL: Li
construct the pmjeet(Sec.7641.Business and Professions Code:)The ContracmYs Li-
c u Law does not apply to an owner of property who builds or improves thm,on,and QTY, PLUMBING PERMIT FE �AI) '1 r r/f
who contracts forsttdt projects with acantmmn
etags)licensed personal the Contractor% IIS` 1 S •996
License law. PERMIT ISSUANCE
0 I am exempt under See. .B&PC fold,mann lJrt 1r, .
Owner Dae ALTER-DRAIN&VENT-WATER(EA) "VARUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby offimi under Penalty of perjury one of the following Worker's
C.v:
.Thaw and proll vided
by Section 3700fivoic ofCausent toLabs soG.fiew lir Worker'sce of he DRAINS-PLUOk.kOOIt AREA,GDND. STORIES 'TYPECONSTRUCTION
,cion,as provided for mi Section J](NI of the Labor Cee,for the perfotmrnce of the
work for which this muctri is isvued. FIXTURES-PER TRAP
❑1 have La will maintain Worker's Come ofthe n Insurance,us his Per by$nelinn
l]OO Mthe Lahr Csslq fonhe perfotrrtnce nfthe work for which this permit is iswed, C S SYS'TEM-I 1NC.4011'FLETS OCC.GROUP AI'N
My WmISC d. ti I s carrier and Poly nuIDYr�
Cocien� PolicyD JV Ir� �Q GAS- .A.SYSTEM-0VER4(EA7
CIiRTIFICAT'Ii OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
Obi,section need net le completed if the permit is for one hundred dollars is 100) OR Ii TRAP
or less,) PLANCHISCK FEE
I certify that in the pedommnsc trfthe work forwhich this permit is issue,l shall SEWE• -SANITARY-STORM ISA.200 FT.
not employ any persoe in any unander,c as t hadmae subjecuo the Workers'Compcn- ENERGY FEE
OZ scion Luwsor Culifmni..outs .TER BEATER WNENI'NLF.CTk GRADING FEEZ O Applicant
y All
NOTICE TO APPLICANT.IL situ making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker'a Compenamon provisions of the labor Cddc,you must SOILS ME
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
� ZCONSTRUCTION LENDING AG�NCY NEW RESIDENTIALPLFIR. SQ.FC PAID Dao
V zI herebyaftirm that there N.c.ty tra,le lconingagedey hadid ryrfonnan<e o! °eiptp
1^ the work for which this.emit is issued(Sec.3097,Civ,C.)
C) U leader's Name TOTAL
Lender',Address L:I
LSI 1 certify that I have read this application and state that the above information is BUILDI -
F N correct,l room to comply with all city and county ordinance,and state laws relating to QTY. MECHANICAL PERMIT FEE
L) Z building d...mctinn,and hereby atuoriae representatives ofthis city meter upon the SEISMIC
�--� .bovcmwtioned pmpmy for inspection pm,o,cs. PERMIT ISSUANCE
(We)agree to save,imkmnify and kap harmless the City of Cupertino against ELECTRIC TEE
liabllitie.s,judgments.costs and expenses which may in any way acemc against said City ALTER OR ADD TO MECH.
PLUMBING FEE
in consequence of the grating of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OU 10,000 CFM) MECHANICA EE
SOURCE REGULATIONS, -
/f� AIR HANDLING UNIT(OVBR 111,000 CFM) CONSTRUCT/0N TAX
nawre of App tern C ntmcmr Dae/ EXHAUST HOOD(WMUC) HOUSING TIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantorrumrebuilding Occupantaorc orhandlchaivdowmauriul HEATING ON]'F(TO 100.000 BTU)
as define by the Cupenim Municipal Code,Chapter 9.12,and dm Health and Safety
Cee,Section 25532(.)! HEATING UNIT(OVER 1100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Dam Receipt#
Will the applicant or future building Occupant use equipment or devices which
fma brodrdous air contommarts as defined by the pay Area Air Quality Munagemmit BOILER-COMP OHP OR I00L0fu BTU) I AL.
District?
0Ycs C]No BOILER-COMP(OVER 100.069 BTU)
AIR CONDITIONER
I have read the hamrdous industrials hryuimments under Chapter 0.95 of the Cali- ISSUAN DATE
Runk Boom&Safety Cook,Sections 25!105,25533 and 2 Y1.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. `�`�GT�///,/\
building does not currently have a tenant,that it is my responsibility to notify the occupant
Of the requirements which nnot be net prior n,is,uaace of a Certificate of 0,cupancy,
Owner or authorized agent Data TOTAL: ISSUE[)BY: - se -
OFFICE