29893 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29893
BUILDING PROJECT IDEM1TIFICA'1'If1N
BUILDING ADDR[S5: � /)� tiANITARY NO. APNLIGI'IUN SUtBM�I'1'�'A�L UATF.
.21697
OWM1 '� / NU1I/ HONE CON)'I�y[T�I.II ��/��� L//U�'J'C NO: NIC C(INTROLa
's RCHITELMENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DEdeanof hap QTY ELECTRIC PERMIT FEE
Q=ZIhereby ion700ff that lmo lftheBdunder
xmid Is..i-sof Chaprorndmmmemeis JOB DESCRIPTION
WOO with Section Division ofthe Pusinosand Professions Cssle.and my license is RESIDENTIAL:
F. i full torco mid effect. PERMIT ISSUANCE
WF '" ❑SIOWL [I KITCHEN REMODEL
�UV Dan,nc Class Lich APPLIANCES—RESIDENTIAL []ADDITION ❑PLUMBING RIz-PIPE
y�111 Uele Cnnllnclnr
LLDon ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
Z O r^ u
Z I understand my Plans be used as public records PANELS MODIFICATION
OZ=O UPT02WAMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Profcssionnl 201-100IIAMI'S IMPROVF,MENI
J
OWNER-BUILDER DECLARATION
=gOVER 1000 AMPS O BATH REMODELfREPAIR ❑DEMOLITION
Q 1 hereby affirm that 1 am exempt from the Conlmcusrs License Law for the
?G51 O y V following reactor.(Section]0)1.5.Business and Professions Code:Any city m county SIGNS ELECTRICAL []OTHER
W 3 4 N which an a tex a permit In ttmsa mi.alter,improve.demolish,or repair any structure
prion)its issuance,skorequiresthe applicant forsuch penniuo rile a signed statement SPECIAL CIRCUIT/MISC.
y that he is licensed parts
In the prmi.a"n•o(the Contractor's License Law(Chapter 9
yp0 (commencing with Section]00(hof Div'nion3ofthe Businessand Professions Cade)or TEMP.ME'I'ER OCR POLE INST. R I
d d e that he is exempt Nere(mm and the basis house alleged exemption.Any violation of W BLDG/ADDITION [I DEMOLITION
XM Seedion703 LS by any applicant fm a permit subjersthe applicant to a civil penalty of POWER DEVICES 'NANT OI'OOD SERVICE
not more than five hundred dollars(5500).
[-Z Y IMPROVEMENT
p 6� wi Lo the work, the propeuctur my employees with wages f r sale(See.
compensation, SWIMMING POOL ELECIAIC
will Jathework,and that he Contractors
tors teracti License Law does
apply it)an,Business
ner oS OTHP,R
m and Professions COJe:The Commdor's License Law)nes nm apply ser an owner of OUTLE):S—BIS —FI%q'URES 5
Il 3 property who builds or improves thereon,and who Jens such work himself or through
his own employees.provided nearsuch immair
proveeu nare not intended or offered for NEW RESIDENTIAL ELECfR SQ 14.
sale.If.however,the building or improvement is sold within one year ofcompletion.the QPT7p.FLOOR AREA 5/SQ.b..
owner builder will have the burden of proving that he did not build or improve for p t,
pose of Sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: 7
consumer the project
aply](Fist.Business senddy who
ori ProvextheTre curts nd
c law Jasnntapplyntan owner aofpactors whosedporimpmscs thereon,and QTY. PLUMBING PERMIT FEE
Lwho ue...Last for such pmjatx with acontracuMs)licenced pursuant to the Cnntmcnr'x MAY 9
License exempt
PERMIT ISSUANCE 1996
I am exempt nneer see. ,n m P e for this reason
(Owner DateALTER—DRAIN&VEN (E
T—WATER AIVALUATION
LlVAATION
�-V;bgkERSPtNSATION43ECLARATION BACK FLOW PROTECT DEVICE
hereby affirm under penalty of pe jury one of the following decla✓tion,.
•❑ have and will maintain it Certificate of Co"sent toself-inxare for Workcex Compen- DRAINS—FLUOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
nation,us provided for by Section 3700 of the IaMr Code,lir the performance of the
work for which this pemtit is i.,mal. FIXTURES—PER TRAP
I have and will maintain Workers Compensation Insurance,as"or"by Section
37M of the labor Code,for the performance of the work for which this permit is issued. GAS—FA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My Workds Compensation Insurance carrier and Policy nomMi arc:
Cim er. Policy No GAS—EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifthe pemdt is forme,hundreJAnllnrs(SIM) GREASETRAP
or less.) PLANCHECK FEC
I certify that inthe performance nflhc work forwhich thin permit is isad.ishall SEWER—SANITARY—STORM EA.2W FT.
not employ any person In nay numner so as m become subjtot m the Workers'Compen. ENERGY FEE
0Z ..tion Luwsof Culifoml..Date WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE
NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should WATER SYSTEM/TREATING
a; become subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS ITE
forthwith comply with such provisions or this permit shall be Jecmed evoked. WATER SERVICE
6 Q
CONSTRUCTION Ltion lending agency
NEW RESIDENTIAL PLMII. SQ ET PAID
}z (hereby affirm that is.construction lending agency for the performance of Date Receiptp
U.OU. the work for which this peis issued(Sec.3097,Civ.C.)
0 Fs permit L) Lender's Num. TOTAL:
� Lendre,AJJrc,s TOTAL:" W
at1 certify that I have read this opal tendon and state that the aMse inlbrmation is BUILDING FEE
V) come.l agree to comply with ell city end county ordinances and neelews mlmtingm QTY. MECHANICAL PERMIT FEE
V Z buildingc.nemction.and hereby authorize representative of this city memo upon the SEISMIC FEE
above-mentioned property for inspection varpme, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liahil run,judgments.casts and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
consequencein of the granting of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNTT(TO LLMd CFM) I MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER(DOW CFM) CONSTRUCIBON TAX
Signature of Applicma/Canoanor Due F.XHAUS'IIHMD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willlhe.pplicanl ur(umm building occupant stone or handle h.zmdous material HEATING UNIT(TO 10.000 BTU)
as defined by the Cupcnino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section T5532(a)? HEATING UNIT(OVER IM.000 BTU)
F1 Ycs 71 Sit VENTILATION PAN(SINGLE RESID) PAID
Will thea applicant or future building occupant use equipment or device which Date Reccipt M
pp gt Fan Area
n BOILER—COMPOHPOR 100,MOBTU)
mit hezallous air contaminants as defined by the Bay Ante Air Quality Management TO
DisWm?
❑Yes 0 N BOILER—COME(OVER 10U."BTU)
Ihavereudthch adoaamamrialsrc is under Cba ler 6.95 of the Cali- AIR CONDI'1'IONER ISSUANCE UATR
g255 p
fomiaHealth gdoesn Scurry Code.Sections 255O5.25531and 255ility to understand theif the NEW kIS1UENTIAL MECH. 50.FT.
building dos not currently have a tenant,that o is my responsibility Int testify Nc acupant
of the requirements which must M met prim m iuuamx of a Certificate of Occupancy.
Owner or autnorived occur Date TOTAL: ISSUED BY:
OFFICE