29386 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL.
BUILDING PROJECI'IDENTIFICATION 29386
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
1�
O Ela'S A PHONE: Cl 'lot's NAM LIC NO:
/ NYC CONTROL#
gamigs. TOA CHITECT GINL'ER: LIC O: At RESS: / I^ ❑
r CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ 11 �[I/V''pq ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I sir licensed under provisions of Chapter (commencing JOB DESCRIPTION
�Z with Section 7000)of Division Sof he Business and Palestinians Code,andm license i
OO y s PERMIT ISSUANCE' RESIDENTIAL:
in full force and effect.
V License 3 Lee OSFDWI. [3 KITCHEN REMODEL
NzW Uam ant ter / APPLIANCIS-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE.
RCH :CT HiCLARATION OMULTLIINIT OSTRUCfURAL
Z p E2 Z 1 un ph al used vs ublic retools PANELS MODIFICATION
OZ—, / UPTO200AMPS C3 INTERIOR ❑CHIMNEY REPAIR
F�r,I:m 4 uJy 201.10IMAMPS IMPROVEMENT
e9+ E / o OWNER-BUILDER DECLARA'T'ION
y 6 I her firm for I am esempt from the Contractors License Law(.,,he OVER["AMPS ❑BATH REMODELIREPAIR 0 DEMOLITION
[� 3 y V (allowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL.' []OTHERs�a 16 F which requires a permit to uanurech alter,improve,demolish,or repair any someone
prior to its issuance,also reclaims the applicant for such Error to file a signed statement SPECIAL CIRCUIT/MISC. �n �r
ttprevisions} that he is licensed pursuant the pvisions of the Commisrs License Law,(Chapter 9 elZ7 G
GAO mommencimg with Section 7000)of Division Sof the Biomes and Prnfessions Codclm TEMB METER OR POLE INS'll COMMERCIAL:
that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
Y%1 Is, Section 7031 S by anyappliant for a permitiahjenstbeapplicamma civil penalty of POWER DEVICES OTENANT [I FOOD SERVICE
�. not more than five bond it dollars(SSW). IIMPROVEMENTO [-] 1,es nwncr of the properly,or my employees with wages as their axle compensation, SWIMMING POOL ELECTRIC
will do the work,and the suumure iis.,intended oroBertd for one(See.7044.Business 0 OTHER
til and Profusions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR FT
I Note,If,however the building or improvement is.sold within one year of completion,tire SQ.FL FLOOR:AREe �, S/SQ.FT
(Pwnervhoilder will have the burden of Preying that he did not build or improve for par-
,me of sale.).
❑1,es nwncr of the property.am exclusively rnnwning with licensed co eracom m IAL: npip ppp
mesad the projem(Sec,TILL Business and Profession.Code:7'I'heConwemr. YVIHII 7 19 6
cense Law does not apply to an owner of property who builds or impasses theater,and QTY PLUMBING PERMIT FEE
who contmcu for such projects with a commands)licensed pmxaam to fee Commit
License law. - CIIY Ur (/UI L'lll NU
3I am exempt under Sec. ,R&PCfmthismason PERMIT ISSUANCP.
fhvner
ALTER-DRAIN&VENT-WATER TA) VALUATION
Dum
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affair under Penalty of perjury one of the following d¢laranismi: '
❑Ihme andwill nmimaina Cesdfcamnf Conscm to self-insum for Worker.Compete DRAINS-FLOOR,ROOF,AREA,COND. S'IY)RILS TYPE CONSTRUCTION
sation,as provided far by Section 3700 of the Labor Gyle,for @c performance of the
work for which this,rotor is issued. FIXTURES_PER TRAP
0 1 have and will maintain Workers Compensation Insurance,as required by Semon
3700 of in.Labor Code,for the perfamanc,of t he work for which this permit is issued, GAS-HA.SYSTEM. INC.4 OUTLETS
APN
My WorkCompensationCompensaInsurancerl
r.Compensation Insurance comet and Policy number arc: OCC.GROUP
Carrier: policy No.: GAS-EA.SYSTEM-OVER 4(RA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASRINDUSTRL WASTE LNfERCF.FMR BUILDING DIVISION FEFS
(This aectionncednot be completed if the permit is borons,hundred dolsm(SIWI GREASETRAP Or less.) PLANCHECK FEE
I carat,that in do,crfommurnenDhe work for which this permit is issued,i shall SEWIiR-SANITARY-STORM EA.
not employ any pes.nn in any manna an as m became subju
eco the Wmkm COmpen- 200 Ff. ENERGY FEE
OO Apeon Lawn of Culifomia.Dire WATER HEATERW/VENT/ELECI'R ��
TICSafter GRADING FEE NOTICE TOAPPLICANT Work rs Compensation
this Ciii...e of Labor Code
WATER SYSfCM?REATING
h Tj' become subject m the Worker.Compensation permit
shal of the Lmed r Code,you must SOILS FEE
� t•r
forthwith comply with such provisions noble permit shall be deemed revoked. WgI'ER SERVICE
0
.0.7. 7.
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.IaE PAID
U I for
rwhich rhi that iesued(Sec.3097lending agency for the perfnrmanee of Date Receipt
U. F the work for which this pemtit is issue)(Sec.3097.Civ.CJ
U
p{kla Lende.Nane
TOTAL:
LendeesATOTAL:
I versify that
I have real this application anJ state thvnhe above information i. BUILDING FEE
tM coned.l agree to comply with all city and county ordinances and state laws rela0ngto QTY. MECHANICAL PERMIT FEE
(.1Z haddingeonswction,andherchy amm
himic represcmives of this city menter.,offie SEISMIC FEE
.hove-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cepenin,against ELECTRIC FEE
liabilities,judgmema,costs and expenses whi ay army way atom against said City ALTER OR ADD TO MUCH. PLUMPING FEE
in consequenceoft ting of this
APPLICANT U , S NDS LL COMPLY WITH ALL NON- OIN AIR HANDLING UNIT(TO IO.00lO CFM)
SOURCEIt S. MECHANICAL FEE
.13 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si tom tic onu,)lor De EXHAUST HOOD(W/DUCT)
AZAR
,,)lot
hiAfGR1A1S DISCLOSURE HOUSING MITIGATION I'BE
"Will th liter or future building occupant state or handle haiardous material HEATING UNIT(TO 100,000 BTU)
as defined by a Cupertino Municipal Coble,Chapter 9.@,and the Hea1N and Selcty
Code.Section 25532m)P HEATING UNI T(OVER W,00011'1'U)
❑Yes ❑NO VENTR.ATION PAN(SINGLE RBST❑) PAID
Will the applicant or f fere building occupant use equipment or devices which Date Receipt#
emit hmart air codusaudints as defined by the Bay Area Air Quality Management BOILER-COMP OBP OR 100,000 BTU)
District TOTAL:
F7 Yea 0 N BOILER-COMP(OVER 100,001 BTU)
I
I have read the bassnlnus materiAs AIR CONDITIONER
rcquiteme.,under Chainulco 5 l'Ne Cali- ISSUANCE DATE
to.Imil o Health,does no Sabmy Code Sections,that i 25533 and 25534.I to amitomd'he(if the NEW RESIDENTIAL MECH. SQ.Pf.
building does nor iscrarcral,which home mount,that o is ua ceof a responsibility as notify the aecupaet
of the requirements which must he met prior issuance of a Certificate of Occupancy.
Ownerorauthoured.gent Dam TOTAL: ISSUED BY:
OFFICE