29400 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO, O 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT WENT IFICTI'ION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS NAME' - PHONE: �� CONTRACTOR'CAM6s_. LIC NO. Y
r
k E;r0 NIC- CONTROL#
sr�RCHiTECT/ENCINEER: I.IC NO'. ADDRESS:' II ��-- ❑
1�
CONTACT PHONE M*VI,o - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that Iran licensed ander provisions of Chnpier 9 tnsmnmro1ng H DESCRIPTION
O tYZ with 5ation TOfl(q ofDivision3of the Businexs and Professions Cwe,andtrlicensees
Op in full force and effect, y PERMIT ISSUANCE RESIDENTIAL
=-V License Class Lie.# ❑SPDWL ❑KITCHEN REMODEL
APPLIANCES—RESIDENTIAL.
sc W Date Cameroon, APPLIANCES ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION
PANELS ❑MULTI-UNIT ❑STRUCTURAL
E 7 y
Z 0 tn.Z. 1 understand my plain shall he used as public records MODIFICATION
OZ-O 'UP'10200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
�4--' Licensed professional - 201-IEWAMI'S IMPROVEMENT
�Yd for I am BU oupt f DECLARATION OVER IMOAMPS
a�< 1 heresy umnn for 1 um exempt from the Comnvtor's Lkenic Law I'or he - ❑BATH REMODEflREPAIR 0 DEMOLITION
K36U following reason.(Section]831.5.Business and Pmficemas Cade:A,city or county SIGNS ELECTRICAL RUT]HiR S. UC F
'R IO -
41 LL O�a which requires a permit m construct,alter,improve,demolish,or repair any structure
m 1 r
�ItN.l prior m its issuance,also requires the applicant mistreat al file.signed statement SPECIAL CIRCUIT/MISC. �sT
} that he is licensed pursuant to provisions Orme Contractor's License Law(Chapter 9
d0�0 (commencing with Section 7000)of Division 3 ofthe Business and Vroficsicts Cnde)or TEMP.ME]1111()It POLE INS'P. COMMERCIAL:
06a C� that he is exempt therefrom and the basis for the alleged exemption.Any truistic.of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y Section](131.5 hyany applicant fors permit subjects the oppllcanl moelvll peraltyof POWER DIIVIG ❑TENANT ❑FOOD SERVICE
I.,more than five hundred Jolla.($5010).
F-2Q ❑ Las owner ofthe property,or my employees is IMPROVEMENTith wages as their sole compensation, SWIMMING BL' C
' will do III,work,and Ncstructme isnot itnendedmoffered formic(See B94,Business C1 OTHER
W and Professions Code:The Contracmr's License Law does not apply men owner of OUTLET'S—SWITCHES—FIXTURES
property who builds or Improves thereon,and who docs such work himself or through
his own employees,provided but such improvements are not intended or uRcred for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the buil ding or improvement is sold within one year of completion,the SQ.IT.FLOOR AREA $/SQ.FT.
enbudder will have the burden of proving that he did out hold or improve for put- Fi
own V
pose of V
❑I,us over owner of the proiwny,am exclusively cnninnting with licensor'emnme.xs u, - TOTAL: '
construct the project(Sec.'/IW4.Business and Professions Code:)The Convector's Li- a 111996
cense law does not apply to on ownerveofpropeny who builds or inipmves thereon,and QTY. PLUMBING PERMIT FEE p��s K
who contracts lx osuch projects with a cuntmetm(s)licensed pursuanno the Contraries X71
cPERMIT ISSUANCE
l exempt under Sec & m
. -,BP C for Nis reason
On f,l T Ur wrL�(PVV
ALTER—DRAIN&VENT—WATER(EA)
Owner Dae VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
I hereby affirm under penalty of perjury one ofthe following deelamtions:
Hateand all ormatmnu Cenincate.f Cure,, n tolimuchn WorkdsClasen. DRAINS—FLOOR,ROOF AREA,COND. STORIES 'fYPECONS'1'RUC1'LON
nation,as provided for by Section 3]1X1 of the lads Cade.for m
e pcif. u.ce of the -
isork for which this Permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section -
37Mofthe labor Cuts.for Performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC,GROUP APN
My Work CompemtI ins.ranac carrier and Policy nu
ammur: eMt-1'.. .-sgic .Policy No.: xQ6000Dy GAS—EA.SYSTEM-OVER4 EA)
CERTI FICATE OF EX EMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASFJINUUXI'RL WASTE INTERCEPTOR
(This aecti.n need not be completed Brun permit is fnrone hundred dollars($100) BUILDING DIVISION FEES
m less) GREASE TRAP PLANCHECK FEE
Loy mythat
looma in an,mance, ,Ne work for which this'heperaril WisissuaLlahall SEWER
n.t erupts an SANITARY—STORM EA.200 FT.
y ypeneenim an, so anmhecnme subject to the Wnrkecs Cnmpero ENERGY FEE
Oz scion Laws of Celifomia.Dam WATER HPATER WNENT/ELECTR -
Z 0 Applicant GRADING PEE,
ski
NOTICETOAPPLICANT:IL atom cooking This Cenin s of the
Exemption,you should
s'
a , became subject NC Werke/s Compensation provisions of Ne laMr Cade,you must WAIF:R SYS'fF.M/TNIiAtING 50115 i'F.E
forthwith comply with such pinsist ans o this permit sbell be deemed revoked. WATER SERVICE .
O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.PT. PAID
V 0 l hereby sperm but Nem is a construction lending agency lin the performance at Date Receipt#
{L H the work for whichthis permit is issued(Sce.3090.Civ.C.)
0 Lender's Namef t TOTAL:
adder's Address TOTAL:
HPi 1 certify that I have read this application and state that the above information is BUILDING FEE
h comect.l ogieemmmplywillidledyandcnunty.reinanacs anJ note laws relining n' QTY. MECHANICAL PERMIT FEE
is
& building construction,and hereby authorize representative ofthis city menccupm Ne SEISMIC FEE
Z73
above-ntanti.ned prolxxty foriimpreli.n purpuses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC PER
Ioddhdro,judgtnents.c.sroend expenses which may immy way,aecmeagirmil,aid City ALTER OR ADD TO MECH.
in consequence of the gaming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,000 CFM)
SOUNC GDLATI S. MECHANICAL FEE
�Q AIR HANDLING UNIT(OVER 10.0011 CFM) CONSTRUCTION TAX
'i atumor pplicantlCun 'tor ,.. DateEXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
GAZA'A MATERIALS DISCLOSURE
WIIINe applicant or far..mildingoecupam time or handle haxurdous nmmdnl ABATING UNIT GO 100,00311'TU) , .
as defined by the Cupertino Municipal Code.Chapter 9.12;sad the Health and Safny
Code,Section 2.5532od? HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. VENTILATION PAN(SINGLE RESID) PAID
Will then lie:mt m future building - Date Receipt#
pp d by the Bay Am.Air Q t lily Mecca which BOILER—COMP CHIP OR 100,000 BTU) _
mil hvvrdous sir comeminema as JenoW by the Hay Arca Air Quality Managctrtcm District? BOILER—COMI'(OVER 100,088 BTU) T A1.:
❑Yes ❑Nn
s
I have read the hazmdous materials AIR CONDITIONER
m,M533 an under .1 makins95 of NC Cub- ISSUAN TE
fomia Health&Safety Code,Sections 255(15,Silly and 25534.I understand Not Rib, NEW RESIDENTIAL MECH. SQ.FT.
building does
reurntscurrently which roma
mann[,theao i my t,of.Ceraiyme al'overprot
of the requirements which mull N mu prior m issuunm of a CeniOcate of Occupancy. ,
O virtue m.umonzed agent Date TOTAL: ISSUED BY:
OFFICE