29913APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY -
CITY OF CUPERTINO , I ' ' . -I BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING 1 MECHANICAL
BUILDING PROJECT IDENTIFICATION
) PERMIT NO.
itn (] (]
GJJ 13
BUILDING ADDRESS; ' - - -
�2o`zc�c5 AFf TQ�� LN..
SANfI'ARYNO.
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-
APPLICATION SUBMITTAL BATT
►� (3OWNE�Rr'SNAME:-
a PHONE:^.
-t R LH %J
QONT AC'�'OR'SNAMF:: --°LIC NO:"
N/C
F
CONT^ROLW .
RCHITF.0 NGINEER: LIC NO:.
I O RN6 6
ADDRESS:
CONTACT. 'PHONE:
4a p Diez
""
❑ CnnSuitant Fee9 Paid by Applicant (Initial)'
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION'
I hnretiy aft That 1 am tensed ander provisio s of Chapter 9 (commparing
ZO with Section]000) of Division 3 afore Business and Professions Code, and my license is
JLiceneClafall force and effect.
License Class Contract.,
W Dote - Comiacmr
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
0SFDWL O KITCHEN REMODEL
�,-v' ,
�pHOUTON ❑PLUMBING RE -PIPE
/❑MULTI -UNIT []STRUCTURAL
MODIFICATION
I
❑INTERIOR W ry E] CHIMNEY REPAIR
IMPROVEMENT aS tl (AS,
Ll )a [71j1QELBEPAIR'El DEMOLITION
❑ OTHBR (,a/6�
PERMIT ISSUANCE
•APPLIANCES-RESIDBNTfAL
' ARCHITECT'S DECLARATION
Zr. luvdersmnd my plans xha116e used us puMle records,
❑
PANELS
UP T02IXIAMPS
Licensed professional
- -
Oat Iso. 1.11 to DECLARATION Comp ON
d 1 hereby affirm that 1 am exempt from the Contraomr's License Law for the
U following ing teax - puldrii hi cauLS, Business and Professions Code: Any city or county
W requires a commit to censtmci, ober, Improve, damollsh, nr repair any structure
prior to its iesuence,also requirra the applicnm for such parmitrofilea signed statement
that he firmoldpursuant tthe poo.mor,offli, Contractors License Lt (Chirac, 9
to g lh5 ii ]Btl(p fD"' 3 td B dP f'.' Cdel or
a; math pt th ref roti thh f m II gad pt Any v' t on of
n Seco ]031.5 by any applicant fora permil,uldrUs theapph nim a civil penalty of
N not mor, than five hundred dollars($500).
❑I, as ownerofthc property, or my mnployas with wages as lheirsol,compemmlon,
e will do the work, and the stmcture is not iotendialmoffered foraplo(See. 9044, Business
Zand Professions Cade: The'Cuntracmrs License Law does not apply to an owner of
propeny who builds m improves thereon, and who das such work himself or through
his own employees, provided that such improvements are not Intended or offered for
sale, If, however. the building or improvement ix sold within one year ofcompletion.the
owner -builder will have the burden of proving Nat he did not build or improve for cur-
freef I )
&, a. o f the propeny - exclusivelycontracting with licensed contractors m
st t thep j ct (Sec 9044 Itaince, a' ) Prodfic,,iins Code) The C No tor, Li
- verect-awd.w,ranapplywint awralhpappery, wintlabldsmin'pall. nes th reon and0
who concocts for such Projects with a contractors) licensed personal to the Commcmrs Licence Law.
0latnexemptunderSm. ',B&PCfm1u,uixma
201-I(NIO AMPS -
OVER❑HHI AMPS
_
SIGNS ELECTRICAL
SPEC IAL CIkCUIT/MISC.-
Alfr'UM
TEMP. MET ER OR POLE INST.
r-
OMM R IA t•, '
-0 NEW BLDG/ADDITION IME] DEMOLITION
❑TENANT OFOODSERNICE'
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POLL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NH.W RESIDENTIAL ELECTR
-
'
-
SQ. FT. FLOOR AREA $/SQ. FT.
,
I F.
QTY PLUM RING PERM IT FEE
-
PERMITISSUANCE
ALTER - DRAIN & VENT -WATER(EA
BACK FLOW PROTECT DEVICE
w iter Date
VALUATIONWOR
Y� I
` \`O
dere ERSCOMPENSAIJONDFCLARATION'
IIhereby slfimn underpenalty of perjury one of the following declarations:
❑ I havead nwillmuintuin a Cenilm.m of Ca.,ca( toself-insure for Worker's Compcn-
cation; as provided for by Section 3900 of the Labor Code, fit, performanceS
of the
t wmkforwhichthispermitisissued. ,•
I have and will maintain Workers Compensation Insurance, as required by Section
39W ofthe LaborCode, for the performance ofthe work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. - Policy No.:
DRAINS- FLOOR, ROOF, AREA, CONI.
TORK
- -
TYPE CONSTRUCTION
FIXTURES -PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROU APN
-
,
B I DIVISION FEES
-_
GAS -EA. SYSTEM -OVER 4(EA)
. CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed ifthe permit is forme, hundred dollars 0$ Had-
ar less.) • I .-
1 certify mat in ilio perfnrmnvca attic work fur which nd, permit Is iaem xLI shall
not employ any person in any manner so as to bersorm subject tome Wmkera'Compen-
Lawf California. Dote'
Apps o
j Applicata -
Applies.,
GREASEAINDUSTRL WASTE INTERCEPTOR
GREASETRAP _
PLANCHE
SEWER - SANITARY - STORM F.A. 200 FT.sta
_
ENERG
,
WATER HEATER WIVENT/ELECI'R
GRADIN 8
NOTICE TO APPLICANT: If, after making [his Cenitlecte cf Exemption, you should
become subject to the Worker's Compersurion provisions of the Labor Code, you m_as[
fdrthwith comply with such provisions or thiiphinit shall be deemed revoked r
^ CONSTRUCTION LENDING AGENCY
I hereby off thauhore isaconstmcdon lending agency rnr Ne performuncenf
the work for which this permit is issued (Sea 3099, Civ. C.)
Lender's Name
'Lender', Address -' .. -
I cattily that 1 have read this application and state that the above information is
atM agree mcemply with all city and county ordinances and state laws relating to
building construction, and hereby canteen representatives ofthis city m enter upon (In
shove -mentioned propeny for inspection purposes.
(We) agree m save, indemnify and keep hay in an the City of against s against
IiaM1ilitin,judgmems. cams and expenses which may in any way accme against said City
in consequenceof the granting of this permit. ., +'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SGURCE REGULATIONS. /
9,
WATEk SYSTEM(fREATING
_
SOILS FEE
WATER SERVICE
'PAID
- Date -to p
NEW RESIDENTIAL PLMIL SQ. FT.
- -
.
BUIL B r
-TOTAL:
•'. T AL:
'
.
QTY MECITANICAL PER IT PEE
SETS F.
PLRMIT..
ISSUANCE
ELECTRIC P E
gLTER OR ADD I'U MGCH.
PLUMBIN PEE r
gIRHANULING UNIT (TD IO,OIXI CFM)
MECHANICALIs-r
AIR HANDLING UNIT(OVER 10,0bOCPM)
CONSTRUCTION TAX
Signature of Applicant/Comrator Dmo
. , HAZARDOUS MATERIALS DISCLOSURE:
Will the applicant or future building occupant store or handle hazardous materiel
os defined by the Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
Code, Section 25532(0)7
E] yes E] No
-
Will the applicant or future building proclaim use equipment or devices which
fait hazardous air contaminants as defined by the Bay A. Air Quality Management
District?
DYex El No '
I have ieaJ the h vardous materials hopuirem,lns under Chapter 6;95 of the Cali-
fomin Heaps &, afetyemor Celle, a ateea 8505, 25533 and 25534.1 understand mm if the
of'buthe rgJcee eats whichmly haveate et pthat it isua ceafa eariyto catesifymeoccupant hey.
of the requirements which must be met prior to issuance nfa Cenificme of Occm'pancy.-
h.
EXHAUS"1'HOOD(W/DUCP7
HOUSING MITIGATION E /
If EATING UNIT (TO 100," BTU)
HEATING UNIT (OVER 100,M) BTU)
_
-- '
,
PAID
Date r ° Receipt N
VENTILATION FAN (SINGLE RESID)
BOILER -CAMP (3HP OR 100,0110 BTU)
TOTAL: -
BOILER- COMP (OVER 1110.000 BTI)
' AIR CONDITIONER .
ISSUANCE DATE
'
-"
ISSUED BY:
NEW RESIDENTIALMECH. -. SQ: T.
Owner oradim ed agent - - Date
T is