29608 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^(� Q O H
BUILDING DIVISION APPLICATION/PE"IT PLUMBING-MECHANICAL LJV
BUILDING pROJF.C'1'11)FNTIFICA'I'ION
BUILDING ADDRESS: - _ �� SANITARY NO. APPLICA'1'IONSUBMUTALDATI
0 LED
O '.R'SNAME: PHONE CONT A '[OR'SN LIC NO,-� NIC CONTROLM
ARCHITECEPENIGINHER: LIC NO: ADDRESS: �� ❑
CONTACT':. PHONE: BUILDING PERM[T INFO
.• ❑ Consultant Floras Paid by Applicant(IBItla1) BLDG ELECT PLUMB
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION of CON QTY ELECTRIC PERMIT PEE .LOB DESCRIPTION
1herebyn.fLthat1,3 (the Ba.underpnrvi.vionsof Chapter9Tcomme.,ois
y�yl00 with Section]WO)of Dlvisinn3 nfthc Business mdl'ruf dons CoJc,undo license is
F�� in full force and effect. y PERMIT ISSUANCE? RESIDENTIAL
F�F..UV License Class L.ic.a ❑SFDWL ❑KITCHEN REMODEL
N64 Dam Coutmcmr APPLIANCES—RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE.
'
FS
ARCHITECTS DECLARATION PANELS rn ❑MULTI-UNIT ❑STRUCfURAL
O Z L understand my plans shall he hucJ as pontic records MODIFICATION
UP TO 2W AMPS
W License)Nofeuional - ❑INTERIOR _ C1 CHIMNEY REPAIR
GYN. OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMI'NT
C�Q I hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1000AMPS - - ❑BATH REMODEUREPAIR ❑DEMOLITION
'a4 a d V following reason.(Section]U31.5,Business and Professions Calc:Any city or nnmty SIGNS ELECTRICAL ❑OTHER
LLl Y, which requires a permit to construct,Nor,improve,Jemulish,or repair any structure
�V � prior its issuance,alsn requires the applicant for such permit file a.signed statement SPECIAL CIRCUIT/MISC.
rn that he is licensed pursuant to the ( per
Y p provisions of the Commcmfs Licens law Chat 9
Is
O (commencing with Sectinn]Up)of Divisinn3 of the tlusiness and Pmfcssions Cade7or TEMP.METER OR POLE INS1'. COMMERCIAL
d
that he is exempt doncfmm and the basis fur the alleged exemption.Any sad tion of [I NEW BLDGIADDITION
❑UFlMOLITION
Section 1031.5 byanyupplicant for it jo, to auhjahs the application a civil pemdtynl POWER DEVICES 'IiNANT
�I'
$y not more than five hundred dollars($5(10). ❑FOOD SERVICE
=QQ1.as owner of the progeny,or my employees with wages as their sole compensation, SWIMMING P001.ELECTRIC IMPROVEMENT
F will do thework.and the smucmm is not imendedmrnffeed hnavlc(Set.]0s4,Business ❑OTHER
d 3 and Professions Cale:The Contractors License Law does nm apply m an owner of OUTLETS—SWITCHES—TEXTURES
property.who builds or do,on es then, r,and who docs inch wark himself ter onegh
his own emplayees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ 112
sale.If,however,the building or improvement is sold within one year o(completion,the SQ.FT.FLOOR AREA $/SQ.pT.
wn
cr-huilder will have the burden of proving that he did not build or improve for put-
"a")
.'owner
of the property,um exclusively convecting with licensed contracmra to TOTAL:
nmmct theprojecr(Sa.]044,Huainess and Professinnx Code:)'L he Con¢acmr's hi- N nn r�ss '
enselaw does not apply to an owner of property who builds or improves moves,and QTY. PLUMBING PERMIT PCE p '+l
ho contracts for such projects with a instructions) Caricaturesions)licensed pursuant to the Caricatures /I a��
License law. PERMIT ISSUANCE �'1�+
Pam mpt ander Se ,B&PC nNs axon ^ 6
DETER—DRAIN&;VENT—WATER MA) —hsl VALUAYEE
OWner Dam
WORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT.DEVICE UP VUh- '
!he.cb)affirm under Penalty of perjury one of the following dedamtions: �'�///pV
E have and will maintain a Cenifo"m efCmmvm m self-insure far Worker's Compen- DRAINS—FLOOR,ROOF AREA,COND.
sodeus provided lin by Section 3700 of the Lsb r Cale,far the performance of rho SSTORIES 'TYPE CON$TRUCf10N
n
work fur which this permit is issued FIXTURES—PER'TRAP
❑1 have and will maintain Worker's Compensation Insurance,as squired by Section
3IlI0ef the Lehr Cid,,for the petfermvnceofthe work for whilh,hia gamut is issued GAS—EA.SYSTEM.]INC.4 OUTLET
OCC,GROUP APN
My Worker's Compensation Insurance carrier and Policy number are
Carrier: Policy No: GAS—P,A.SYSTEM-OVER 4(EA) ,
CERTIFICATE OF EXFMPTLON FROM WORKERS'
COMPENSATION INSURANCE OREASETNDUS'L'RE,WASTE INTERCEPTOR
(This section need not be cemplemd if the Permit is formal hundred dollars SIGH BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCHECK PER
Tcenify that in the performance nfthework fnrwhidnhiv permit Moaned,Tshall SEWER—SANITARY—STORM EA.200 Fr
not employ any person m any manner o,as to tommne object to the WnrkcrK Cmnlnm' ENERGY FEE
Oz sation Luwsof California.Date WATER HEATER W/VF.NT/ELIiCfR
Z Q Applicant GRADING FEE
y NOTICE!TO APPLICANT:If,after making this Cenifhcam of Exemption,you should WATIiR SYSTEM/fREATTNG
become suhject to the Worker's Compensation pmvisiens orthe Lehr Code,you most SOILS FEE
forthwith comply with such prevision,r this v rmit shall he deemed revoked. WATER SERVICE
F,' z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.14. PAID
U Ibereby affirm thauhere iseconvmction lending agency for the perfotmanc<of Date Receiprk
D, r the work for which this permit is issued(Sec.309],Co,C.)
p U Lender's Nanhm - TOTAL:
Lenders Address TOTAL;
1 certify that I have read this application and state that the above information is BUILDING TEE
r..^ fA cortecL l ugme to comply with all city and country ordinances and state laws relating to QTY. MECHANICAL PERMIT FF:E
U Z building construction,and hereby autlunizeteponematives Ufthis city retaliation the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to xnvc,indemnifytmd keep hunmlcsx rhe City of Cupcnino against PERMIT ISSUANCE ELECTRI—FEE ,
liabilitiesjudgmcros,costs and expenses which may in anyway accrue against said City g1aER OR ADD TO MECH.
consequence of 0e granting of this pnmir. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,080 CPM) - CONSTRUCTION TAX
Signature of Appliuma/Contmemr Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
14AZARDOUS MATERIALS DISCLOSURE .
Will the applicant or future building occuWntstore or handle hmaMous material 1 HEATIN06NITQOI00, BTU)
as defined by the Cupcnino Municipal Calc,Chapter 912,and the Health and Safety
Code.Section 25532(0)'1 HEATING UNIT(OVER 100,000 BTU)
[j Yes Oleo
VENTILATION FAN(SINGLE RIS ID) PAID
•e Will the applicant or Empire building occupant use equipment or devices which Dam Receipt p
mit hazmmmus air comnminantsa,defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU) -
District? TOTAL:
❑Yes FIN. BOILER—COMP(OVER 100,000 BTU)-
I have mad the havWeus materials mquimmenu under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUA Or.
folde,ia Health&Safety CoSections 25505,25533 and 25534.T understand that if the NEW RF.SIDF.N'1'IAI.NEED. SQ,Ff.
huilding does not contend,bre a record,that it is my reepnhsihility to nntil'y the occupant
of the hequiremenrs whichmuo he met no to issuance ofu CeNfcme ml'Orcupancy,
Owner or authorized agent Date
ISSUED BY.
OFFICE