29703• APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT, PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL. -
BUILDING DIVISION APPLICATION/PERMIT' '- PLUMBING- MI,CHANICAL
PERMIT NO.
n 0
BUILDING PROJECT IDENTIFICATION
L
R ILDINC ADDRESS: -
SANITARY NO.
APPLICATION SUBMITTAL DATE
NAME: PHONE: NTRACTO 'S NAME:
n:i `tel"I
I
I
aril
sRCHITECT/ENGINIiF:R: LIC NO: ADDRESS:
CONTACT: PHONE:- -
BUILDING PERMIT INFO
Com �r O Consultant Fees Paid By Applicant (Initial)
BLDp ELFT PLUMB MECH
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LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am limused under provisions of Chapter 9 (commencing
with Section 7000) ol'Dlvlsinn 3 nl'Ihc 1'.. -un it'rafcesions Cd, antlm I'cc .s
in full force and y..cn, PERMITISSUANCE
k �� - 55
Licens ler LiaAPPLIANCES E
- RESIDENTIAL
Dae - Cmu acmT -❑ADDITION
-
ARCHITECTS DECLARATION PANELS
1 undemtand .sty plans shell he used as puhlic records
-
LaPOsd Rareadumal UPT021X)AMPS
OWNER-BUILDER DECLARATION 201-I00UAMPS
1 hereby affirm that 1 am exempt from the Contrucmrs License Law for the OVER Into AMPS
following reason. (Section ]031 5, Business and Professions Cuter: Any city or county SICNS ELIiG'1'RICAL
which requires a permit to eoustmel, alla6 improve, demolish, or repair any'slructum
poor it) its issuance, elan requites thc applicant forsuch permit," file. signed....amen, SPECIAL CIRCUIT/MISC.
Nat he is licensed pursuanuo the provisions of the Commct"rs License law (Clabber 9
JOB DESCRIPTION
RESIDENTIAL '
❑SFDWL a ITCHEN REMODEL
❑ PLUMBING RE PIPFL
❑MULTI-UNIT C1 STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
Cl OTHER
'
COMMERCIAL:
❑NEW BLDG/ADDITION EI DEMOLITION
El TENANT ❑FOOD SERVICE
IMPROVEMENT
[I OTHER
dW CG
d
.Z.�
Lail-'
•
(c inumnang with Secdrm70Xb.f Divoion3 ofthe Busmeaaand Professions Cadelor TEMP. METER OR POLE()IST.
that he is entrap, therefrom and the basis for the alleged exemption, Any violation or
Section 7031.56 an applicant born molt subjects the applicun. lou civil -
Y Y p 1 pcnnity nl' POWER DEVIC"
a more than Eve hundred dollar,(15on.
O Lasawbarterdar ropengoTmyempl.yees with wages es their sale compensation, SWIMMING P IC
willdalhcwork,und the Somal is not immbedmnffered fbranle(Sea 7044. Business
and Professions Code: 7Te Cnatmetors License Law does not apply to an owner of OUTLETS -,SWIC ES- ORES
Property wan builds m Improves theo"n, and who does such work himself or hrough
his own employees, provided Nat such improvements are not intended or offered for NEW REST 1) E JAVI_3CI'R SW.
,
n
sale. If, however, be building or improvement is sold within one I'm of cnmplctlon the LSQ.
caner-lamider will have he burden "(proving Nat he did not build or improve for bur-,
11'. FLOOR AREA
-
$/SQ, FT.
'
pose of s_
astowner
El L rofciteprogeny,amexclusively contracting with .ices_......seers to
�a•) ^.rn�
1 xsgi
cone a
strutht project (See. Business end Pmfeoxajor,ns Codcp 7To Con,rector'x Li-
�CD
I•�i7
cense Law Ices no, apply to an owner of progeny who builds or improves thereon, and QTY PLUMBING PERVP FEE
whocommetsforsuch projects wiNac..neracmns) Iicensedpunuam rothe Cmdandor's
f �V C riIINV
,
License Lew. PERMIT ISSUANCE
❑ I um caempt under Sce. B & P C for this real".
(sYv
C'11
ALTER-DRAIN&VENT-WATER (FLA)
Owner - Date
VALUATION
I
•Ihcrebyafion.nde,pen.lnyof
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
cone, ..a of the following declarations:
I have and will maintain a Carilicate ofCousenn..self-insure for Worker's Compen' DRAINS- FLOOR ROOF, AREA, COND.
radon, av provided for by Section 3](10 of Na Lahr CWe, for the performance "f the
STORIES
TYPE CONSTRUCTION
work for which this permit is isamm, FIXTURES-PER TRAP _a
-
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section I It
3700ofma leb..rCek, for the perfnnnwce.it, work for which his permit is issued. GAS-EA. SYSTEM-( INC.40fITLETS
Wor tt��@@esu ccs rand Pnlia 9�I her
EdNtq nc rticrtic
OCC.GROUP
APN
artier: py Policy NnY {] 'a t,p GAS-EA. SYSTEM -OVER 4(HA)"
-
CER�TIFICCAATTEE\ OP EXEMPTION FROM WORKERS'
',�
O
COMPENSATION INSURANCE GREASU NDUSTRL WASTE INTERCEPTOR
['Otis section need not becompleted Howperm' t is for one hundred dollars (HOB)
or leas) GREASETRAP
Icrony
,,banNbperr..ourow, nbNwherne work ewhich nlhislthemitisissued,Lsco- SEWER-SANI'T'ARY-STORM EA. 20011'.
bol employ any penton i^any manner en a.. w become subject m the Workers' Compen-
radon laws of Califomiv. Date - -
BUILDING DIVISION FEES
PLANCHECK I7EE
ENERGY FEE
-
Applicant WATER HF.AIF.R WNENT/ELF.CTR
GRADING FEE
h
abecome
a�
NOTICE TO APPLICANT:If. after making this Cenilicme of Exemption, you should WATER SYS'TEMOREATING
subject to the Workers Compensation provisions of the Later Code, you nest
forthwith comply with such provisions nr this permit Shull be deemed basked. WATER SERVICE
SOILS FEE.
U0
U
CONSTRUCTION LENDINGAGENCY NEW RFSIUENTIAL PLMB. SQ. FT.
T that iszcostmeti0lending agency for pertormmme of
PAID
Data Receipt is
'
. W P
Q U
fill which
the work for whicM1 Nix permit is :awed (Sec.3(197, Civ. C.)
Lender's Name
TOTAL:
lenders Address - Tp
y I certify that 1 have read this.pplicalion and state that Ne aMve inform.,:.... is
Ls) counsel, l agree to comply with all city and county ordinances and state laws adming to QTy, MECHANICAL PERMIT ' FEE
LJZ building countmcti..mand hereby militarize representatives ofthis city to enter upon the
BUILDING FEE
ST71SMIC PEE'.
above-memio^ed prapcny for inspection pmpoxea - PERMIT ISSUANCE
(We) agree m avec, indemnify and keep hu biles,. the City of Cupenino,ardt
ELECTRIC FEE
" "' judgments,cosraand experees which may in any way neem, against said City ALTER ORADDTO MECH.
unseque fthe gmntingofthis permit ',
APPLICANT UNWISTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT (TO BI,000CFM)
URCE REGULA INS. ,. -
PLUMBING FEE OSO
MECHANICAL PEP.. '
AIR HANDLING UNIT(OVER ILOOCFM
-Date
CONSTRUCfIONTAX
igna ..ante, EXHAUST HOOD(W/DUC)
MATERIALS DISCLOSURE
HOUSING MITIGATION FEE.
Will the applicant or future building ownpum.dor, or handle hazardous material HEATING UND'('1'0100,W)(I BTIH
-
as defined by Ne Cupertino Municipal Code, Chapter 9.12, and the IIcaIN and Safely
Code. Section 25532(a)Y HEATING UNIT (OVER 100J1(p BTU)
-
E] Yes ❑No
VENTILATION CAN (SINGLE. RF.SID)
I Will the. air cicumnrfuture building occupantuseea Air mnt..Tdeviceswhich -
emit hazuNous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(3HP OR I W,000 BTU)
District?
-
PAID
Data
l
TOTAL:
❑Yes ❑No -• BOILER-COMP(OVER I(p,(kp BTU)
^v
I have mad the hazusloos materials requirements under Chapter 695 of the Coli- AIR CONDITIONER
forma Health & Safety Code, Sections 25505. 15533 ad 25534) undeba nd that if the NEW RESIDENTIAL MECH. - SQ. FT.
buildingJasnot curmntly haveatenant, that in ismyresptmeibiliny m niify Neaceupvn
.fthere,marro as which must be at prior n" usuarme nfa Ce.iRcmeuf0ambency.
ISSUANCE DATE
' -
"
ISSUED BY:
Owner (it authorized agent - pate
OFFICE