29628 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. A ss a.. ,.S
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL LJV '2 l8J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRE3Ac N SANITARY NO. APPLICATION SUBMITTAL DATE
/oa.1 -X /.ra,e �`� n-o Ofpk16-q6
OWNER' NAME: PHONH: CONTRACTOR'S NAME: LIC NO:
NIC CONTEG64
RCHITECILTNGINEER: LICNO:. ADDRESS: ❑ CRA j
CONTACT. PHONE: fI-- BUILDING PERMIT INFO
LJ1I Consultant Fees Paid by Applicant(Initial) PLUG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
I herebyaffmm that 1 am licensed under QTY ELECTRIC PERMIT FEE
and
Proonsof Chapter and
- 10B DESCRIPTION
�0OZO withal home
ad,ffifDivisioniof the Business and Professions Ctd,,anJ mylicense is PERMIT ISSUANCE RESIDENTIAL:
��,, in full force end effect.
,Vu Liceass Class Lic.N OSFDWL KITCHEN REMODEL
FlLL[�7 Duce Cmanwtm APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O 7, 1 understand and my plans shall be used us public records MODIFICATION.
OZ. O UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
y((❑❑.. Licensed Pmfessional 201.1000AMPS IMPROVEMENT
m91L aJT OWNIA.BUILDER DECLARATIONmuromm OVER IOW AMPS ❑BATH REMODEUREPAIR C1 DEMOLITION
0o aCC ya�� I hereby ESectfficar Net I ora exempt Tram the Conan,Co eAnyLicense Law for the
a L U following reason(Section 0031 ru t.Business and Professions h,or Any city or county SIGNS ELECTRICAL i ❑OTHER
4O which requsu n peril to uimst a alcor,improve,demolish, file
repair any smctare
prior he is licensed
palm requires previsions of for such Contractor's
ontrarmfrio Senssigned LaCammem SPECIAL CIRCUIT/MISC.
;!I y that he is Items it pursuant m the provisions 3 the Coatnn sss suit
Law(Chapter 9
apo that he is aermth Seem.7")ad the
Di,isl fer of Ne.,ed essand Pmfessionslmi.00r TEMP.METER OR POLE(NST. COMMERCIAL:
la. e e that he is exempt thercfmm and the basis fns the alleged exemption.Any l Pen lty of ❑NEW BLDG/AUDITION ❑DEMOLITION
Y•
Section 703 L5 by any applicantfor a permit subjects Ne applicant toecivil penally of POWER DEVICES
rrn ❑TENANT ❑FOOD SERVICE
>q
or more Nen 0 hundmldollars y employees
- - IMPROVEMENT
Sp Q I,as owner of the pmpeny.or myot amended withwages ed forotheir sole. 04,1,8 sines SWIMMING POOL ELECTRIC
y. wdl doth,work,and theswaure is notimeMW orofferedforsale(Sec.]614,Business ❑OTHER
6b end Professiore Code:The Contmcmrs License Live due,not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.. property who builds or improves thereon,and who likes such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENT L ELECTR SQ FT.
sale.IL however,the building or improvement is sold within oneyearmcompletmac the SQ.FT.FLOOR AREA SISQ.n..
owner-builder will have the burden of proving that he did not build or improve for Pul-
p
ur
po.eof sale.).
1,m owner of the property,ora exclusively contacting with licensed contractors to TOTAL:
con. ct the pmjea(Su.]044,Business nnJ Professions Cade:)The Commnar's Li- n
can Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBIN I FEE MAY 2 O ��
who contracts for such p jects with a contactods)licensed pursuant the Contractors
96
License Law. PERMIT ISSUANCE
I mmpt under Sm. ,B&P C for this reason _ Gilr ul- Lir... .
- )
se Dam ALTER-GRAIN&VEND VALUATIONVL
WORKER'SC PENSATION DECLARATION BACK FLOW PR . EVICE '
1 hereby affirm under penallyof perjury one mf Ne following olmlamtium:
❑Iheve and will trmimeinaCcnificae of Cmnsem to slit-inxum for Work<fs Compen- DRAINS-FLUOR,ROOF ,COND. STORIES TYPE CONSTRUCTION sation,as provided for by Section 3]a)of the Labor Code,for the peiforance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700m17the Labor Craft,for the perforemnseofthe work far whiehthis perram is issued. GAS-EA.SYSTFM-1 INC.4 OUTLETS OCC,GROUP APN
My Workers Compensation Issuance currier and Policy number are:
Corierr. Policy No.; GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRHASOINDUSTRL WASTE INTERCEPTOR
(This station need not becompleted ifthe permit is forms,hundred dollars(SINE BUILDING DIVISIOrim. ES
At less.) GREASETRAP PLANCHECK FEE
l certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in Any manner an As to hmmme mbjecno the Workers'Co., ENERGY FEE
O ,z sation Laws of California.Dam WATER HEATER WNENDELECTR
z O Applicant GRADING FEE
).wy NOTICE TO APPLICANT:If,after making this Cenifscate of Exemption,you should WATER SYSTEM?REATI NO -
F^ ; became subjmno the Worker's Compensation provisions of the labor Code,you must SOILS FEE
forthwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE _
Q
CONSTRUCTION LENDING AGENCYAgency NEW RESIDENTIAL PLMB. SQ.FT. PAID
' U O (hereby offirthm them isacnnmm�inn lending agency for performance of Dare Receipt
U.P the work for which this permit is issued(Sec.3097,Civ.C.)
O U Landers Name TOTAL:
Le. ',Address TOTAL:
1 cmify the I have mad this application and seem Nm Ne eMwe infometinn is BUILDING FEE
h correct.I agree to comply with all city and county ordinance and state laws relming to QTY. MECHANICAL PERMIT FEE
U Z building construction,and herebyauthonm mpnouniarces ofthis city to enter upon the SEISMIC FEE
above-rnentiuned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep harmless the Cory o1'Cupertino age,
liabilities,judgments.costs and expenses which may in any way ramie against said City ALTER OR ADD TO MECH. PLUMBING FEE
_ consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE REGULATIONS. MECHANICALME
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCf10NTAX
Signature of ApplicanUCoutracmr DoteEXHAUST HOOD(W/DUCID HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicmt nrfume building rectipanumreor handle hormsbaus mmedal HEATING UNIT(TO 100,000 BTU)
As defined by the Cupertino Municipal Cale,Chapter 9,12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant or future building occupant use equipment or devices which
�cmit bazallous air contaminants ae defined by the Boy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
TOTAL:
Dison?
E]Yea C]No BOILER COMP 100,000 BTU)
/'� - '
I have revel the harurdous mammals requirements under Chapter 6,95 of the Calo- AIR CONDITION(?R ISSUANCE DATE
foarm Health&Safely Coale,Sectors 25505,25533 real 25534.1 undersand use if the NEW RESIDENTIAL MECH. SQ.FT.
building does not curmly have v tenant,that it is my responsibility to notify the torment
of the mquorements which must be met poor to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
e OFFICE