29629 APPLICANTYO FILL INiINFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY .
CITY OF CUPERTINOq' ` 'BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION "'r APPLICATION/PERMIT PLUMBING-MECHANICAL - nO
BUILDING PROJECT IDENTIFICATION L�J
B1l1L��O11IN�ZGiAD•�^UStR85S: o SANITARY NO. APPLICATION SUBMITTAL DATE
5.
OW F 'SNA`4 �` CONTRR'S NAME: LIC NO: �•
M PC T'.•'t` NIC CONTROL#
- RCHITECT/F.NGINEER: - LIC NO: ADDRESS: - ., ❑ - '
corvTACf: .. exorvE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEOT PLUMB MECH
I ❑ ❑ ETLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby nffinn that t can licensed unser previsions of Chapter 9(commencing JOB DESCRIPTION
1000 with Section7000)ndefef Divisinn3 of the Boniness and Professions Cade,and my license is
FOO in full force and effect y PERMIT ISSUANCE RESIDENTIAL•
R�U ❑SFDWL El KITCHEN REMODEL
G Uz U License Class Lia.p -
Nd0. Data Centradnr APPLIANCES-RESIDENTIAL ❑ADDITION 11 PLUMBING RE-PIPE
z8[[....p y ARCHITECTS DECLARATION PANELS El MULTI-UNIT Q STRUCTURAL
m Z 1 understand my plans shall be used as public records MODIFICATION
.OZ4— - ' .. 'UP TO 200 AMPS ❑INTERIOR [:1 CHIMNEY REPAIR
Lensed Professional 201-111011AMPS IMPROVEMENT,
OWNER-BUILD Ce Contractor's
OVER I"AMPS 'Q BATH REMODEVREPAIR El DEMOLITION
1 hereby affirm that 1 am exempt from the Cssions Co License Law for my
V4a,F following rine.,.permit
1.lIDLS, t,iduess and Professions Code,Any city or county SIGNS ELECTRICAL ❑OTHER
O which its issuance,
s ea o permit to construct,alrce improve,demolish,m repair any structure _
�m thior ton heisiodmdcgblsoreq.me the applicant of for such permiuofile aicense Law
(Chapter
SPECIAL CIRCUIT/MISC.
>. that he is IicenaeG pursuant m the provisioue of No Commetnrs License law(Chapter 9
COMMERCIAL:
��00 (commencing with Section 7U(I(O ofDivisionl nfine Business and Prmfcasiens Code)or TEMP.METER OR POLE INST. .i
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION [-IDEMOLITION
iC Lr. Section 7031.5 by any applicant for a Permit subjects,the applicant to a civil penalty of POWER DEVICES u ❑TENANT Q FOOD SERVICE',
F+Z per^ not more than five hundred dollars WOOL - �' IMPROVEMENT
Sp Q Lasowner of theproperty,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will de the work,and the swewr<is not intended er ollere4 fnrsale(Sec]044,Busine<s Q OTHER
3 and Professions Code:The Conmaftor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves income and who does such work himself or through
his ow employees,provided that such improvement,are not intended ur eRered for NEW RESIDENTIA "ES77R SQ FT.
sale.Ifnhawever,the building or improvement ieodd within ora,,no eompletime,the SQ.PT.FLOOR AREA $/SQ.PC
owner-builder will have the burden mL proving that he did net build or improve far par- pp pp
se of eeI I A Y ® -
as owner of the property,um exclusively contracting with licensed canuncmrs to TOTAL:
eons t the project(Sec.7044,Business and Professions Code.)The Contractor's Li- a
cense Law does not apply to an owner f property who builds or improves thereon,and QTY. PLUMBING Contractors
FEE MAY 2 ®'1996
who contracts for such projects with a conunclor(s)licensed pursuant to the Conetors °
License Law, PERMIT ISSUANCE
Q 19th &
exempt under Sec. ,B P C for this mason V I I't 1 v (JI- V JI'CI'(I 116't�
ALTER-DRAIN&VENT- R(EA)
0 r - D VALUATION
WO�CO SATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm ander penalty of pa j.,one of the following declarations:
Q l have and will mtimain a CeniEcme of Consent to self-iname for Workers Compen- DRAINS-FLUOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
nation,es provided for by Section 3]00 of the Labor Code,for the perfmmimea of the'
work for which this perout is issued. FIXTURES-PER TRAP
Q I have and will maintain Werked's Comperidemp Insurance,as required by Section -
37W of the Labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS ;OCC.GROUP AM
Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-PA.SYSTEM-OVER 4(EA)
CERTIFICATE,OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR '
BUILDING DIVISION FEES
This section neednot be completed side,permit is foronp hundred dollars($100) GREASE TRAP
or less-) -
PLANCHECK FEE
Ie,any hot inthe any..ties d I are of the
for which NisPemmials'Campine-
SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner eo as to become subject rude,Workers'Cmmfien- ENERGY FEE
,Z Applicant
L....f Califamia.Duce
�O A licant WATER HEATER W/VENT/ELECTR
PP GRADING FEE
q y NOTICE TO APPLICANT.If,after making this Certificate of F,xemption,you should WATER SYSTENITREATING -
abecome subject o the Worker's Compensation previsions of the Labor Cede,you must SOILS FEE ' .•.
Iia forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
Q '
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ FT. PAID
V 0 Ihereby affirm that mere is a construction lending agency for performance of Data Receipt
Dw F the work for which Nis permit is issued(Sec.3197.Civ.C.) -
Q Lender's Name TOTAL:
WLender's Address - - TOTAL:
a 1 certify that 1 have read this application and state that the above information is _t BUILDING FEE
U7) correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V A building emser ion,and hereby malurize opresenmtives of this cuym emerupso the SEISMIC FEE
above-mentioned property for inspection purposes, PERMIT ISSUANCE -
(We)agree 1.save,indemnify and keep harssmlethe City of Coleman against ELECTRIC FEE
liabilities,judgments,cests and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. - PLUMBING FEE
in consequence of the granting of this Permit. t
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS MECHANICAL FEE
- AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signatumcf Applicant/Contmmor Date EXHAUST HOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theapplicam or future building occupant score or handle hazadmortmearisl' HEATING UNIT(TO h1mW BTU)'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Cade,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
I QYes QNo VENTILATION FAN(SINGLE RESID) PAID -
Will the applicant or future building t use a Date Receipt If
PP dby the
Area
mute Micngere,h BOILER-COMP QHP OR 100,000 BTU)
emit hazardous air contaminants as dclined by,the Bay Area Air Quality Management�Oistn, Yes QNe TOTAL:
1Q _ BOILER-COME 1(10,11(10 BTU '
f
I have read me hamdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUAN TE
moria Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does notcunenlly have a tenant,that it is my responsibility m notify the occupant
of the requirements which must be and prior to issuance of a Certificate of Occupancy. -
Owner ora llmolad agent - Date TOTAL: ISSUED BY:
OFFICE