29919 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 29919
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - SANITARY NO. I APPLICXMON SUBMITTAL DATE
/O OD
OW A E: qo P : COSTRACfOI]$ty_AME: WC NO: -
I 973
-y;";, CJjE NIC ONTROL
1 C /EN INF.F.R: D
LIC NO: ADDRESS ❑
- CONTACT: 2 CPHoE: BUILDING PERMIT INFO
mlwgf GES Pis 9�3-zio ,❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ o ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I ionhereby70 affirm that 1 ant licensed under provision of Chapter 9(commencing JOB DESCRIP-CION
0- with llforcnndafer Division3ofthe Businessand Professions Code,and my license Ls RESIDENTIAL
n full forty evil effed. PERMIT ISSUANCE
'0 F t License ❑SFDWL ❑KITCHEN REMODEL
F- W DataClass Conte _ APPLIANCES-RESIDENTIAL
inti 0. Date Cnm ECL ❑ADDITION El PLUMBING RE-PIPE
.ARCHITECPS DECLARATION PANELS
z O r/+Z I understand my plans shell be used es public records ❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
Oz4O - - UPTO 2WAMP5 El INTERIOR ❑CHIMNEY REPAIR
Lmensed Profeastonvl 201-I WOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
Conte ON OVER PXDAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
yy 1 naso ,(prat that 1 um exempt from the Conten,Co License Law for the
%3 0.F fallowing reusna(Section]onstru t,slid,.sand vet de Profession,Cale:Any city wcounty SIGNS ELECTRICAL OTHER
��ci�ftiill 0 which requires issuance,permit m cone'dow aper.improve,deermit t or repair any stmcmrc
hope slits esedtolsorequires thovisiappo iahsof he Cchpemtit micensfile e gae(Cha mem SPECIAL CIRCUIT/MISC.
y that he is license)pursuanurthe provisions of Crnlmcmr's license Low(CM1aptd9
Q� (wmmendng with Seetion70W)of Division)of the Buslnmsund Pndession Crdc)rr TEMP.METER OR POLE INST. COMMERCIAL.
06 n that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section]031.Sh licam fora 3 pp penalty ❑NEW BLDG/ADDITION ❑DEMOLITION
y any app permifaub'ectsthe applicant to a civil enalt f POWER DEVICES El TENANT ❑FOOD SERVICE
F y oat more Nan Rae handled dollars($500).
^q q ❑Liewaratofthe poamy,maryempinyees with orgasm m
theirsole copensaline SWIMMING POOL ELECTRIC IMPROVEMENT
dodo, an
Ca will dodo,awLd thestrucmre is not intended reoffered fmxale(Sec.70,14,Businexs ❑OTHER
m and Professions Code:no Contractors License Law docs ma,apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ pT.
sale.If,howevec the building or improvement is.sold within one year ofeweplermthe Q.FT FLOOR AREA S/SQ.FT.
ter-huilder will have the burden of proving that he did not build or improve for par-
sale.).
o err of the property,am exclusively cwhircting with licensed dmtrucmrs to TOTAL: ��
ns as t the project(Seo.7144,Business and Professions Code:)The Conuador's Li- Y
cense Lme does tet apply m arommerofpropeny wbobuildsorimproves thereoaand QTY. PLUMBING PERMIT FEE
who comramn for such projects with a commeans)licensed pursuant to the Contractor's
License Law,
I am exam tun ,B&PCfo isre.on PERMIT ISSUANCE
1 54m e Dnte ALTER-GRAIN&VENT-WATER(EA) Vp1{,U{p,TIOIN�An
WO 'R'S OMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE � +a/U111rl�Yfw
Iherehyafpr neer penalty of perjury one ofthe following declarations: (/C' �J
Ihave and willm inmin aCenifcatenf Conserv to self-insure fur Worker's Cnmpem DRAINS-FLOOR,ROOF,AREA,COND. (tSTORitlS PE ONSTRUCTION
anion,as provided for by Section 3700 of the Labor Cale,for the performance of the JI I✓Uf C ',„yk j
work for which this Permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation his umnce,as required by Section
3700ofthe Labor Code,forms,fardwrroance ofthework for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier Policy number are: -
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
FP.F
(Thio wetlon need ort becompleed if the permit is for ono hundred dollars($IIN) BI (VISIONGREASETRAP
or less.) PLANCHECK FE
Ioy any that in the fordarmany
oast Increase
which this the W rkes ed,Ca shall SEWER-SANITARY-STORM EA.200 Fp
not employ any person in any manner so as to become subject m the Workers'Camper- ENERGY FEE
watch Laws of California.Data
O Applicant - WATER HEATER W/VENT/ELECfR 4FE
ADING HE
ti NOTICE.TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMiTREATING
become subject to the Worker's Compensation provisions of the"her Code,you must LS FEE .
W forthwith comply with such provisions onhis'permit shall be deemed revoked. WATER SERVICE
aQ
� z
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.ITD
theV k for
rwhichirm tbermiti issued construction len ding agency for the performance of Data RaeiptN
Le work(ar which thin permit is issued(Sty.909],Civ.CJ
0 U Lenders Name TOTAL:
�" yLenders Address TOTAL
1 cmify that 1 have rend this application and state that the above information is - LDING FEEconebuildingconeeto comply wire all cityriz ceutnyotaiives of and ante la ntruparrve QTY. MECHANICAI,PERMIT above-mentionedomend hereby au@onprposes mtivea o[thlselrymenter uponthe $MICFEE
above-mentioned property Por inspection putptseaPERMIT ISSUANCE(We)agree to save,indemnify and keep hornless the City of Cupertino against CTRIC FE
Iiabilities,judgmenti,costs and expenses which may in any way accrue against said City pf.TER OR ADD TO MECH.
in consequence M the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM) E4PAID
STRUC'DONTAX
Signature of Applicant/Comracmr Date EXHAUST HOOD(WMUC'T) SING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant r(mare building occupant store or handle hazardous material HEATING UNIT TO 100,000 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9.12,nad the Health and Safety
Cade,Section 2553200" HEATING UNIT(OVER 1 W,M)BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RESID) Date ReceiptN
Will the ,Inc..[aircn e enure building byin,comalthe Buse equipment or devices which BOILER-COMP JET OR 100.000 BTU)
tit hazardous air contaminanu as defined by the Bay Area Air Quality Management
avid^ TOTAL:
,. ❑Yes E]No BOILER-COME(OVER 100,000 BTU)
- I have read the bccardousmaterials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ FT.
building does not currently have a tenant,that it is my responsibility to ratify the occupant
of the requirements which must be and prior to Issuance of n Certificate of Occupancy.
Owner or authorized agent Date TOTAL
ISSUED BY:
WRN�?
OFFICE