29057 ••• • -•-- •-•.•.•• r. Is'vnmswt lute Test I Hill HLU LINh9-U5h WALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL- PERMIT NO.
BUILDING DIVISION APPLICATION/PE - - PLUMBING-MECHANICAL. 29057
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO APPLICATION SUBMITTAL DATI
OWNER'S NAME: ( PHONE: ere
NAME:
LIC NO:
V e _ NIC CONTROL%
RCHITECT/ENGINEER LIC NO: ESS: ❑
CONTACT: -- 2
PHONE:
11
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑ ❑
1 hereby affirm thin 1 am licensed under provisions of Chapter,9(commencing QTY' ELECTRIC PERMIT FEE
WWZ with Secdon]000)ofpivision3ofthe Business and Professions Code.ane my Bcense is JOB DESCRIPTION
r7 in full force and effect. , PERMIT ISSUANCE RESIDENTIAL
Uj License ClassLic.k
'�W Data--- Conlraaor APPLIANCES-kESIDENTIAI. El SFDWL ❑KITCHEN REMODEL
1.7IUY ARCHITECT'Sommut DECLARATION - ❑ADDITION [I PLUMBING RE-PIPE
O Z n C 1 understand my plans shall he food as public rewords PANELS ❑MULTI-UNE ❑STRUCTURAL
UP TO 200 AMPS MODIFICATION
9�Eq"N Lmensed Profe.mnal ❑INTERIOR - ❑CHIMNEY REPAIR'
qqqq yy] OWNER-BUILDER DECLARATION OVER AMPS
IMPROVEMENT
yykd, w U 1 hereby affvm that I am exempt from the Commemrs License Law for the OVER ILDg AMPS ❑BATH REMODEUREPAIR'❑DEMOLITION
W 3 GL fallowing reason,(Section 7831.5;Business and Professions Code:Any city or county SIGNS ELECTRICAL '
trl {e{a� which requires a cermit to construct,ager,improve,demolish,or repair any scre ^
priorta its issuance,al so requires theaPI'licant for such permit to file.signed statement a•
p0thmheielicenudpuesuanno the provisions ofthe Commmers License Law(Chapter9 SPECIAL CIRCUIT/MISC.
(commencing with Section]000)of Division3of the Business and Professiune Code)or TEMP.METER OR POLE INST •'CAMMFR IA
L, thin he is exempt therefrom and the basis for the alleged exemption,Any violation of
[tXl to Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES . ❑NEW,BLDG/ADDITION [I DEMOLITION
} t mre then five hundred dollars($500). - - ❑TENANT ❑FOOD SERVICE
❑I,aas ownenof the property,-1 my employees with wages.s theirsole compopertme, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the stm me"is not intended or offered for sale(Sec.7044,Business ❑OTHER
S and Professions Code.The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves theresn,and who does such work himself or through
his own employees,provided that such improvements are not intended ar offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however the building or improvement is sold within one yearofcompletion.the
owner-builder will have the human of proving that he did not build or ins for $/SQ.Er.
sof sate.)./ prove pea- s. _ k t
❑1,as owner of the propeny,am exclusively contracting with licensed contractors to TOTAL: DtC d A
construct project(Sec.7 W ,Business and Professions Code:)The Commemr's Li-
cense Law does not apply to on owner of property who builds or impasses themon,and QTy, PLUMBING PERMIT PER ! y7J
who contracts fur such projects with a commclm(o licensed pam..m Teo the Contractors Ur
Li se Law. PERMIT ISSUANCE ��PA: II1NQ
l em exempt under Sec. ,B&PCfar this reason
u Date ALTER-DRAIN&VENT-WATER THAT
�377 RKER'S COMPENSATION DECLARATION VALUATION
I hcmhynfh m underpenalt f BACK FLOW PROTECT.DEVICE
yo pe officiary nn:
❑Ihave andwiRfomaintainbeCeni37M of the Labor
Code,
for
for Worker'see of the
DRAINS-FLOORR, OOP,AREA,COND.
ration,r provided for by Section d, of the Lahor Code,far the performance of the .. STORIES -TYPE CONSTRUCTION
work for which This permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37W ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Worker's Compensation Insurance carrier and Policy number are: OCC. UP APN
grarier: Policy N., GAS-EA.SYSTEM-OVER 4(EA)
7e-� CERTIFICATE OF EXEMPTION FROM WORKERS' °
COMPENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is for one hundred dollars($Han BUILDING DI ON ES
or less.) GREASE TRAP
I cmUfy that in the performance ofthe work for which this permit is issued,Ishall - PLANCHECK FEE
znot employ any person in any manner so as to become subject to the WorkerCCompen- SEWER-SANITARY-STORM EA.200 IT.
woad Laws of C.lifomia.Dale ENERGY FEE
O Applicant WATER HEATER WNENT/ELECTR -
NOTICE TO APPLICANT:If,after making this Cer ificate of Exemption,you shouldW a � GRADING FEE become subject to the Workers Compensation provisions of the Labor Code,you must WATER SYSTEMOUREATING
comply ly with such provisions or this permit shall he deemed revoked. SOILS FEE WATER SERVICE - -
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O Ihereby affirm that there is a construction lending agency for the perfurm.nce of - Date Receipt N,
LTs (~ the work for which this permit is Issued(Sea,3197,Cly.C.)
Lender N f
Lender Address TOTAL
(L, I cedify[h t I h d his ppl' t d state that Ihe above mfnrmntian is r BUILDING FEE
Um correct I rg t ply with ll city d county N' d state laws relating to QTy, MECIIAp71CAL PERMIT FEE
�y building construction,and hereby authorize representatives of this city to color upon the . SEISMIC FEE
above-mentioned prnpeny,for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupenino against PERMIT ISSUANCE ELECTRIC FEE
Iiabilities,judgmenis,costs and expenses which may in any way accrue against said City - „
inconsequent f I egmntingofthis pemliL - ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT STANDS ANDMILL COMPLY WITH ALL NON-POINT �-
SO CEREG TI . S. IR HANDLING UNIT TO 10,000 CFM) smI.A.11-
C 41 715-1
FEE
2 R HANDLING UNIT(OVER 10 M,CFM)
_ CONSTRUCTION TAX
n sof ApplicantlContrsanr t, m EXHAUST HOOD(W/DUCE)
HAZARDOUS MATERIAI DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or furore building nee entatmoembindlehaz.rdoosmma fid HEATING UNIT TO IW,"BTU) �
as defined by the Cupertino Municipal Cade, pier 9.12,and the Health and Safety -
Code,Section25532(.)? - HEATING UNIT(OVER 100,000 BTU)
❑Yen No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt k m
emit Tampion,air coniaminants as defined by the Bay Arca Air Quality Management - BOILER-COMP CHP OR 100,000 BTU)
District'
❑Yes �Nou BOILER-Comp(OVER 100000 BTU) TOTAL: .'
I have read the hastened,materials requirements under Chapter 6.93 of the Call
AIR CONDITIONER J•
forde Health&Safety Code,Sections 25505,25533 and 25534,1 understand Nat if the ISSUANCED
A
uilding does tet evmndyhasentiment that it ix my respmsibilirym notify the occupant NEW RESIDENTIAL MECH. SQ.PT.ofthe uiremrnu whitH h must be met 'ormiss pct dance ofa CeniOcnte of(kxupvncy.75b
wner or uuthonzcdagem pare v TOTAL:
• ISSUED BY:
OFFICE