29248 Permit APPLICANT TO FILL IN I N WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,ELECTRICAL. PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING,.MECHANICAL
BUILDING.PROJECT IDEN'TIF'ICATION
BUILDING aADDRESS
Oy _ G �
SANITARY NOPLICATION SUBMITTAL DATE
D
ATE
O?yFM .
CONTRACT
ORSNAME
NIC CONTROL#
RCFIITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE:
BUILDING PERMIT INFO
_ ' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELELT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE Y_
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�R with Section 7000)ofDichron 3m the Business and Professions Code,and my license is - RESIDENTIAL: ,
00 in fall force and effect. PERMIT ISSUANCE
V 1c� License Class ' Lic.p [jSFDWL EI KITCHEN REMODEL
N6 p, Date ❑
Contractor APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
k.=ol
ARCHITECT' PANELS SDECLARATION [IMULTI-UNIT ❑STRUCTURAL
ZoO P2�•4 I understand my pl...hall M Dred ns public records � MODIFICATION
OZ UP TO 200 AMPS [I INTERIOR [2 CHIMNEY REPAIR
Licensed Professional, 201-100BAMPS - IMPROVEMENT
a
OWNER-BUILDER BUILDER DE Ce Certainties
OVER But AMPS ❑BATH REMODEUREPAIR C1 DEMOLITION
I hereby affirm that I31. exempt from the Contrns Co Liana law for the'
�p5,04 U following rcasoa(Section 703LS Business and Professions Code:Any city or county SIGNS L•LBCTRICAI. ❑OTHER
W 40 a which requires a permit m container,alter,improve,demolish,or repair any structure "
...4...111 priorm its issuance,also rtyuirts the applicant for such pefmino rile a signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant m the provisions of the Contractor's license Law(CTapter9
(commencing with Section 70(0)uf Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST.
L A.c K that he is eaempt therefrom and the basis for the alleged exemption.Any violation of W BLDG/ADDITION ❑DEMOLITION
,fid 4• Section 7031.5 by any applicant for a permit subjects the applicantto to.civil pe.stay of POWER DEVICES
R7 m TENANT ❑FOOD SERVICE
E Z i" ern more than rive hundred dollen(SSIXD.
�p� ❑Lao ownerofthe property.ar my employees with wagesaztheirwle mmlxnseil.n, SWIMMING POOL ELECTRIC IMPROVEMENT
y GLGL'' will do the work,attd the structure is not intended oroHercd for (Sm.7044,Business ❑OTHER
Y] Dad Pfessions Codc The hContractors License law dues not apply to an'owner of OI1T1. S-SWITCHES-FIXTURES
a'3.. roprogeny who builds or impnrves derenn,and who dues such work himself d,through
his own employees,provided that such improvements are not intended or offered for ftiV RESIDENTIAL ELECTR SQ FT.
aide.If,however the building or improvement is sold within one ycaroIcompletion.Ne SQ.FT.FLOOR AREA VSQ.PI'.
caner-builder will have the burden of proving that he did n,u huilJ or improve fur par-
from of s lm). _
❑I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.704uL Business and Professions Code:)The Comfaanrs Lt.
move Law w not apply to an owner of property who builds or improves thereon;and QTY PLU PERMIT FEE
who contracts for such projects with a conn lords)licensed pursuant to the Contractor's _
License law. PERMIT CE
❑i am eaempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRA F -WATER(FA) VALUATION
WORKER'S COMPENSATION DECLARATION BACKFLOWPROTE6T. VICE
I hereby affirm under penalty of pequry one of the following declarations;
Iheveeml will maintain eCenificam.fConunnn sdGinsurt for Worker's Co RAINS-FLOOR,ROOEAREA,COND. STORIES TYPE CONSTRUCTION
ion,as provided far by Section 3700 of the Lmo,Code,for the performnnc he
work for which thin permit is issued. XTURFS-PERTRAP
I have and will maintain Workers Compensation Insu hnce,as required by Section
3700 of the Lobar Code.for the performance ofthe work finthis Permit is issued. GAS- .SYSTEM-I INC 40UTLETS OCC.GROUP APN
My Workers Compensation Insurance carder and Policy number are:
Carrier: Policy N., GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
('This sectinnnwd nor be completed if rhe permit is forme hundred J,Ihrrs 181107 GREASE TRAP BUILDING DIVISION FEES
or less) PLANCHECK FEE
I modify that in the Performance ofthe work far which thispermit is issued,Ishall SEWER-SANITARY-STORM EA.21g1 FT.
not employ any person in any manner so as to becomg subject to
the Work.,Co.,.- ENERGY WE
Z ,Z china Laws of California.Dam WATER HEATER W/VENT/ELECTR
O Applicant GRADING FEE
to NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
5 become subject to the Worker's Compensation provisions of the Labor Code,you mustSOILS FEE
tall /� foMwitheomply with such provisions.,this permitsball be decmedrevoked. WATER SERVICE
CONSTRUCTIONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID
U O : Thereby milled that thereem is isacomwction lending agency for the performance of Data
P2 r+ the work for which this Permit is issued(Sec.3097,Co.C.) -
O l� Under.Name - TOTAL:
{Utl Lenders Address TOTAL:
I},r'ly 1 certify that 1 have mad this application and&tam that the above information is BUILDIN E
cmuct.Yargme to comply with all city and county ordinances and sum laws relating to QTY. MECHANICAL PERMIT FEE
U 7a building comtrustme,and hereby untr6re representatives of this city to enter ups.the SEISMIC FF
abausnom oonW property ler inspection purtoses. PERMIT ISSUANCE
TIVe)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC FEE
liabilities;judgments,costs and expenses which may in any way acme against sad City gLTER OR ADD TO MEGH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,010CFM)
SOURCE REGULATIONS: MECHANICAL FEE -
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCDON TAX
Si rc,f paanVConaum,r late EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the applicant or future building occupant store orhandle hazardous material HRXHNG UNIT(TO 100."BTU) ,
as defined by the Catarina,Municipal Cade,Chapter 9.12,and the Heath and Safer,
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) f
E]Yes ❑NoPAID
VENTILATION FAN(SINOLE RFSID) Dare ReceiptN
AftWill the applicant on future building occupant use equipment or devices which OOILER-COh1P(JHP OR 100,100 BI'U)
mit hbzardnus air applicant
as defined by the Bay Area Air Quality Management TOTAL:
is 1. r BOILER-COMP(OVER IOIh)(OBTU)
-s ❑Yes No
1 have read the hmardous mutelas rclmannu ms torder Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Code,Sections 2l5505,25533 and 25534.1 understand dot if the NEW RESIDENTIAL MECH. SQ.FE
building does not cudendy have a tenant that it is my responsibility to notify the occupant
of the requirements which must be met Poor to issuance of a Certificate of Occupancy.
Ownermiandiodredagern - 'Date TOTAL: ISSUED BY:
OFFICE