29260 APPLICANT,TO FILCIN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO t. BUILD:NG-ELECTRICAL. .•PERMIT NO, g� ^, O
BUILDING DIVISION APPLICATION/PERMIT PLOMBNC,-MRCIIANICAL LL
I iU11,D1NG PROJECT IDI!NTIFICATION
BUILDINGADDRESS. - / , SANITARYNO. APPLICATION SUBMITTAL DATF
OWNER'S NAME: PHONE: _ CONTRACTOR'S NAME: LIC NO:
t 0 O NIC CONTROL is
RCHITECTIENGINEF LIC NO'. ADDRESS: /J ❑
C r Cog• 9MI11
CONTACTPHONE: BUILDING PERMIT INFO
' ' Q Consultant Fees Paid by,Applicant'(Initiap BLDG ELECT PLUMB 'MECH
I YeY 737-l3,.r, - '.X, ,X p5z, ,
LICENSED CONTRACTDR:S DECLARATION QTy, ELECTRIC PERMIT FEE
I hereby.M.that 1 um licensed under provisions of Chapier,9(gommencivg JOB DESCRIPTION
DMZ what Scction'I(100)of Dlvhion3ofthe Bicomessand Professions Code.undmy licensees ,v RESIDENTIAL:
W r PERMIT ISSUANCE
in full force6nd effttt.
MODEL
JUU License Class Lica ❑SFDWL ❑PLUMBINREE-PIPE
Dam Comrector ::APPLIANCES-RESIDENTIAL ❑ADDITION (2 PLUMBING RE-PIPE
t'' ARCFIITECCSDECLARATION - ❑MULTI-0NIT ❑STRUCTURAL
F O'er PANELS
Z O S/1 K I undemand my piens shall be used us public tttoNs MODIFICATION
OZ O 'y'3 UPT0200AMPS ❑INTERIOR 0CHIMNEY REPAIR
541; Licensee rofessianal i. 201-1LYl0AMPS IMPROVEMENT
y OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR DEMOLITION
W OW U 1 hereby affirm that 1 nn exempt from the Contractor's License Law for the T, w��I�IL-11
3 6 following reason.(Section 7031.5,Business and Pmfessivas Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Cyj which requires a permit an consirvct,alter,improve,demolish,or repair any structure
.Q.1 prior to its issuance.also requim,ilb.pplicam fofsuch pertino file.signed smtfinem SPECIAL CIRCUIT/MISC. �f
WsWW�11 iy+ that he is licensed tommant to the provisions of the Contractors License Law(Chapter 9
q (eammenciny with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
d :
p,c W that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION, []DEMOLITION'
x Y• Section](131,S byany applicant faro psimiltubjer,the applicant o a civil penalty of PO WE DI?VICES
W^m
not mom than five hundred dollars(SSW). ❑IMPROVANT ❑FOODSERVICE
1-4 CI as.wixrof the property.or my employees with wages nv,heir sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
will du the aimLiid the svucture d
is not intended forsale(Sri.7044,Business ❑OTHER
and Professions C(de:The Commences License Law does not apply to an owner of OUTLL•TS-SWITCHES-FIXTURES
6 3
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc n.,intended.,offered for NEW RESIDENTIAL ELECTR
sole.If,however,the building.,improvement is sold withinoneyearof completion,are SQ.PT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of leaving that he did not build or improve for pun
(rose of sale:): -
❑1.a owner of thapropenY•an exclusively contracting withheemed contract is to TOTAL:
.nsuan the project(Sec.7114,Business and Professions Co...,The—.....amts Li-
estatwho Law dtsforschplytoan ith a cofpmpcny whored piment the ontme.nd QT'Y. PLUMBING PERMIT r
who carols fore..h Projects with t contractors)licensed buil pursuant vi the C.a om and
License Caw. PERMIT ISSUAN
I aexempt under Sea ,B&P C for thisxssan
m
Owner Date -" ALTL•R-DRAIN&VENT- TE a VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DCVICE
I hereby affimt under Penalty of perjury one of the fallowing declarations:
J lNveaM will maintain.Cenificem ofConunt to self-inmre fm Wmker'.Conn,d- DRAINS-FLOOR.RODE AREA.COND.
osteon,a provided for by Section 3700 of the Labor Code,Ruda,perfommnce of he STONIFS TYPE CONSTRUCTION
work for which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance.as required by Section
37M of the Labor Code,for the perbantltince of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are: •-
Carier Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
This section need not M completed if the permit is for one hundred dollars Ht 100) BUILDING DIVISION FEES
or IessJ GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner so as m became subject to the Workari Camped- ENERGY FEE
Z ,Z tuamn Laws of California.Date WATER HEATER W/VENT/ELECfR
Q Applicant GRADING FEE.
NOTICE TO APPLICANT:If.after making this a Certificate of Exemption.you should WATER SYSTEMTREATING SOILS FEE[^ become xubject to the Worker's Compensation pmthevi6luns of Lubar Code,you mus{4
G forthwith comply with such provisions or atia Petmiiihall be deemed revoked. t! WATER SERVICE
�^ CONSTRUCHON LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT. - PAID
U Q 1hl:reby affnm that them,is a construction lending agency for the performance of Date Receid#
tstp�s Newmkfmwhich Nispe prodisisomalSec.3097,Civ.G)
.a•xLcndern Name t- - - _ TOTAL:
VV lenders Address TOTAL:
�L.s m;Icenify that 1 have rend this application continue thnnhc udwe information is BUILDING FEE
it to cmrecnl ag.,.comply with.116ty ane,county oNinaaas aal state lows relining to QTY. '{ MECHANICAL PERMIT FEE
GZ Inildiogmnswction.and herchyemheri'm repoo,,mutives.f this city to enter upon the SEISMIC FEE
alcove-mentioned properly for inspection purposes, PERMIT ISSUANCE
:Ltve)'.gra i.nova,indemnify and kttp handless the City of Cupenimi against ELECTRIC FEE
liabili,ies,judgmems.costs and expenses which may in any way acme ignitor said City ALT641RADDTOMECH.;
in consequence of the granting of this parva. PLUMBING FEE -
APPWCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(MCFM)
SOURER ItEGLICA DNS. �i - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) C014STRUCf10N TAX
igm ApphcinVConua f ^� im EXHAUST HOLD(W/DUCTr
.` ZARDOUS HAMATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicator or future building mcupant store or handle limat mSierial 'FrEATING UNIT(TO 100,004)BTU) f�
as defined by the Cupertino Municipal Code,Chapter 9.12,and the-Health and Safety - 6's'
Code.Section 25532(.)!, HEATING UNIT(OVER 100.000 BTU) a
E]Yes ❑Nn VENTILATION PAN(SINGLE RESID) PAID V
Will thea lica t m future bi ildin t •f r use equipment or devices which ^ Recupt k
PP lbythenBOILER-COMP(3HP OR 100,(00 BTU) y p
it haardoa au cmnaminanss a defnd by the Boy Ates Air Quality Mmngement T03'AL:
AnnictY❑Yea ❑Nn BOILER-COMP(OVER I00,(gIOBTU) N
AIR CONDITIONER
I have read be mourdous mumrials re,mannums code(Chapter 6.95 of the Cali- ISSUA 6 DATE
Tomer Health&Safety Code,Sections 25505.25533 and 23534.1 undemand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which mus,be met prior to issuance of o Certificate of Occupancy.
Owner or authorized agent Dom TOTAL: I ISSUED BY:
OFFICE