29281 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO r BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING PROJECT IDENTIFICATION o
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL GATE
1001/5-
WN
vv2YWN R'S NAME 1/ 1 '.� r`� PHONE:p -yr�q CONTRACTOR'SN LIC NO:
'ITN h L(JI{Q'uJ�D OI -'9-/U - N/C CONTE N
Mt HITECLEN (NEER: LIC NO: -- ADDRESS: ❑' "_
rhuAG 2$82
CONTACE �.h..�I-T"�'f" PHONE: - s BUILDING PERMIT] FO
r, I ¢D g^x2 ❑ Consultant PLUMB MUCH
Fees by Applicant(Initial) BLDG ELE
s4, ig J 8� 67r8. c
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hemay alDrm that 1 am licensed under Provisions of Chapter 9(commencing ]O$DESCRIPTION
O9Z with Section 7")of Division 3 of the Businessied Professions CWe,and my license is
d0 PERMIT ISSUANCE RESIDENTIAL:
in full fano and arket.
Uz U�" ,N ❑SFOWL KITCHEN REMODEL
License Class Lin
N6 Date - Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
FPm ARCHIT'ECT'S DECLARATION PANELS ❑
DMULTI-UNIT STRUCTURAL
Z p�-1 7� I understand my plans shall he used us public records 'MOD[FI('ATION
0z UPT0 2M AMPS
t
A - El INTERIOR [I CHIMNEY REPAIR
F� 4� Licensed Professional - 201-100DAMPS MOVEMENT
OWNER-BUILDERexempt
DECe Conti ON OVER1000AMPS �LL1�se'TN REM P EM 7TION
1 hereby affirm that 1 am enempt initiative Cantranar's License Law for the
6 U following uireason.(Senian]031.5.Business and Professions CWe:Any city or county SIGNS ELECTRICAL OTHER _
WO y which reqres a perconstruct, lter
it construct,a ,improve,demolish,or repair any sure „
prior to it,issuance;also requires the applicant for such Permit in file.signed statement SPECIAL CIRCUITIMISC. —44
ythat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
�O£ (commencing with Section OWO)of Division 3 ofthe Business and Professions Code)or TIME METER OR POLE INST. COMMERCIAL:
d W M tG that he is exempt therefrom and the basis for the alleged exemption.Any violation of . D NEW BLDG/ADDITION D DEMOLITION
W�m.Section 7031.5 by any applicant far.permit subject the applicant to a civil penalty of POWER DEVICES El TENANT ❑FOODSERVICE
5 D
t more than five hundred dollars($500). IMPROVEMENT
'�^ 1,os owner of the property,or my employees with wager as their sole compensation, SWIMMING POOL ELECTRIC
Fx will do thewmk.md thestrname,I,a.,inlendixim.ffered forsale(Set.71xLL Business El OTHER
3 and Professions Code:The Contractors License Low does no[apply to an owner of OUTLETS—SWITCHES—FIXTURES
�� '
property who builds or improves thereon,and who does such work h�mxelf ur through -his own employees,provided that such improvements are not intended ar oRered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or Improvement is said withirwre yemofeamPletion,the SQ.FT.FLOOR AREA $/SQ,FT
ter-builder will have the burden of proving that he did not build or improve for Aur- A
Pe s f,ulel - T H+'
I,as owner of the property,am exclusively contracting with licensed contractors in �(J
con, t the project apply
moa.Business and y,Who build
Cade:)The Commctars Li-
cause Law does not apply m an owner of property,who builds or improves thereon,and QTY. PLUMBING PERMIT FEE //11
who caramels for Inch_projects with a contmemaii)licensed putuant to me Contractor's !✓OL�����
License Law. PERMIT]SSU CE -
❑ lam rSec. ;B&PCfo this a G��-. , ..
rte r Date' ALTER-DRAIN V T-WATER fE.A) ham, VAL N
ORKE COMPENSATION DECLARATION BACK FLOW P ECT.DEVIC 1 Y ttr�
w r 1 hereby affirm under penalty of perjury ane of the following declarations:
I haveand will maimaine Certificate of Consemmself-Insure for Workers Comxm_ DRAINS-FLOOR, EA,'IND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor CWe,to,the performanoe of Me
work for which this permit is issued. FIXTURES-PER TRAP
El 1 favored will maintain Worker's Compensatiomho urance,as required by Section
3]W ofthe Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40 E OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA,SYSTEM-OVER 4(EA) "
.I CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINUUSTRL WASTE INTERCEPTOR
This sectlonneed not beemonaled ifthepernd,is faroolocasreddo11at($I0E - BUILDING DIVIS191KFE&S
or less.). - GREASETRAP PLANCHECKFBE
I certify that in the performance ofthe workforwhich this permit is issued,l,h.11 SEWER-SANITARY-STORM EA. FT.
not employ any person in any manner so as to become subject m the Workers' .
Compen- ENERGY FEE
O sono,Laws of California.Date
Applicant WATER HEATER W/VENT/ELECTR - -t
bO - GRADING FEE
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING .
abecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE IF
W forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGnGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Q I for Whichthispe there isaed(See.3097.leading agency for performance of to ReceiplN
LA the work for Which this permit is Issued(Sec.309].Civ.CJ
O� lender's Name TOTAL:
Lender's Address
Ny 1 certify that 1 have read this application and,rate thm the'oMve infomtetinn is BUILDING FEE �-
H h emov,lagree to comply with all city and county ordinances and state laws relating to QTY. MECHANICALPERMIT FEE
V building construction,and hori
ereby authorize representatives of this city to enter own the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE . ELECTRIC FEE
(Wa)agree to save,Indemnify and kap harmless the City of Cupertino against _Lot
liabilities,judgments,1611,and expenses Which may many way same against said City ALTER ORADDI'OMECH. - PLUMBING FE .� t
is on,equenee of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(LOW CFWU - 11
SOURCE REGULATIONS. �MECHANICA FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCT NTAX
Sign.mreaf AppliWarycmuracmr - Data EXHAUST HOOD OMMUCT) t HOUSING MITI GA NME
HAZARDOUS MATERIALS DISCLOSURE - r
Will theapplicant or future building occupant score or handle haammous material HEATING UNIT(TO 100,0110 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety R
Code,Section 25532(a)] HEATPlb UNIT(OVER']00,000 BTU)'
❑Yes ONo t' q
VENTILATION FAN(SINGLE RF.SID) PAID '
Will the applicant building occupant use equipment or devices which - Date - Receip
mit hazardous air contaminm ants nts as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 100,009 BTU)
tatr¢t" " 100,000BOILER-COMP(OVLR IO BTU) `
❑Yes El No
,
1 have read the hmmdme material,requirement under Chapter 6.95 of the Cali- AIR CONDITIONER -ISSUANCE
fomis Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if be NEW RESIDENTIAL MECH. SQ.FT.
wilding does not currently have a waant5lhat it is my responsihility to notify d c esompant
of the requirements which must be ran prior to issuance oft Ceitificute of Occupancy.. ' �� '
Owner or authorized agent Date ISSUED BY:
OFFICE