29074APYL.ICANT TO FILL IN+INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO� " '" .:
BUILDING m, ELECTRICAL
PERMIT NO.
- BUILDING DIVISION APPLICATION/PERMIT
•PLUMBING - MECHANICAL
' O.C107 /I
%
2.7
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BUILDING PROJECT IDENTIFICATION
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BUILDING ADDRESS.
-
SANITARY NO . '
APPLICATION SUBMITTAL DATE
.
OWNERS NAME: ,- ,PHO Ems^'
WC
CONTROL#
RCHITECT/ENGINEER:" LIC NO:
ADD
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CONTACT: - PHONE
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O,ConeBltent Fee9 Paid by Applicant (Initial)+
BUILDING PERMIT INFO
BLDG ELECT ECH
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..PLUMB
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❑
LICENSED CONTRACTOR'S
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OC
DECLARATION
1 hereby affirm that I ed ander .. 'I
of Chapter 9 (commencing
with Secuun]0110)ofDi
QTY ELECTRIC PERMIT
- -
FEE
IDB DESCRIPTION
W
e 3 fthe id Pmonx
.i n3 f@ Rosiness and ProfCwomns C de/9�nd my lmenseis
nfuil force dadfmce dnde
�Y
-
PERMIT ISSUANCE �,
El -CID NTIA
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Licen s^ L'c.# J
❑SFDWL KITCHEN REMODEL
FZzW
m6y
Data Contractor
APPLIANCES -RESIDENTIAL
CADDITION ❑PLUMBING RE -PIPE
E.y.7 y>
G
,ARCHITECT'S DEC AT -
I undersand my plans xhall be used p hlid recONs
PANELS ,
` h•
_
C MULTI -UNIT El STRUCTURAL -
CZ :!
-r,�
UPT020AMPS
-
MODIFICATION
til
LicensedP f OneP
-
201-1 WOAMPS
❑ INTERIOR -'-q, C CHIMNEY REPAIR'
OWNER BUILDER DECLARATION-
diMPROVEMENT^
hereby affirm that l am exempt from theContractors Ccs La for the
follow -
OVER 1000 AMPS '''
❑BATH REMODEUREPAIR OF
W 3
ng rcus (Sea ]031 5 Business d Profs' Cafe A y coy coumY
'alter,
SIGNS ELECTRICAL
C OTHER. - -
O
which requiresa permit 10 consumer. improve, demolish, r repel y awcto
priortot'.vane 1 re -s the applicant suchpermit
4 PP t asigncd smmmcm
•' SPECIAL CIRCUITIM1SC
r
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th at he I - licensed Pursuant 1. the Provisions of the Contractors License law (Chaps r9,
t _
00
(comm ng Section ]000) of Division Business and Professions Code) Or
TEMP. METER OR POLE INST.'^
C
L'OMMFRCZ�AI.
COMMERCIAL
rbut he is exempt therefromd thebasis is for Ne alleged exemption Any violation of,
t
Section 7031.5 by any applicant for a permu subjects the applicant to a civil penalty of Yn
POWERDEVICES •,:
NEW ❑ DEMOLffION'
not mom than f ve hundr d dollars ($SD3)
-
❑ TENANT r FOOD SERVICE
❑ I,a ow rof the property y employees with wages as their sole compensation.,
will do th rk and the
„ _
SWIMMING POOL ELECTRIC
IMPROVEMENT
si t rc .not nrendedor offered tarsale (Sec ]044, Bus
and Professions Cade The C ntraams License Law does not apply to
OUTLETS
COTTER
M
a, owner of
properly who bmlds or improves Nereun,'and who does such work himself or through
-SWITCHES FIXTURES
-
-
his own employees, provided that such improvements are not intended or Offered for
NEW RESIDENTI L ELECTR. SQ FT.
it
,
+ .
sale. lf, heweve ilding n a ane ye
it t
SQ. FT. FLOOR AREA
- &SQ. UL
ill haved of pemeng
owns bddef will have theband it fp mgthm he did notb'ID p vpf Aur-
at he did ., improve
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'
Pose of sole
b
.. P
A. I- D'
owner
colas weerojecthe property,am exclusively contioains with I easedconactora
TOTAL:
H .
construct the pro3evt (Sac 7044 Business and Professions 1.1,:)'Rio Cnntracmrs Li-'
i-
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f
'
cense Law does not apply t an w f property who builds or improves thereon and
QTY, PLUM MIT
ppo.
who contracts for such Projects with a aoiinactoos) licensed pursuant m the Cimoveni's
FEE
Li
OOT
iO 619Q�
License Lew
'PERMIT
V
r
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❑ 1 a amps under Sa.- , B & P C for this reason
ISS
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d /x'ryy •
Owner- - -
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0 ALTER - DRAIN WATER GIA) 'k"'
V 11
I will
AL
WORKER'S COMPENSATION DECLARATION "I,
(hereby affum under penalty of perjuryone Of Ne folCATION
lowingd 1 ations
BACK FLOW PROTECT
4
❑ I have and will maintain eCenificate of Cmxamm,elf-in...cur Worker's Compen-
DRAINS - FLOOR, ROOF, AREA,
I "
sedan, as provided for by Section 3700 of the Labor Code, far the performance of the
'S
STORIES TYPE CONSTRUCTION
w rk for which this ja m it is issued, '
FIXTURES - PER TRAP
1 have and will maintain Worker's Compensation Insurance, as required by Section
300 of the Labor Code, for the performance of the work thisPermit is iissmied:
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
�ffo�ur�j�ww�phiic9cLhh
My WorkRYa,Ceilneusationl carrier and
Cartier. LAS/Y
OCC. GROUP
pPN'
No T>:07�J�.
GAS -EA. SYSTEM -OVER 4(EA)
,
CERTIFICATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE
a - GREA MNDUSTRL WASTE INTERCEPTOR
i
i ,
(This section need not be completed if the permit is for one hundred dollars 1$ 1011)
r,
BUILIIING DIVISION FF,FS
or less.) -•
GREASETRAP
I comfy that in the performance tithe work far which th sp tisissued, ['hall
,�
pLANCHECK FEE
-
"
any person m y ane a to become subject to 'heW k COmpen
SEWER - SANITARY=STORM EA. 200 FT
%notemploy
.
Laws Of Califomin Date
-
WATER HEATERWNENVELECTR1.
ENERGY FEE
I'
Applicant
Applicant
GRADING FEE
Vl
NOTICE TO APPLICANT If, after eking this Certificate of Exemption, you should
-
FF�Q
"'
ai
become subject to the Worker a Compensation
p provisions of the Labor Cade, you must
WATER SYSTEMOREATING
SOILS FEE,
,
forthwith comply with Inch provisions or this permit shall be deemed revoked.`
WATER SERVICE '•
_
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V 0
CONSTRUCTION LENDING AGENCY - I
- Ili by affirm thauh rc acanxwet I d'ngagency for theperformanc of
Q. FT, -
.• NEW RESIDENT11RM1
PAID, '
Data
•
fA f~'
the work far hchnis Permit ssued(Sec 3097Civ. C.)
Lenders Name
-
R. i
TOTAL.q
T 'fAl.:
'LendelsAtldrcss
I certify that I hav read N ppl cati d tate th t the above information e
`601LDING
V]
co rren. Y agree m comply th II ty nil co ty di antes aad state laws relating to
constmmmcand hereby th rim ep sanative, ofthrs city to enner upon the
QTY. MEC
FEEUbmldmg
mentioned propeny for inspectionpurposes.' '
SEISMIC FEEabove
We a -PERMIT
) gree m save Ind turfy end keep harmless 0c City of Cupertino againstELECTRIC
ISSUAN(
FEEliabilities,
judgments, costs ands p n.es which may in any way acture against said City
`m
consequence ofthe granting Of this permit. r
ALTER OR ADD -
PLUMBING FEEAPPLICANT
UNDERSTANDS,AND WILL COMPLY WITH ALL NON -POINT
qIR HANDWNG)
SOURCE rU fl
'MECHANICAL
FEE
�
AIR HANDLING UNIT,(OVER,10,1% UM)
' e
allagnat
if.ApplicenUCOntrvctor a Date
EXHAUST HOOD DV/DUCT) -
CONSTRUCTION TA%
HAZARDOUS MATERIALS DISCLOSURE
-
HOUSING MITIGATION FEE
Will the applicari future building eccupdnt store or handle hazardous material
HEATING UNIT (TO I MOW BTU)
Q-
as defined by the Cupertino Munici vl Code, Chapter 9.12, and the Health and Safely
- r
Code, Section 25532(a)?
HEATING UNIT (OVER 100,1100 BTU)
-
.
•
i • ❑Yes
_
.
VENTILATION FAN (SINGLE RESID)
PAID
Will the applicant or furore building oecupam use eyuipmeator devices which
-
- Data Receipt #
mit ha id ilei, conmminanlse defined by the Bay Area Air Quality Management
` BOILER- COMP ONT OR 100,1%10 BTU)
_
District,
-
TOTAL:
❑Yes - -
BOILER,_ COMP (OVER 100,000 BTU)
_
_
N
' I have read the hamous materials requirements under Chapter fi 95 of tha Cali-
AIR CONDITIONER
f mea Healthety Cade S tons 25505 25533 and 25534 1 undo Land the If the'
.� ISSUANCE DATE
b Idintidy ha t i, than my sporixibiltym ufyNe copaNEWRESIOENTIALMECH
SQ. FT.a�'c
st emetpnmm' cane ofa<`ry})p c
-
'
Own—t authorized agent authorized agent ate
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3S BY: k