29966 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY" '
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMIT NO. 6
2 9 9^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - L VM lhJ MV
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITT LDATE
I S9 Co cect4Y spctn CA- aYQ,�
OWNER'S NAME: Iw PHONE:
CONTRACTOR'S NAME: LIC NO:
f, f'. f. �/ NIC CONTROL It
RCHITECT/EN NEER: `Y `ELIC NO. �f' b ADDRESS: ❑
CONTACT. PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby all,.that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
4z with Section 7")of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL:
00 PERMITISSUANCF.
W� Poll force s effect. - ❑SFDWL ❑KITCHEN REMODEL
�CJ[' License Class Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F•<L<Z Y� Orate Contractor
F.Om
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Z O 1 undemmnd my plans shall be used as public rocoNs MODIFICATION
oz— UPT0200AMP5 0WTER100. ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER LOBO AMPS L1 BATH REMODEIIREPAIR ❑DEMOLITION
I hereby affirm that 1 am exempt from the Contractors License law for the
ip5,O wy U following reason.(Section 7031.5.Business and Professions Code:Any city or countySIGNS ELECTRICAL. ❑OTHER
which requires a permit to construct,Ater,improve,demolish,or repair any structure
ypdo,to its issuance,also requires the applicant for such permi0o file a signed statement SP13CIAL CIRCUIT/M USC
} that he is licensed pursuanuods,prrovisionsofthe Contractor's License I-mv Chaptert, �—
�� (commencing with Section 0000)of Division 3 ofthe Businessand Professions Ctde)or TEMP.METER OR EINST ; COMMERCIAL:
o a that he is exempt therefrom and the breis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant for a Permit subjects the applicant o a civil penalty of POWER DEV I OTENANT ❑FOODSERVICE
.1 more man five hundred dollop(8500). IMPROVEMENT
a�CIpl,m owner alum property or my employees with wages as their sole compensation. SWIMMIN POOL ELECTRIC
' CO will do the wmk,oml the common is not intended or offered initial.(Set 7144,Business ❑OTHER
W and Professions Code:The Convector's License Ww rices am apply to sn owner of OUTLET(-SWITCHES-FIXTURES sal
property who hands or improves thereon,and who does such work himself or through
his own employees,provident that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR 5 f
aide.If.however,the building or improvement is sold within one year efcompletion,theSQ.FT[.FLOOR AREAE
onsoner-builder will have the burden of proving that he did not build or improve for par
f4 <_
n� A � BT
pax of sister.
C]1,as owner of the prapeny,um exclusively contracting with licensed contractors to TOTAL'
construct the project(Sec.7044,Business and professions de)ions CaThe Corrientes Li. tj
cense Lawdoesnotapplytoanownerorpropertywhobuildsorimprovesthereon,and QT'Y, PLUMBING PERMIT FEE 17 7996
who contacts for such projects with a connectio(s)EventualPursuant to the Convector's r- 'I
License Law, C I vJ'
' C]1 am exempt under Sea ,B&P C for this reason PERMIT ISSUANCE `4f"try J 9 s
ALTER-DRAIN&VENT-WATER EA) VALUATION
Owner - Date -
WORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT DEVICE -
I hereby affna under penalty of perjury one of the following deductions:
I have and will maintain a Cenificare ofConxm to xlf-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIESTYPE CONSTRUCTION
anon,as proance vided far by Section 37M of the Labor Code,for the performof the
work for which this pemtit is issued. FIXTURES-PER TRAP '
❑I have and will maintain Worker's Compntaatmir Insurance,as required by Section
37W of the Labor Code,for the performance of the work for which(his permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCCGROUP APN
My Workers Compensation Insurance carrier and Policy number ram
Carrier: Policy Na: GAS-EA.SYSTEM.OVER EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTR.WAITE INTERCEPTOR
BUILDING DIVISION FEES
(Ibis section neral not be completed Hum Hum peadt is for one hundred dollars IS 100) GREASBTRAP
nr less.) PLANCHECK FEE
I certify mat in the Performance ofthe work for which this permit is issued,l shall SEWER-SANIT -STORMEA.200 FT.
not employ any person in any manner so as to become subject o the Workers'Compen. ENERGY FEE
sZ snoun Laws of Celifurnia.Data WATER HEAT WNENT/ELECTR
C) Applicant GRADING FEE
Gi NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATERS EMOTTATING
abecome subject to the Wincefs Compensation Previsions of the tabor Code,you must SOILS FEE
LIJfoMwith comply with such provisions or this Permitshull be deemed revoked. Wp SERVICE
aQ
:D CONSTRUCTION LENDING AGENCY N RESTIDate Recciptp
IDENAL PUSH. SQ.FT. PAID
1 hereby affimt that Ix a construction lending agency ford a red..ou ounce of
the wok,far which this Permit is issued(Sec.3097,Co,C.)
Ii' Lender's Name _ TOTAL:
Lender's Address TOTAL:
1 certify that I have mad this application unit state that above information is BUILDING FEE
TQA cored.I agree to comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE
U,Z building construction,and herebyautbonze representatives ufttdscity to eructation the SEISMIC FEE
above-mentioned property for inspection purprses. .
(We)agree m save,indemnify and keep harmless the City of Cuper ino against PERMIT ISSUANC12 ELECTRIC FEE
i. liabilities,judgments,casts and expenses which may in any way same against said City ALTER OR ADD TO MECH.
in conxquence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE. !er>
SOURCE REGULATIONS. i/
' AIR HANDLING UNIT(OVER 10,(100 CFM) CONSTRUCTION TAX
Signature of Applicant/Conhactor Date EXHAUSTHOOD(W/DUCII HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant atom or handle harmdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cameroon Municipal Code,Chapter 9,12,and the Health and Safety
Cod,Socrates 25532(a)'! HEATING UNIT(OVER 100,000 BTU)
❑Yes Fl No VENTILATION FAN(SINGLE RESID) PAID
Will are applicant or future building occupant use equipment or devices which Data Receipt M
emit hazardous it contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 100,000 BTU)
i Distract? , TOTAL:
E]Yes [I No BOILER-COMP(OVER 100,000 BTU)
Ihave real the hmordous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER =CD ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 25534,1 understand tout it the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant that it is my responsibility to nmify the occupant
of the requirements which mm(le met prior to issuance of a Certificate of Occupancy. ,
Owner or authorised agent Data - ISSUED BY:
OFFICE