29707 APPLICANTTO FILL IN INFORMATION WItHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29707,
liUH DING PROJECT IDENTIFICAITON
BUILDING f/RE.S:2_ O - / � .1Z �D ` SANITARY NO. APPLICATION SUBMITTALDATI
OWNERS NAME:
PHONE: CONTRACTORS NAME: , J LIC NO:
r* I VE- COfVS L W N/C CONTROL p
ARCHITECT/PAGINEER: LIC NO: ADDRESS: ❑
3p 87 (,j�vF .'wit )/W/7a4411491'
CONTACT: . _PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ -9 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
.. '1 nercbr arum mat 1 am btemxea ander provixmns ar enapter 9 roammenaing - JOB DESCRIPTION
wZ with Station 7")of Division 3 ofthe Businessand Professions Cade,and my license is RESIDENTIAL:
�� in full fameandeffat. PERMIT ISSUANCE.
W GSFDWL DKIfCNF.N REMODEL
in U"eClass Lia. APPLIANCES-RESIDENTIAL ❑ADDITION DPLUMBING RE-PIPE�u] Deme Contractor
DW ARCHITECTS DECLARATION PANELS G MULTI-UNIT 0 STRUCTURAL
pvv��Z I understand my plans shall be used as public records MODIFICATION
r,:J� UPT0200AMPS DINTERIOR [ICHIMNEY REPAIR
F-4F-'W Licensed Pmfnsional 201-i"AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000AMPS. D BATH REMODE:UREPAIR DDEMOLITION -
1 hereby affirm that Lam exempt from the Contractor's License Law for the
3 dF following reason.Permit
in
703IS.Business and sae,demolish,
Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LLO y which requites issuance.permit w construct,alter,improve,demolish, fi repair any swmure O
thathe icesensepurse require the applicant for vchpenraiuoicensle ae Law(Chapter
SPECIAL CIRCUIT/MISC.
} (co me cing with
pursuant tome provisions of the Contmcess,an Prae Law(Chode) 9'
00 toot he
(commencing ithSection
rson and of basis for the
the Businessandon.AnionsCMe)or TEMP.METER OR POLE INST. 2Sj COMMERCIAL:
Z'. o" that he is exempt therefrom and the basis for Ina alleged exemption.Any violation of ONEW BLDG/ADDD70N ❑DEMOLITION
LL Section]03L5 by any applicant for a pemdt subjects the applicant to a civil penalty of POWER DEVICES
o" Section ❑TENANT GFOOD SERVICE
s, notmom
owm five hundred dollars(SSW). IMPROVEMENT
has owner of the progeny,or my employes wiN wages us their sole compenvlion. SWIMMING POOL ELECTRIC
rowill do thework,unJ mhcswcturc is not intendeJ or offered Tannate(Sec.]IW4,Rosiness GDTHER
end Professions Code:The Curnowmrs License law does rant apply to an owner of OUTLETS-SWITCHES- T fS
property who builds nor improves thereon,and who does such work himself or through
his own employees,provided that such improvements me nut intended or offered for NEW RESIDENTIAL.ELE SQ FT.
sale.If,however.the building or improvement is sold within one year of cnmplcmion,the SQ.FT.FLOOR AREA S/SQ.FT.
toner builder will have the buNem of proving that he did not build or improve for pus,
pose of sale.).
D 1,as owner of the ptopeny,am exclusively contracting with licensed contractors to
answer the Project(Sm.7044,Business and Professions Cale:)The Contractors U.
cense Law does not apply to a a owner of prolemy who nuildsm improves thereon.and QTY, PLUMBING PERMIT FEE t
who contracts for such projects with a cmareamns)licensed......on 1.the Contavines
License Law. PERMIT ISSUANCE
D l am exempt under Sec. ,B&PC for this mann
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
-
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby affirm under penalty of perjury one of the fallowing declarations:
�❑I have and will maintain aCcnifcate of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
sauon,as provided far by Section 37W of the Labor Code,for the perfmon nce of the
work for which this permit is issued. FIXTURES-PER TRAP
D 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.d OUTLETS . DEC.GROUP APN
My Workers Compensation Insurance carrier end Policy number are:
Cartier: Policy Na.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FPPS
(This section rated nm be compleRai if the Nonan s for one hundred dollars IS l W) GREASETRAP
or less.) PLANCHECK FEE
I certify that isi perfarmenet,.Oho week for which this permit is issued.I shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as as hecome subject in the Workers'Compmr ENERGY FEE
,Z station Laws of California.Data WATER HEATER W/VENT/ELECTR
O GRADING FEE
� Q Applicant
y NOTICE comesubject
APPL a ANGE.Work If.after Compensation
this Certificate ofExemption.Lahmde,you
WATER SYSTEM/TRF.ATING
abecome mbjecno the Worker's Compensation provisions of the Luhor Code.you must SOILS FEE
Da
forthwith comply with such provisions or permit shall he deemed revoked. WATER SERVICE ,.
O
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FE PAID
Data Receipt
U 0 ffirm(hereby athat them is a construction lending agency forthe performance of
W. the work for which this pentyl is ixsuul(Sea 3097,Civ.C.)
Leaders's Name TOTAL:
Landc's Address TOTAL:
r y I are ify that 1 have read this application and stale thin the above information is BUILDING FEE
IZI cored.l agree to comply with all city and county ordinances and state laws minting m QTY. MECHANICAL PERMIT FEE
U G building construction,and hereby outhssize representatives of this city to enter upon the SEISMIC FEE
7
aMwe-mentioned property for inspection purpses. ' PERMIT ISSUANCH
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acme againstvld City ALTER OR ADD TO MECH.
in consequence of the gumming of permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(10 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appliant/Conuxsamr Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theappliantor future building occupant more or handle hatudous material HEATING UNIT OPO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Code.Section 2553200? HEATING UNIT(OVER 100,000 BTU)
DYes DNo VENTILATION FAN(SINGLE RPSID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt q
pp Eby theBOILER-COME3HP OR I W,M)BTU)
mil hualloos air contaminants as defined by the Bay Arca Air Quality Management
District? TOTAL:
E]Yes GNn ' BOILER-COME(OVER 100.000BTU)
l have read the haaarem.,momrma requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505,25533 and 25534.I uMerstaM thm if Inc NEW RESIDENTIAL MECH. SQ.PT.
buildingdocs tom curmndy haven mnant.that it is my responsibility m nodfy thearcaptnt
of the requirements which must be met prior to issuance ofis Cer ifieame of Occupooey.
Owner or suthorired agent - Date TOTAL: ISSUED BY:
OFFICE