29923APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO '' BUILDING -ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL rs 29923
NP RCHITECT2ENGINEER: LIC NO: DRESS:
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CONTACT PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (initial)
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LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby afftm that 1 an licensed under provisions of chapter 9 mammencing
with Swarm Division 3 ofthe Business and Professions Cade, and my license is -
in full force and effect//.j PERMITISSUANCB
Lica C3l7of
a Corer dWtDO'R.J - RESIDENTIAL
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL C1 KITCHEN REMODEL
❑ADDITION ❑PLUMBIPIPE
URAL
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
ARCHITECTS DECLARATION ',pgNCLS
1 underslan my plans shall bo useJ os public records
O04HUPT02MAMPS
El INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201-1"AMPS
OWNER -BUILDER DECLARATION OVER IO001AMPS
1 hereby affirm that I .m exempt from the Contractor's License Low for the
following reason. (Section 7831.5, Business end Professions COM: Any city ar county SIGNS ELECTRICAL
which requires a permit m consumer, alm, improve, demolish, or repair any swchime
yy a 6
16 3 d V
Ya1l
IMPROVEMENT
❑ BATH REMODEUREPAIR [I DEMOLITION
O OTHER
naQl2(
y OLL
prior to its issuance. also requires the applicant for such permit mfile usignited statement SPECIAL CIRCUTI'/MISC.
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thou he is licensu)pursoanl to no prnvinirna of the Contmchtt's License law (Chaprer9
COMMERCIAL:
❑ NEW BLDG/ADDITION 0DEMOLITION
p�
Iq p0
C.,
an
(commencing with Section 7")of Division 3 of the Business and Professions Cade)ar TEMP. METER OR POLE INSI'.
that he is exempt throdom and the basis for the alleged exemption. Any violation of
sed
al^w
❑ 6n
22 FT
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Section 7031.5 by any applicant for a frrmit subjects the applicant to v civil penalty of POWER DEVICES
morewne Me hundred dollars or my employees
❑ Lae eworof the,and propery, remyemntendeswilhwages astheir (Sm. compensation, SWIMMING POOL ELECTRIC
willJo lesions and the he Coreis arl mm's License erval
apply to an Business
andpro Professions Code: The Cantmcmrs License Lvw dors not apply to if owner of OIIfLETS- SWITCHES - Fl%'NRES
who builds or improves thereon, and who dors such work himself or through
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
his own for NEW RESIDENTIALELECTR SQ PI'.
hisownemployees. provided that such not intended
SQ.FT. FLOOR AREA
5/SQ. FT.
e mentisoldware
sale. ILhowever thhavet ie completion,
is ithinone of the
buret of he build
pur—owner -builder will have the burden of proving that he did not build or improve for
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to TOTAL:
constructthe project (Sec. 73H4. Business and Professions Code:) The Contmcmr's Li-
Is, I' rs
cense Law does not apply to an owner of property who builds or improves thereonQT
. and 'g PLUMBING PERMIT FEE
who contracts for such pmjects with a contractors) licensed pummu t tome Contractors
'
License Law. PERMIT ISSUANCE
Iverexempt under Sec. ,B&PCfor this rtamn
C]4
196
SEP J 1� 2id .97 s7V
Owner Date ALTER -DRAIN & VEN7' WATER (EA)
WORKER'S COMPENSATION DECLARATION BACK FLOW PR EVICE
I hereby vfluto under Penalty of perjury one of the following declarations:O
VALUATION
x{11 Js 1_r ml W't-1
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❑Iheve endwill mai hours Cerifioreo(Cmmnuo self-incen, far Worker's Compeer- DRAINS -FL ,ROO A. COND.RIES
inion, as provided for by Section 370 of the Labor Cade, for the performance of the
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 Cade, for the Performance of the work for which this rmil is issued. GAS -EA. SYSTEM -1 40 Er'
a pe
OCC GROUP
APN
My Workers Cod ,weation Insurance c—arr1 r and Policy n
Canier.�Ui eNDN�/N//1e Puts, No.: - 07A 7.3%.p GAS -BA. SYST FhI-O 4 7
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRLWASTEINT RC
BUILDING DIVISION FEES
(Thissection need not becompleted ifthe permit is fvronuhundrddollars(5100) GREASETRAP
or less.) - '..
PLANCHECK PL•E / VQ
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I rectify that in the performance of the work for which thispermil is issued, l shall SEWER -SANITARY -STORM EA. 200 FT.
not employ any person in any manner sO as to become subject o the Workeri Compen-
Laws California. Dole
ENERGY PEE.� all91• '10
salla. of WATER HEATER WNENTTLECTR
Applicant
GRADING FE
NOTICE TO APPLICANT. If, after making Nis Cimifscme of Exemption, you should WATER SYSTEM/IREATING
become subject to the Worker's Compensation provisions of the Labor Cole. you must
forthwith comply with such provisions or this Permit shall he deconvol revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NRWRESIDENTIALPLMB. SQ. PT.
(hereby affirm that hem is a construction lending agency fonthe performance of
the work far which this permit is issued (Sea 3097, Ci, C.)
Lenders Name
Lenders Address TOTAL:
SOILS FEE
PAID —/
Dole Re ipt#
TOTAL:
tlU1LDING
I verify that 1 have rcaJ this application and ,are that the shove information is
V
correct Tagrecmmmply wire all city and ewmy oNinarmecs and store laws relating to QTY. MECHANICAL PERMIT
buildingcommurninn, and hereby authorize reptesmiatives of this thymenteruponthe
above-mentioned propery for inspection purposes. PERMIT ISSUANCE.
(We) agree m save, indemnify anal kttp haranlesx the City of Cupertino against
EISMIC FEI AIA
ELECTR
O
liabilities, judgments, cops and expenses which may in my way areme against said City AL'fERORADDTOMECH.
nsequenceofthegmntingofthi.s permit.
MHOUSING
LUMB(
F . -
APPLICANT UNDHR "ANDS AND WILL C dPLY WITH AL1. NON -POINT AIR HANDLING UNIT (TO 10,000 CFM)
S( IRCERF^1L NS.
MECHANIC .FEE
'1
Zy- FAIR HANDLING UNIT (OVER 10,000 CFM)CONSTRU
Sign ppismu/ r or Data EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE.
MITIGATION F E
Will the applicant or furore building aacupanumre or handle hazardous material HEATING UNIT (TO 100.000 BTU)
III
ns defined by the Cuperino Municipal Cole, Chapter 9.12, smite He.Ilh and Safety
Code. Section 25532(m? HEATING UNIT (OVER 110,000 BTU)
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❑Yes Fl No
VENTILATION FAN (SINGLE RESIO)
PAID
Data Receipt lF
Poll
Will the applicant in home building occupant equipment or devices which
mi( hazardous aircnmeminems ns defined by the Bayy A Arca Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
❑Yes ❑Nn BOILER-COMP(OVER 100,000 BTU)
TOTAL:inrid?
I have real are heraNOus meterioLa requirements under Chapter 6.95 of the Cut- AIRCONDITIONER
ISSUANCE DATE
foods, Health & Safety Cale, Sections 2550. 25533 had 8534.1 understand 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 must w mel prior to issuane, of a Cenifcate of Occupancy.
ISSUED BY:�T�11[�
Osturoramhmized.,on, Date TOTAL
OFFICE