29150 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29150
A9150
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
"Il CCS *L%0% I
�'1r2�
R'S NAME: PHONE: CON CTOR'S LIC NO.
NIC CONTROLg
AR ITE BE \ LIC NO: ADDRESS: ❑
CONTAM G PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB ECy
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby afro that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
yQjcO esidt Section 7")of Division 3 of the Business and Professions Code,and my license is I PERMIT ISSUANCE
RESIDENTIAL
—
FWUDF. in full foreeandeHect. ❑SFDWL El KITCHEN REMODEL
UW License Class Lit.p
Date Contractor APPLIANCES-RLSIUENTIAL ❑ADDITION [I PLUMBING RE-PIPE
�' ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F� PANELS
Z O�'� 1 undersand my pWns shall be used as public rtcnrds MODIFICATION
0Z-•0 UPT02MAMPS '0INTERIOR ❑CHIMNEY REPAIR
r,'�'. Licensed Prefessiotul 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION as,,,��
�yy C 1 hereby affirm that 1 am exempt from me Contractor's License Law for the
OVER 1000 AMPS ArLLATH REMODEIIREPAI2. DEMOLITION
41
Do o L F mTR
following reason.(Station 7031.5,Business add Professions Code:Any city or county SIGNS ELECICAL ❑OTHER
ffsH] U, which requires a permit in consuuck alar,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant forsuch permit to Ere asigned smarted SPECIAL CIRCUITNTSC.
C , that he is licensed punt to the Provisions ofthe Contractors License Law(Chapa-9
�Ao (commencing with rsuaScotian 7000)uf Divisiun3 of the Business teed PmfessionsCWe)or TEMP.METER OR POLE INST. COMMERCIAL:
d G E that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLTION
or Section 1031.5 by any applicantlar a permitsubjects the applicant to a civil penalty of POWER DEVICES ❑'TENANT 0FOOD SERVICE
not more then Eve hundred dollars(SSW). IMPROVEMENT
3q C ❑Los.wncr of the property,or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sec.7144.Business ❑OTHER
tY a and Profession
tnm
Code:The Concr's License Law does not apply to an owner of OUTLETS-SWI ICHES-FIXTURES
L property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RG•SIDCNTIAL ELECTR SQ FT.
mit.IL however.the building or impr.venunt is sold within one yearmexmpletion,the SQ.FT.FLOOR AREA $1SQ.FT -
owner-builder will have the burden of proving the he did not build or improve for par.
pose of sure.). A B
❑I,as owner of the property,am exclusively contracting with licensed contractors to W �
construct the project(Sec.7014.Business end Professions Code:)The Contector's Li- of
cense Low does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE g�
who...baces fur such prots m m jecwith a communists)licensed pumuathe Connector's 4
License Law. PERMIT ISSUANCE ci,)' • • 8 X995
❑lam empt under Sec. ,B&P C for thisM e-reuson �J, f•1
AITHE—DRAIN&VENT—WATER(EA) sNALI1gY 1N
OADL Date
w WORKER'S COMPENSATION DECLARATIO BACK FLOW PROTECT,DEVICE
by affirm under Penalty ofperjury one of the following declarations: ` {/
❑ I have and will maintain a Cenifcate MComenuo self-insue for Worker's Comped DRAINS—FLOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
soon,as Provided for by Stenion 37M of the Labor Code,for the performance.1 the
work for which this permit is issued. FIXTURES—PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Labor Code,forte perfomunceofthc work forwhichthispennit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP
My Workers Compensation insurance carrier add Policy number arc:
Carrier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMISDUSTRE,WASTE INTERCEPTOR
BUILDING DIVISION FEES
(76ie section need not be completed if the pemsit in for hundred dollars($100)) CREASETRAP
m less.) PLANCHECK FEC
Toy any Hest I.the purmy mmeacrofthe work for whichthistheperfaidtWisissued'I stain'Conipn- SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner sn as to become whjem m the WorkerF Compen- ENERGY FEE
zZ Barite.Lawsof Cmifnim..Date WATER HEATER WNENTIELE&R
0 Applicant GRADING FEE
ti NOTICE TO APPLICANT.If,after making this Cenificaa of Exemption,you should WATER SYS'I'EMITREATING
a become subject to the Worker's Compensation provisions of the Labor Code,you mind SOILS FEE
fonovith comply withmeh provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONST ION NEW RESIDENTIAL PLMB. SQ. PAID
L)Oaffirmis,,c Date Receipt N
I hereby affirm that them s a construction lending agency for the performance of
LA I••i the work fm which this pcmrir is issued(Sec.30197,Civ.C.)
t" Lenders Name TOTAL:
W Lenders Address T L'
{].so 04 1 certify that 1 have read this applicmion end stag Nat the shove information is 110 BUILDING PER
i.�10 correct.l agree no comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
L) 7, building construction.and hereby authorize representatives ofthis city to enter upon the 0 SEISMIC FEE
ti above-mentioned property for inspection purposes. PERMIT ISSUANCE 1w
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE `V
liabilitiesjudgments,costs and expenses which may In any way merme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit.in FEE L
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IOA00 CFM) MECHANICAL HE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER Ig0011 CFM) CONSTRUCTION TAX
Signaam of ApplicasUConbacar Data E)CHAUSTHOOD(W/DUCT) HOUSING MI'T'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupantsmre or handle intruders material HEATING UNIT CIT)100,000 BTU)
as defined by the Cupernino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section ll5532(a)T HEATING UNIT(OVER I00,0M BTU)
EI Yes F7 No PAID
VGNTILA'1'ION FAN(SINGLE RESID) Dam Receipt N
Will the applicant m future building oecupant use equipment or devices which
mit harsrdous air coutaminarts as defined by the Bay Arco Air Quality Management BOILER—COMP(3HP OR 100,000 BT U) TOTAL:
DisWct?
Fl Yes ❑N. BOILER—COMP(OVER 100,100 BTU)
I inverted be harandmunmuariulsrequirementx under Chapter 6.95 of the CAi- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 255M.I understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not mitherelyhave a anent rest d is my msponsibiliry m nmify the occupant
office requirements which must be met prior to issuance of a Ciatificut,of Occupancy
Owasemiithomedegem Dane • QOI�L. ISSUED BY: 71L716-1—Arp
OFFICE ^�