29932APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING -ELECTRICAL PERMIT N0. 2 993 9
BUIL DING DIVISION APPLICATIONIPERMIT PLUMBINGMECHANICALx�• J<L
CONTRACTOR'S NAME: LIC NO:
N/C e
ADDRESS: ❑ XO
BUILDIUNG PEP
Q Consultant Fees Paid by Applicant (Initial) BLDG , ELECT
24 004
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41
LILeNNEU LUN t KAU mRS UmLLAKA UUN
1 hereby affirm that I dm licensed under provisions of Chapter 9 (commencing
with Section 70W) ofDivision 3 ofthe Business and Professions Code. and my license is
in full force and effect.
License Class Conte
Date COntmmOr
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
CIS WL O KITCHEN REMODEL
D)ITION El PLUMBING RE -PIPE
OM UTI -UNIT []STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
- •
APPLIANCES — RESIDENTIAL
open
ARCHITECTS DECLARATION
IundentanJ my plans shall he used spuMic records
PANELS
Lvv11
Cf
p
41
Licensed Professional
UI' TO 200 AMPS
❑ INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
201-10WAMPS
'74 U
i LLOa
mDECLARATION
1 hereby affirm that I 1 S exempt from Ne Contractor's License Law for the
that I abeU apt from
following cera,.. (Section ]mount Business and ove, demolish.
h. or Any city orcounry
which requires a permit to teres the aper, improve, n Permit t or repair any structure
prim to in issuance, also requirevhe applicant for sucM1 Permit file exigded statement
O BATH REMODEUREPAIR ❑ DEMOLITION
❑OTHER
OVER 1000 AMPS
SIGNS ELECTRICAL
_
SPECIAL CIRCUIT/MIST.
.a
�s7yy
that he in licensed pursuant o the provisions of the Contractors License Law (Chapar9
TEMMETER OR POLE INST.
COMMERCIAL:
00
e Business and Code)
(commencing with Section 7")of Division 3 of NProfessionsP.
y ya
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
NEW BLDG/ADDITION O DEMOLITION
k y
y
Q
Section 71111.1 by any applicant for u permitsubjcds the applicant no a civil pensltyof
not mate than five hwdmd dollars(SSW).
O1, as owncrofrhe property, or my employees with wages as their sale compensation,
will do Ne work.mal Ne soucmre is not intended ar offend for sale (SecA044, Business
POWER DEVICES
OTENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
a1 �_
and Profrssiom Code: The Conductors License Lou, does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
OUTLETS—SWITCHES—FIXTURES
his own employees, provided that such improvements are not intended or offered for
sale. If,however. the building or improvement is sold within one year ofcompletion, the
NEW RESIDENTIAL ELF,CPR SQ
SQ.FT. FL R REA
&SQ. FT.
owner -builder will have the burden of proving that he did not build or initiate for put.
OI,usowner of the to
contracting with licensed commor
,
a J
TOTAL:
Sm 70,14, Business
censwm the project (Sec. Business and i I
The Contractor's Li-
o an wh
censeIsmdoesnetapplymanownerofpropmywhobuildsorimprovesNsacon,onJ
property but ds or i
QTY. PLUMBING PERMIT FEEpyja,Y
who condacte for such projects with ecomracmn
r(s)IicenseJ pursuant theContractor's
License law.
I am exempt under Sec. ,B&PCfor Nis recon
2
'I'R 199 6
iJ//
PERMIT ISSUANCE
Owner Date
WO ,R'S COMPO SATION DECLARATION
ALTER—DRAIN&VENT—WATER (CA)VALU!A�'T%'IO�-N
'
V '""o' I Pa
BACK FLO PROT ,DEVICG
1 hereby aRrm under penalty of perjury one of the following declarations:
DkAINS— OOR ARfA,COND.
l have and will maintain a Certificate ofConsenuo self-insum for Workers Comped-
arid., as provided for by Section 37W of the Labor Code, for the performance of the
STORIES
TYPE CONSTRUCTION
work for which this permit is issued
FIXTUR — GRT
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37M of Ne Labor Con, forthe Performance of the work for which this Permit is issued,
GAS—CA. E IN
at
OCOGROUP
APN
My Workers Compensation Insurance career and Policy number arc:
Currie,. Policy No.;
GAS—EA.5 OVER 4(E
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not foo completed iflhe permit is for one hundred dollars ($10d)
m less.)
GREASUINDUSTRL A RCEPTOR
BUILDING DIVISION FEES
GREASP. TRAP
PLANCHECK FEC
I certify that in the Performance ofthe work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workern' Compen-
ZZ smion Us. of California. Date
2 Applicant
SIiWF,R —SANITARY—STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENDELECfR
GRADING FEE
WATER SYSTEIATITATING
y NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
a
SOILS FEF. '
forthwith comply with such prnskionsor this permit shall he deemed revoked.
O
CONSTRUCTION LENDING AGENCY
U O work which thi that Nor issued(Sm.309endis, agency for performance of
ti the work for which this Permit is issued (Sm. J09], Civ. C.)
Lender's Name
WATER SERVICE
PAID
Data Reccipr#
NIiW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
TOTAL
{U
y
IsnderAddress
I:
certify that 1 have read this application and state that the shave information is
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
U 4
comet. l agree to comply with all city and county ordinances andstate, laws relating m
building construction, and thereby amhnrire representatives ofthis city to enter upon dte
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
above-mentioned property for inspection purpowc. -
(We) agree to save, indemnify and keep harmless the City of CLpetino against
liabilities,judgments, costs and expenses which may in any way accrue against mid City
in consequence of the granting of this permit.
ALTER OR ADD TO METH.
PLUMBING FEE
PIR HANDLING UNIT fin 10,000 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS. -
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CPM)
CONSTRUCTIONTAX
Signature of Appliummontmctor Dara
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCI)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 BTU)
Will theapplicant or future building eceupanutnreor handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 2553200t
HEATING UNIT (OVER 100,000 BTU)
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which
mit hazardous air cnntuminnnL as Defined by the Buy Arcu Air Quality Management
District^
❑Yes ONo
PAID
Dam Receipt#
VENTILATION PAN (SINGLE RESIU)
BOILER —COMP DHP OR IDLWO BTU)
TOTAL:
BOILER—COMP (OVER 100.000 BTU)
AIR CONDITIONER
I have readthe haturomsmaterials requirements under Coupler 6.95 of Ne Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT
frmia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
building doesmat cwrtmly have a mnanl that it is my responsibilay m noufy the occupant
of the rtquiaments which must be met prior to issuance of s Certificate of Occupancy.
V
ISSUED BY:
Owner m itothodsed mseat Data
TOTAL:
OFFICE