29169 APPLICANTTO FILL IMINFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29169
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PIADJEC1'IDENTIFICATION
BUILDING ADDRISS: pp - SANITARY NO. APPLICATION SUBMITTAL DATE
O&JeS NAME: `I �y PHONE _ C/�/ A R'S NAME: LIC NO:
(/ `-� //C.Q/VO �S 3DO y ��X NIC COMROLM
,>:T.t at:T
CHITECTiE;GINL;kiR: - LIC NO: AD RESS: ❑ L (5/
CO ACT: - HONE: ''// BUILDING PERMIT INFO
2-53— T�Xb ❑ Consultant Fees Paid by Applicant(Initial) - B EI ECT PLUMB MECH
Eti��sX-Z-Y. X el!�_ X .
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing - JOBDESCRIPTION0p with Section 7000)of Division 3 afthe Business pod Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL:
�UUmfenmu<anJ eB«t ❑ FOWL El KITCHEN REMODEL
License Class Lica APPLIANCES-RESIDENTIAL EDITION El PLUMBING RE-PIPE
v~i 6 4 Date T'S DECLARATION
ARCHITECTS DECLARATION - ❑MUCD.UNIT El STRUCTURAL
F.7u1 PANELS
I Zpv�7,. IunJersand my plans shall be useA as public records - MODIFICATION
OZY4M UP TO 200 AMPS [I INTERIOR 0CHIMNEY REPAIR
� ttl Licensed Pro(aslonal 201-1000AMPS IMPROVEMENT
M-aj OWNER-BUILDER DECLARATION OVER 1000AMP5 CBATH REMODEVREPAIR [IDEMULITION
1 hereby affirm that 1 am exempt from the Contractor's License Law far the
iySOyU fall,,wingreason.lSection7031,5,Businessand Professions Codc Anyciry ore my SIGNS[LF.CfA1CAl. BATH
FQ yQ which requires a permit to rnnstma,alar,improve,demolish,or repair any swctore
J priorm its issuance,also requires the applicantfar such Permit no file.signed statement SPECIAL CIRCUI'1'/MISC.
Nthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
(romaencing with Section 7000)of Division 3 of the Business end Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
t+• Section 7031.5 by any applicant for a pormt subjects the applicant n a civil penalty of POWER DEVICES
roan ❑TENANT ❑FOOD SERVICE
not marc Nun five hundred dollars p.
6 �1,as owner ufthe property,
oror my amemployceswith wages as their sole compensation, SWIMMING POOL ELECTRIC A5PIMPROVEMENT
C will do he work,undthe suure imu
otinnded or offered for 7044,Bun
siess OTHER
um
(mil and Forecasters Code:The Commuters License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTU S
property who builds or improves thereon,and who does such work himself or through "
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.El ECfR SQ Fr
We.If,howevice the building or improvement is wid within one yearofoompletion,the SQ.Fr MOOR AREA S/SQ,PT,
owner budder will have the burden of proving that he did not build or improve for pury
11 of salcI.
as r of the property,am exclusively contacting with licensed connecters to
s el the project(Sec.1044,Business and Professions CW e:)The Contracrorx Li- pp
came Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT*FEE ✓ W ®�
who contracts for such projects with a conum
acturod licensed pursuant to the Cuntracr's
License Law. T °Y
❑ enan,I x Sc ,B& as
PC far this mon PERMIT ISSUANCE. C�'Y 3
7,1
I Uma ALTER-DRAIN&VE - TER UTA) pION
BREWS COMPENSATION . .
CLARATION BACK FLOW PROTD LUP
I herebyufflrmuoderpenalty0fperjuryonc Ufthc fullowingd.houtiomf l.F:yrr O�
❑Ih.ve and will meimaineCmifieea of Cmnsenuoself-insure for Workers Grmpen- DRAINS-FLOOR,ROOF,AREA OND. STORIES TYPE CONSTRUCTION
sution,as provided for by Section 37W of the tabor Code,for the parfmmance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
370(of the labraCede,forthe perforomenuf the work fur which this permit is issued. GAS-EA.SYSTEM-]INC.4E
OCC.GROUP APN
My Workers Compensation Imra
uace carrier and Policy number am: - ,
Cameo Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE?INTERCEPTOR
BUILDING DIVISION R?CS
(lhia senior red not tKcompleadif thepmnit is forone hundreddollars(f 100) GREASE.TRAP �I
or less) PLANCHECK FEE 1_
Loy any patio the Perany mmmrttofthework for becomesubjetch to permit the Wrkeri'Cornie . SEWER-SANITARY-STORM EA.200 F1'.
not employ any person in any mannerwas to become xubjecno the Workera'Crmpem - ENERGY FEE
'
,`� sa[i..laws of Califomla.Data WATER HEATER WNENT/ELECTR
O Applicant - - GRADING FEE
fp NOTICETO APPLICANT:If,afar anaking,this Cenificute of Exemption,you should WATER SYSTEMITRFATING
f-s became subject to the Worker's Compensation provision of the Labor Code,you mus SOILS FEE
Wforthwith comply with such provisions or this Permit shall be deamed revoked. WATER SERVICE
d
Z
CONSTRUCTION emst LENDING AGENCY NEW RESIDENTIAL PCMB.. SQ.PT. PAID
o-7•
1 hereby affirm that there is a cnnstactiun lending agency far the performance n(
Dote R¢ciptX
LJ the work for which this permit is issued(See.3097,Civ.C.) '
0 U Lenders Name TOTAL:
{2I Landers Address
[y,, 1 certify that 1 have seed this application and state that the above infaBUILDING FEEma5on is
tact0 correct,I agree to comply with all city and county oNitmnces and state laws relating to QTY. MECHANICAL PERMIT FEE
U 7 building conswaion,and hereby authome representatives ofthis city to enter upon the SEISMIC FEE 6
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCEELECTRIC FEE
O
(We)agree to save,indemnify and keep harmless the City of Cupertino against `
liabilities,judgments,costsund expenses which may irony way acemeagaimt said City ALTER OR ADD TO MECH. PLUMBING FEE O
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,00)CFM) MECHANICAL FEE
eL
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signature of ApplienVCotmetor Dat EXHAUST HGOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building extension store m handle Mzardom material HEATING UNIT(TO I Wood BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,odd the Health and Safety
Cale,Section 25532(a)'1 HEATING UNIT(OVER 100,010 BTU)
E]Yes RN. VENTILATION PAN(SINGLE BESIDE PAID
Will the applicant or future building occupant use equipment or devices which Data Receipt#
emit huenrdous air cumaminants as defined by the Bay Area Air Quality Management BOILER-COMP 6HP OR 100,010 BTU) -
District? TOTAh:
❑Yes ❑Nr BOILER-COMP(OVER 100,000 BTU)
Ihave¢ad the hvamnm maarials requirements under Chapter b.95 of the Cnli- AIR CONDITIONER ISSUANCE DATE
braid Health&Safety Gee,S«0ons25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr.
building Jrcs not currently have u tenant,that it is my responsibility to notify the occupant
of the requirements which must be me,prior in issuance of a Certificate of Occupmsy.
Owner or mahoriud.gem Date ISSUED BY:
OFFICE