29462 APPLICANTTO,FILL IN.INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PF:RMITNO 6 2
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BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIUNICAI, 2 9 4
BUILDING PROJECT IDENTIFICATION N V
BUILDING ADDR S: SANITARY NO. APPLICATION SUBMITTAL DATE
l9 ��
OW R'SNAME: .,PHONE: CO CTOR' NAME: LINO:' '
(� 4/' S g� N/C CUNTROLp
RCHITECAINGINEER: LIC NO: ADDRESS: 0 K�
/540
CO A PHONE: BUILDING PERMIT INFO
�X5-�—��� ❑ Consultant Fees Paid by Applicant(Initial) BLD EE PLUMB, M�CI�
LICENSED CONTRA R'S DECLARATION QTY ELECIRICPERMIT FEE
1 hereby aN
mrm at 1 an I1ceW munder previsions of Chapter 9lemnmeodng JOB DESCRIPTION
pz with Section V(gg))of Division 3 o06e Business and Profession Code.and an,license is RESIDENTIAL:
O in full to.and effect PERMIT ISSUANCE.
alb
U License Class ❑SFDWI, [D KITCHEN REMODEL
Columnar ppP1.lANCES-RI'SIDENTIAL
N s'�-per, Date ommmr ❑rrrADDITION ❑(PLUMBING RE-PIPE
l,,,py ARCHITE'CT'S DECLARATION PANELg �MULTLUNIT $fSTRUCTURAL
z O K I understand my plans shall lice used as public records MODIFICATION
Oz--O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-I000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IIKKIAMPS -1BATH REMODEUREPAIR QIDEMOLITION
FFyy]] I hereby affirm that 1 am exempt from the Contractors License Law for Ne
pd l;GU following reason.(Section]D31.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL I�."QTHER
YY17`O,� which requires a permit to conswct,doer,improve,demolish,or repair any structure
prion.its iexamm,elsa mquiresmeapplicam formch permit wfileavigned statement SPECIAL CIRCUITIMISC.
yton he is licensed pursuant to the functions of the Conumtur's License Law(Chapter 9 I
p0 (commencing with Section 7")of Division 3 of the Business and Professions Code)or
TEMP.METER OR POLE INST.
6 y M C Nere
at he is exempt thfrom and the man for the alleged exemption.Any violation of -(]NEW BLOC/A DITION [I DEMOLITION
aXl ts•
Section 7031.5 byany applicamfor.pe.i,subjects the upplimat to a civil penalty of POWER DEVICES
y o ❑TENANTp�.a� 1^�.1rF00D SERVICE
not mare than Eve hundred dollars(55001. IMP 1'!!� y��
a ❑1.as owner of Ne property,or my employees with wages ox their sole compensation, SWIMMING POOL ELECTRIC #4
wi1lMNe work.and Neswcturt is notimendeJ m.ffertdformle(Sec.]044,Business ❑OTHIJRI
and Professions Code:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES W 1
a' property who builds or improves thereon,and who does such work himself or through V V t i"�—
his o employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. CI IY Ur -
sale.If,however,the building or improvement is sold within one yeorofcampletion,the SQ.FT.FLOOR AREA $/SQ.Ff.
owner-builder will eve the burden of,coving that he did not build or improve for for. „
p eof sown.
h as owner of the proper ,can exclusively Pool
with:)The Contractor's
ntract contractors to TOTAL:
construct the project(See 7044,Business and 1'rolessions Cale:)The Commcmr s Li-
censeLawdoesnotapplytoanownerofpropenywhobuildsorimprovesNereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractions)licensed pursuant o the Contractor'a
License law. PERMIT ISSUANCE
0 I am exempt under Sec. ,B&P C for this reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE
I hereby nation under Penalty of Perjury one of the following declamtican
❑I have end will maintain a Certificate of Consenuo self-imme far Worker's Compel- DRAINS-MOOR,ROOF.ARE ,CO ND.
sation,as provided for by Section 37M of the Labor Code,for the performance u(Nc STORIES TYPE CONSTRUCTION
wyrk for which this permit is issued. FIXTURES-PER TRAP
g 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the laborCode,for the perforins¢eof Ne work for which this permit is issued. GAS-CA.SYSTEM-I INC.4 OUTLETS
" My Wor cera Compcnsamlon leaymn<{,yyrtiu and Policy uy��.rG �g� OCC.GROUP APN
Carrier. G�h/{'t Ilpa FN Policy No.: r"�uy�71�V1��1 GAS-EA.SYSHIM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASETISDUSTRL WASTE INTERCE
ON,section necdo..be cumplevd ifthe permit is forone hundmddollars(SIM) isB4577ITISION FEES
or less.) GREASETRAP PLANCHE EEf
I ciamiythn in the permance
rfooften work for whichthis permit is issued,lshull s �•
SEWER-SANITARY-STORM EA.2M PT.
not employ any person in any manner so as to become subject m the Workers'Compem ENERG �.
oZ sari.,Laws of California.Date WATER HEATER WNENf/ELECTR
Z Q Applicata It GRADIN
ti ti NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM(TREATING
abecame subject m the Workers Compensation provisions of the Labor Code,you nun SOIL
{2I foMwith comply withsuch provi,joino,this permit shall he electoral invoked. WATER SERVICE
•a Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ,FT. PAID
U 0 I hereby affirm that them is a construction lending agency for the performmocif )ate Recei,tN
the work for which this pe�rrru��1 (Sec.309],Civ.C.)
Q E" Lenders Neme 1'V TOTAL:
U lenders Address TOTI
1 cenify that 1 have read this application and state that above information is JEE
ME �a
Z) correct.I agree to comply with all city and county ordinances and state lawn relating to QTY, MECHANICAL PERMITbuilding conewction,and hereby authmiu representatives of this city to enter upon the EE
above-mentioned propeny for inspection purposes, PERMIT ISSUANCE FEE
(We)agree m seep indemnify end keep hmmlcss the City of Cupertino againss1lubilities,judgmems.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECIL
in consequence of Ne granting of Nis peinit. FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRHANDLINGUNiTfFOl0.0MCFM) CAL FEE
SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,0M CPM) CTIONTAX
SigrumrcofAppliesim/Commaw Dare EXHAUST HOOD GYMUCF) (CATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant Imre or handle hazardous material HEATING ONI'f(TO 100,015)BTU)
as defined by the Cupenine Municipal Crate,Chpter 9,12,end the Health and Safety
Cade,Secon 25532O'I �/ HEATING UNI]'(OVER 100,000 BTU)
❑Yes ,/Ii\rlNlNoVCN3JLA]'ION FAN(SINOLC RESID) Date ReaiprM
Will Ne applicant or fu building occupant use equipment or devices which BOILER-COMP(3HP OR IIXI,IXq BTU)
mit hazardous air contaminants defined by the Bay Area Air Quality Management T
Distrin7 --yy♦, BOILER-COMP(OVER IM,(IDDBTU)
❑Yes •IjINo. -
1 have mad the hmerd,,o�ous``materials requirements under Chapter 6.95 of die Cali- AIR CONDITIONER ISSUAN E DATE
Tedl
& ty C e,Sections 25505.SSJJ and 23534.1 urdemwrd Nat if the NEW RESIDENTIAL MECH. SQ.FT
Isotc yhave t,that it is my re"mibilivat.only Ne occupant
ofm i m tprior uantt afvCrnif
l iud agent We TOTAL: ISSUED BY,
OFFICE