29795 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILMNO-ELECTRICAL - PERMIT NO,
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECIIANICAL 29795
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATI0 SUBMITTALDATE
0 l� nlxAr3l LA-7t.` 41QCI
0 BR'S NAME' PHONE: 'SNA E: - ICN'p�I
•..� Q V {O� NIC �CONIROLM
ARCHITE /ENGINF.F.R: LIC NO: ADDRESS: UU ❑
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby etfum that 1 am licensed under provision:of Chapter 9(commencing JOB DESCRIPTION
f4CZOluftll�Fandc
with Sasion]BIXI)of Uivision3ofthe Business and ProfessionsCO, dray license is PERMIT ISSUANCE RESIDENTIAL:
ea f/pN s�1 ❑SFDWL - ❑KITCHEN REMODEL
UZ e�' Limnss. Lic.g APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�QL DateComracmr
F..3�' ARCHITECTS DECLARATION [I MULTI-UNIT [I STRUCTURAL
PANFaS
m
-
yp 4 Iundersnd my plans shall be used as public records MODIFICATION
d
py (G] UP TO 2W AMPS [I INTERIOR ❑CHIMNEY REPAIR
.3 It: Licensed Professiotml - r - 301-1000AMPS IMPROVEMENT
�W�
OWNER-BUILDER DECLARATION OVER IOW AMPS El BATH RLMODEIIRF.PAIR ❑DEMOLITION
y I hereby affirm that 1 um exempt from the Contractor's License Law for the
'ata a 6 U following rcamn.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LLI`WO which requires a permit to construct,aIle,improve,demolish,me repair any am core
TIL..... pdormizsissuance.alsmretuim.duvpplicam forsdch pe and 1.Bleasigned mmcment SPECIAL CIRCUIT/MISC.
6that he is licensed pursuant to the provisions of the Commences License Law(Chapter 9
W OC (commencing with Section7NK)of Division 3 of the Business and Professions Coit TEMP.METER OR POLE INST. COMMERCIAL:
d nae that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDRION- []DEMOLITION
LL, Smuon 7031.5 by any applicant for a Femur subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT I ❑FOOD SERVICE
Qnm more than five hundred dollars($sud. - IMPROVEMENT
II]I,azmwner of the property.nr myemplayees with wagesastheir sole compensation, SWIMMING POOL ELECTRIC
do the work,anal Ne stmaam is not imendrdormfomd for sale(Sec.](HJ,Business []OTHER
m and Professions Code;The Conmsxroex License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTU
property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR
sale.If,however,the building or improvement is sold within one yearofcompI Iinn.lhe SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden ofpmving that he did not build orimprovefmrpm- +pT a��` g D
poseof.k.). 9�
❑1.as owner of the property,am exclusively contracting with licensed contractors to IOTA a
emnsuuct the project(SCC.]BJJ,Business and Professions Cnde:)TaC CnntmclnrI
cense law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE APR 241996
who contmms forsuch projects with a mmmnm(s)licensed pursuant m the Cmdrach rs
License Law. PERMIT ISSUANCE
I]I am exemptundm Sec. .B&P C for this reason L✓N (•f
Owner - Dnte
ALTER-DRAIN&VENT-WATER(EA) VALUATR3N
WORKER'S COMPENSATION DECLARATION Bq
I hereby affrm under penalty of perjury ane of the following declarations: _
I1 ��Ihave and will maintain eCenificam of Consent to self-insure for Worker's Comped. U S E COND. $TORIES TYPE CONSTRUCTION
/ ,aboral,as provides for by Semion 3700 of the Labor Code,fondue performance of the
work for which this permit is issued. LA -I , T
t�6 LO
❑1 have and will rooimaln Workces Compensation Insurance,us,c,.imd by Section
37W of the Lmau Code,forsheperformance of the work for which this pcmm is issues. GAS-EA.SYSTEM-I INC.J OUTLETS OCCGROUP APN
My Workers Compensation Insurance currier and Polity number are:
Cartier: Policy No.: GAS-EA,SYSTEM-OVER J(EA)
-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INFF.RCEPTOR BUILDING DIVISION FEES
(This sectlonneed net be completed ifthcpermit is for one hundred dollars($)W) GREASETRAP
ad less.) PLANCHECK ME
I certify that in Ne peffosmum of Ne work far which this permit is issued,i shall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so as m becn
ome nobjeco the Workers'Camped- ENERGY FEE ,
satinn Laws of California.Date WATER HEATER WNEWMI-EcTR
Applicant GRADING FEE
.Ni NOTICE TO APPLICANT:IL after making this Ccrdficamof Exemption,you should WATER SYSTEMIIRFATING ,
Ft becmme subject int the Workers Compensation provisions of the Lahr Code,you must SOILS FEE
�s fonhwilh comply with such provisions or this permit shall W created revokes. WATER SERVICE -
Q
CONSTRUCTION LENDINGAGENCY NEW RF.SIDP.NTIALPLMB. SQ.FT. PAID .Dam Receiptp
V hereby which
film that issued(S .309ending agency for perfonnunce of
W the work for which Nis permit is issued(Sec.300],Civ.C)
I•" Lenders Name TOTAL:
V Lenders AddressTOTAL: '
1 unify that I have read this application and state that the above information is BUILDING FEE
hcontact.I agree in comply with all city and county ordinances and store laws relating to QTY, MECHANICAL PERMIT FEE
(„) building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mc boned property for inspection purposes. PERMIT ISSUANCE
(We)agree to.nave,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH.
n consequence of she g ad a,of this Nor.I. PLUMBING FEE
APPLICAM UNDP STANDS AND 'ILL-COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,WOCFM)
SOURCE . U ONS. _a MECHANICAL PEE
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCI'IONTAX
Sig of plicanUConu000r. a EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAI'ERI 'DISCLOSURE
I the applicant or future building sidcupant store or handle harurduus material HEATING UNIT(TO 100.00(,BTU)
as define by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(o)T HEATING UNIT(OVER 1 W,(IW BTU)
❑Yea ❑No VENTILATION FAN(SINGLE RESID) PAID
Date, Receipt
Will fid,applicant or Faure building ocmtpant use equipment or devices which N
mWeardom,air emamminants as defines by she Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
1Ab nitt rrl Yes ❑No BOILER-COMP(OVER 100,000 BTU) -
I have tend the haardmusmomrimlx restatements under Chapter 6.95 of the Cali- AIR CONDITIONER '\ ISSUANCE DATE
fornix Health at Safety Code,Sections 25505,25533 and 25536,I undern med that if the NEW REIDENTIAL MECH. SQ.PT.
Wilding ducts not curemm
currently have a Iro,that it is my responsibility notify the occupant
of the etuim ants which must be over prior to issuance of a Cer iOcme of Occupancy.
' Owner or authorized agent Dam TOTAL ISSUED BY:
OFFICE