Loading...
29825 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY•OF CUPRRTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING•MECHANICAL. n(] O C BUILDING PROJECT IDENTIFICATION G J O J BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE 10-745 �,:DFA,/_7A rj OW ER' NAME: PHONE: CO NIC COMROLpOTTJJ��� 9� � A SS"CTNEER: LIC NO: nXi T ❑ COM'ACT: PHONE: vZ�QN!&)96aS X67 5 ❑ Consultant Fees Paid by Applicant(Initial) BLDG BUI ELECT PLUMB FO MECH � ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby affrm mat I nm IicensW under pmvisiunx of chapter 9(commencing JOB DESCRIPTION yO tYZ im Section]ggpof Division 3af the Biwmassond Professions Cale,cndmy license is RECIDENTIA FOO nfull force and effect. I PERMIT ISSUANCE f�w ❑SFDWL [I KITCHEN REMODEL <UU License Class Lic.N t;U! Dote Contrecm=r-✓�G-JQ�Q APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE F'y A tCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL Z O b l i nderstand my plans shall Re used as public records 'MODIFICATION py- UP TO 2M AMPS El INTERIOR [I CHIMNEY REPAIR Licensed Professional - 201d1V0AMPS IMPROVEMENT OWNER-BUILDER DECLARATION OVER Iqm AMPS [IBATH REMODEUREPAIR ❑DEMOLITION C 1 french,affirm that 1 am exempt from the Comracmra License Law for the O y U following reaxer.(Section 7031.5,Business and Professions Code:Any city of county SIGNS ELECTRICAL ❑OTHER a,00 fy which"moms a formal to consumer,omen improve,demolish,or repair any structure /Q prior in its issaancaalso randoesne applicant far such permit to fileasigned statement SPECIAL CIRCUITIMISC. } that he is licensed pursuam to the provisions of the Contractor's License Law(Chapter 9 G� (commencing with Section 7(]1 of Division 3 ofthe Business and Professions Civic)or TEMP.M ETER OR POLE INST, COMMERCIAL: 0 that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION Z^ 2 not Section7031.5by any hundrelicantfnrvpermit subjects the applicammacivil pemlry of POWER DEVICES ❑TENANT 'El FOOD SERVICE 'Z} not more than fivchundredy,or ($500). IMPROVEMENT QDl,asowner of the propcngm a,moI. .dml.mwageses their sole c(,W Business SWIMMING POOLELECI'RIC ' O will dothe work,ands: suucturebactim mended oro(f,does ml apply too44,Busi,of ❑OTHER a and Professions Code:The Contractors License Lew does not apply to if owner of OUTLETS-SWITCHES-FIXTURES pmpeny who builds or improves t such a and who dine such work himself of through his own employees,provided that such mentis old w are not intended of altered for NEW RESIDENTIAL ELECTR SQ PT. m1e.IL however.the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA 5/SQ.FT. cowner-builder will have the burden of proving that he did not build or improve for put. pose of sale.). n+ , ❑I;as owner of the property,am exclusively contracting with licensed connection to TOTAL: - construct the project(Sm.9(A4,Business and Professions Code:)The Contracmr'a I.I. •nv mass,awdoesnotapplytoanownerofpropenywhobuildsorimprovesthereon.and QTY, PERMIT FEE IIIXI 71996 - r who contracts for such pronm projects with a commeno(s)licensed pursuant the Corvcmrs License Law, . PERMIT ISS NCE I um exempt under Sec. .B&P C for this reason Owner DataALTER-DRAIN&VENT-WATER BA - 'VALUATION - WORKERS COMPENSATION DEOLARA'ION BACK FLOW PROTECT.DEVICE !$O© I bncby affirm order penalty of perjury one of the following declarations: f ❑I have and will maintain a Certificate of Cnnsentin self-insure for Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIESTYPE.CONSTRUCTION sealer,es provided for by Section Tom of the Labor Cade,for Ne perfom arm of the s work for which this permit is issued. FIXTURES-PER TRAP 1 have and will maintain Workers Compensation Insurance,as required by Section 3900 of the Lamm Code.for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN My Wars use ie I t be anierand Polic uJ y yn�er Cartier.- Policy Np✓Il/{Jh`r7 GAS-EA.SYSTEM-OVER 4(EA) Ct IFICATEOPEXEMP'NON FROM WORKERS' - COMPENSATION INSURANCE GREASMISDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This section need not he completed if the Permit is for one hundred dollars(S 100) GREASHTRAP or lees.) PLANCH[CK FEE I certify that in the performance ofthe work for which this paint is issued,l shall SEWER-SANITARY-STORM EA.200 FT. Cbt employ any person in any manner spa to roes re-opthe Workers'Compen- ENERGY FEE Ozi cation Law,oLCal1�ralu2pJre "'a`•-rt •' aWATER HEATER WNENTIELECTR z O pplivam rml - , G GRADING FEE y NOTICE TO APPLICANT:If,utter making this Certificate of Exemption,you should WATER SYS9EMPAEATING a ; become subject to the Worker's Compensation provisions of the Leiser Code,you most SOILS FEE (]a forthwith comply with such Pr a vis'onn or this permit shall he dcemcd revoked. WATER SERVICE p Q D•0 •CONSIsc ONLENDINGAGENCV NEW RESIDENTIAL PLM B. SQ.FT. PAID eceiptis V Thereby W.that them is donstrvction lending agency for me performance of IfIV the work for which this permit is issued(Sec.300,Civ.CJ Lime era Nome TOTAL: O V Lenders Address TOTAL 07 D f�'W o I certify mei 1 have mad this appliemirm end state that the above infortrnam.is BUILDINGYE �r^ fes/) correct.I agree to comply win all city and county nNi....r,and stare laws rchifl. m QTY. MECHANICAL PERMIT FEE V Z buildingconswnion,and herebyautiodu reprcssirimivesofmischymentmupon the SEISMIC FEE ` above-mentioned property far inspection purposes. PERMIT ISSUANCE (We)agree m save,indemnify and keep heradess rte City of Cupertino against ELECTRIC FEE liabilities,. menta,rosin and expenses which may in any way creme against said City ALTER OR ADD TO MECH. ' in rnnse sec ce if the gr analog of this permit. PLUMBING FEE APPL TUNDERST S,AND WILL COMPLY WITH ALL NON-POINT pIRHANDLING UNIT IO.WOCPM) MECHANICAL E SOl C ALATION. - AIR HANDLING UNIT(OVER 10,(KK1 CPM) CONSTRULTI NTA% n urn of Applican Dote EXHAUST HOOD(WMUCTI HOUSINGMI GATIONFEE H RDOUS M TERIAIS DISCLOSURE Will theapplicant or future building accupantsmmor handle hazardous material HEATING UNIT(TO 100,000 BTU), as delisted by the Cupertino Municipal Cade,Chapter 9.12,and rte Hmlth and Safety Code,Section 255321a1T HEATING UNIT(OVER Im.000 BTU) ❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Da Rmeip N rear the applicant or future building by the B use ea Air mor Marta which emitrict? nus air contaminants as defined by me Boy Area Air Qualify Management BOILER-COMP(3NP OR IW.0011 BTU) 'TOTAL District? ❑Y<s ON. BOILER-COMP(OVER I W,00()BTU) (have read the hsaardous materials reyuirements under Chapter 6.93 o(tM Cali AIR CONDITIONER ISSUAN E Imam Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently have a tenant,mat it is my responsibility to notify me nmupsnr _ of me requimmcros which mus,be mer prim to issuance of a CeAfcue of Occupancy. Oviummiutharimdagenr - Date TOTAL: ISSUED BY: OFFICE