29181 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING PROJECT IDENTIFICATION o
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAT'.
/A 2(o -d!! ,eI l 9, qL
OWN:R' NAME: I'HONIi: COM RAC :SNAME: LIC NO.
"hex- NIC COMROLN
ARCHI'TECEENGINEER: LIC NO: ADDRESS: T ❑
a�SJ
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RIM ELECT PLUMB MECH
O ❑ ❑ ,�'
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
o m Z 1 hereby motors that I am licensed under provisions ofCM1vpter 9(wmmencing JOB DESCRIPTION
th Section7")of Divmon3 ofthe Bu,inasvmd Professions Cade,o dmy licensees
kro0 on a a PERMIT IssunrvcE RESIDENTIAL:
of 11 fmcc and cffcc77//���� ��//�� 7� ❑SFDWL ❑KITCHEN REMODEL
QUad L le Class_S_e�SL Lie.M
hQa )ate��6 Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
CHITECTS DECLAR f1 PANELS
eg
MULTI-UNIT ❑STRUCTURAL
,z 1 undmuund my plans xhml hu used as public rccorth MODIFICATION
UPT02MAMP5 Licensed Professional - El INTERIOR ❑CHIMNEY REPAIR
20W000AMYS IMPROVEMENT
OWNER-BUILDER DECLARATION El BATH REMODEf/REPAIR DEMOLITION
y Q 1 hereby affirm that I an¢,crop from the Con r,clm,License Law for the OVER 1000 AMPS
x 36 F following reason.(Section]onstru Business and improve,
Professions Code:Any can or county SIGNS ELECTRICAL ❑OTHER qA,
41 u,y which rty. a perms to 031.5.et,niter,improve,de ionsC or repair any r ructurecounty
L'1=0 prior to its ustane.also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT I
w thin he is licensed nothe (Chapter
y,. pursues pr,io,mofthe Contractors License Low9
Iy�p0 (commencing with Section 7")of Division 3 ofthe Business arW Professions Code)or TEMP.METER OR I'O T OMM $ IA - -
6 X M C -but he ix exempt therefrom and the base,for the alleged esemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W M w Section 7031.5 by any applicant for a permit subject the applicant to a civil penalty of POWER DEVICES
at,,more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
f=C ❑1,asowner of the Property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
WF+ will do the work,and the structure is not intended proffered torsil,(See.AWG,Rosiness ❑OTHER
6 3`m and Profexsiun,Cale:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-RNRV
property who build,or improves theme,.,,it who docs such work himself or thumyh
his own employees,provided thin such improvements are not intended or offered for NEW RESIDENTIAL ELECTR ssr
sale.If,hmvcver,the building or improvement is sold w hhin one yeorofcompleion.the SQ.FT_FLOOR AR 95Q.FT.
owner-1 u ider will have the burden of proving that he did not build or improve for he
K P
pre of sale.). -
[] 1,.a owner of the Properly,oro cwhvively amnacting with licensed contractors to TOT •/
construct the project(See.7040,Business and Profession,Cale:)The CpatracmrI I..- Q �/� AI g �9g6
cense Law dues not apply to an owner of progeny who builds or improves thereon.and TY PLUMBING PERMIT FEE
who contrah p
cts formcrojee¢with a wmmemrns
l,)licoed pursuant mile Cmmmcmrn UF-L'
E]enselean Law. PERMIT ISSUANCE
❑ am ea<mpt under Sec. foribe,B&PCx reacnn C!'(
ALTER-DRAIN&VENT-WATER(EA)
Owner Dam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
• Ihereby affirm cam
i,pehy of perjury nnc of the following dadamuons: -
f7 Hove and will maintain a Certificate of Consent m self-insure for Worker's Carmen- DRAINS-FLOOR,ROOF,AREA,COND.
cationE,as provided for by Section 3](0 of the Labor Code,for the performance of the STORIES TYPCONSTRUCTION
work for which Nis permit is issued. =- URILS-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the LNr Crme,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.i OUTLETS
My W. yll 's '{�� icy No.:
OCC GROUP APN
Gamier, t/OFE EMPPolicy ROMW.b GAS-EA.SYSTESLOVER 3(EA)
CF.RTIFICATEOFEJ�(EMPN INSURANCE
WORKERS'
COMPENSA'OON INSURANCE GRGSEIINDUSTRL WASTE INTERCEPTOR
(This sectiorneed nn-be completed ifthepermit isfoumchundred dollars($IIX) BUILDING DIVISION PEES
or les.) GREASETRAP
I certify the in the performance ofthe work for which this Permit is issued,l shall PLANCHECK HE
not employ any person in any numnersoe in become mbjecuo the WorkersCompeo- SEWER-SANITARY-STORM EA.HO IT.
Z Applicant
of California,Date
ENERGY FF.E
�� Applicant WATIiR HEATER W/VENT/ELECTR
Z GRADING HE
.N-s NOTICE TOAPPLICANT:IL after making this Cen r,ofof Exemption,you shoals WATER SYSTEM,TREATING
a , become subject y the Worker's Compensation provisions of be Labor Cate.you mus SOILS FEE
forthwith comply with such provisions nr this permit shall be Deemed remked. WATIiR SERVICE
6 ❑
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SO P,L PAID
L) Ihcrehy affirm thin them isaamstrunion lending agency for thepimminanmm' Date Receiptp
� (•' the work for which Ibis permit is issue)(Sec.JfN].Civ.C.)
Lenders Name
AL.:
U TOT
Lenders Address TOTAL:
y I certify that I have read his application and.nam that the above information is IM'-E
EE
V) correct.l agree m comply with all city and county ordinances and state laws relmiagm QTY. MECHANICAL PERMIT FEE
L)Z building mmaruction.and herehy:wthorize npar,ntatives of this city m enter upon the E
abs econention al property for inspection purposes.
(We)agree to save,indeninify and keep he City of Cap against \ PERMIT ISSUANCE ELECTRIC '-EEliabiline pul,rarts.swas and a sea yinany aywmmmagainv. idCity A1.ILRORADD'IOMECH.consequence of the gm ispe wit. FEEnPPLICANT UN ,YT SAN WIL .COM WITH ALL N-POINT AIR HANDLING UNIT(TO I(UO CFM)SOURCF.RF L FEEAIR HANDLING UNIT(OVER 10,000 CFM) TION'TA%'rai of Apple p i/Cmunc s, Dare EXHAUST HOOD(W/DUCE)HAZARDOUS MATERIALS DISCLOSURE ITIGATION FEE
Will theaVplicantar future building recup.ntstae ar handle h.rmdnus maredal HEATING UNIT(TO I On—RTI11
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Code,Scotian 25532ho? HEATING UNIT(OVER 100.000 BTU) -Fl yr, ❑No
VENTILATION PAN(SINGLE RF,SID) PAID
Will the applicant or future building occupant use quipnem or device%which Date Receipt M
emit air contaminant-as defined by the Bay Area Air Quality Management BOILER-COMP 13HP OR 100,000 BTU)
�Dismict]
El Yes ❑No BOILER-COME(OVER 100,000 BTU) TOTAL:
I have and the hazandmematerials ommoments under Chaptersi.95 ofthe Cali- AIR CONDITIONER
f sm.Health&Safely Ode.Seetlms 25505.25533 and 255X.1 understantl that if the ISSUANCE DATE
building dans net currently have a tenant.that it ism bilis to notify the accnant NEW RESIDENTIAL MECH. SQ.FL
of the ¢which must be mw ns,ofa Y Y P
tquiremen prior ofu Certificate of Occupancy.
Owneroramhnr¢ed.,,a, Date
ISSUED 9Y'
OFFICE