30996 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT IN030996
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT IDEN 1FICATION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
Gv L14AP Tot hR -W c
' OWNER' NAME: _ PHONE:- CONTRACTOR'S NAME: LICNO:
DA
N/C CONTROLM
CH C11 ' GINEER: , 11 N ADDRESS: ❑
CONTACT: PHONE: BUILDING PnMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B( ` ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hasty affirm that l am licensed under provisions o(Chamer 9(commenting JOB DESCRIPTION
°OZ with Section 7")of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
O PERM11 ISSUANCE
F in Trot Tame and,pat.
Wr WL L3 KITCHEN REMODEL
QF.U U License Class Lic.p
NGWU Date Contractor APPLIANCES-RESIDENTIAL ADDITION CD PLUMBING R&PIPE
ARCHITECT'S DECLARATION pgNEIS
LF..pvt ❑MULTI-UNIT ❑STRUCTURAL
Z O-Z 1 understand my plana xMll be used ss public records MODIFICATION
OZ-- - UP T02(XIAMPS
(:S42W Licensed Professional [:1 INTERIOR ' ❑CHIMNEY REPAIR
ai OWNER-BUILDER DECLARATION 201-I(100AMP5 IMPROVEMENT
O: Q I hereby affirm that l am exempt from the Contractor's License Law for the OVER]"AMPS ❑BATH REh1IR (]DEMOLITION
$d 36 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHE
troll LL which requires a permit to construct,alter.improve,demolish,or reedit my swcmre
hO Mor to its lsmance.also requires me applicant for such Permit to File a signed statement SPECIALCIRCUIT/MISC.
o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 _ V
pity COQ (commencing with Section 7")of Division 3 of me Bosincss mJ Professions Cole)or TEMP,METER OR POLE INS COMMERCIAL' �r
G Q.e yv that he is exempt therefrom and me basis for the alleged exemption.Any violation of
[3 NEW BLDG/AUDITION El DEMOLITION
til 4• Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of ' POWER DEVICES
H Z N not more thm five hundred dollus!$5110). TENANT ❑FOOD SERVICE
£xC ❑I,asow.w.fthe popeny,minyempinyecs with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
g. will do the work,and the structure is not intended or offered for sale(See70r4,Business ❑OTHER
and Pmfessians Code:The Contracmr's License law,does at apply to m owner of OUTLETS-SWITCHES-FIXTURES le
property who builds or improves thea..,and who does such work himself or through
his own employees,provided that such improvements am not intended or opened for NEW RESIDENTIAL ELLCIR SQ FT.
sale.IL however.me building or improvement is sold within one yew of completion,the �� SQ.FT.FLOOR AREA VSQ.FT.
owiter,builder will have the burden of proving that he did not build or improve for pun- �- //�� \
poseafou,). O 2
❑h as owner of the pmpeny,am exclusively contracting with licensed conaum.n to
construct the project(Sec.7044,Business and Professions Code:)The Conuaaur's Li- ���
use law does not apply to an owner of property who builds or improves memen,and QTY. PLUMBING PERMIT FEE
who contracts for such projects wish a containment)licensed pursuant to the Contramsds
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for mix rens..
t OwnerDam - ALTER-DRAIN&VENT-WATER(EA) VALUA'
W4,7KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby a1Hrm under penalty of perjury one of the following declarations:
❑Ih.veand will m.imma.CtmficatcofC...cut to wifirome for Worker's Compen- DRAINS-FLOOR,ROOF AREA,COND.
sation,us provided for by Section 37M of the Inbar Cale,for the perfmmantt of the STORIES TYPE CONSTRUCTION
work far which this pemdt is issued. - FIXTURES-PER TRAP
❑I have and will mainmin Worker's Compensation In c,as na,mad by Section
37Mofthe Labor Code,for she perfomante of the work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.GR P APN
My Workers Compensation lneurmce ca net and Policy number arc: -
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR'
/TW(Thissmtionnwn
dotbecompincJ ifthe penmtia fur mehundred Jnll.rs($Iqq Il GDIVISION PEGS
GREASETRAP
or nus.) PLANCH ,K
Icertiry that in the perf.nmancmfthe work fur which thio pcnnit is ixxmd, peIehall SEWER-SANITARY-S'IURMHA.2on lT.
not employ any Person in any manner so ns to beco ,object me,objeco the WorkWorkers'Comn- F'NERG E LL Za
,Z sation laws of Caliramia.Own WATER HGTER W/VE (( 'C
O Applicant n RADT EP
yNOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTENMREAI NG_-
become subject to the Workers Compensation provisions of the labor Cede,you must ILS PER
4 Q
forthwith comply witbxuch provisions or this permit shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PL B. ,Q. IU
V Ihereb3 affirm that them is a commiction lending agency for the performance of Date Nccciptp
fl. . the workfair which thii permit is issued(See3097,Cie CJ _ r _
U Lenders Name
lender's Address ,TOTAL:
I certify that I have read this application and some that the above information is ILD WG FEE 1'a
rA correct.l agree to comply with all city and county ordinances wall sole laws mining in QTy. MECHANICAL PERMIT FEE
V z building construction,and hereby.uthonac representatives of this city to enter upon the SEISMICFE' 0
above-mentioned property for inspection Paul , PERMIT ISSUANCE
(We)agree to save.indemnify and keep hwmless the City of Cupenino against ELECTRI :E
liabilities,judgments,casts and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. 1 `
in consequence of the granting of this permit. PLUMBI GFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I LON CFM)
SOURCE REGULATIONS. MLCHANICALF '
A� AIR HANDLING UNIT(OVER IUJNp CFM) CONSTRUCTIO TAX
ig.amre of Appl�ide(oV/Can�tmcmr . Date EXHAUST HOOD(WMUCT) HOUSING MITI TION ME
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building uccupant store or handle havard.us material HEATING UNIT DO Inputs)BTU)
us defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)' HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No 0
VGNfILA'1'ION PAN(SINGLE RES ID) PAID IJ
Will the applicant or future building recupant use equipment or devices which l R e
art heraideus air conuminark as defined tyro,Bay Area Air Quality Management BOILER-COMP(3HPOR100,000BTU)
T&A
District!
❑Yes ❑N. 0 BTU)BOILER-COMP(OVER IX).00
I have read me htowl m.tenaisrr.yuircmenn under Chapter 695 of the Cut AIR CONDITIONER
ISSUANCE DATE
gamma Health&Safety Code.Sections 25505,25533 and 8534.1 undenuml that if the NEW RESIDENTIAL MECH. SQ.FT.
lxdldmgdau,wacun,d Mveammant.that it is my rn a6biloymmaityme recupam
of the"dienems\i�YS Mian prior le iss.' f.CCnIB<ule o(Qfupmcy.
Owner m mthmindu ant-� d Data t ,TOTAL: ISSUED BY:
OFFICE