29632" APPLICANTTO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY - .
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLumBINc-MECHANICAL.
y • PERMITNO. 29632
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - `• -
1-0.13 -4 ANN. �L �
SANITARYNO.(
APPLICATIONSUBMITTALDATE
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BUILDING PERMIT INFO
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LICENSED oNTRACroRS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 90k0) of Division 3 ofthe Business and Professions Code, and my bodies is
In full tome and effect. PERMIT ISSUANCE.
License" Lic. # �N40 - -
Dae rContracmr APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
DWL r • 0 KITCHEN REMODEL
ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION "
MODIFICATION
- OCHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEUREPAIR 0 DEMOLITION
0 OTHER
ARCHITECT'S DECLARATION PANELS -
1 understand my plans ahall be usedas public details
r ., UP TO 200 AMPS
Licensed Professional
DECLARATION 101-1000AMPS
I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER IMBAMPS'
following reason. (Section ]031.5, Business and Professions Code: Any city or county
which requires SIGNS ELECTRICAL•
q a permit to construct, aitce improve,.demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
athe is licensed pursuant to the provlsionsofthe Contraetois Licen9
se Law(Chapler
COMMERCIAL,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
C1 TENANT ❑FOODSERVICE
IMPROVEMENT
OUTLIER
QC)Ih
ry, oeG
.mrSection]031.5
zy
CQ
•,C'•
Y3$
(mming
coencwith Section 1000) of Division 3 ofthe Businessand Professions Code)or TEMP. METER OR POLE INST.
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
byanyapplicas forapetmitsubjects theappOcunuoa civil penalty of POWER DEVICES
not more than five hundred dollars ($500).
❑ I, as owner of the property, an my employees with wagesas theirsole emopensation, SWIMMING POOL ELECTRIC
will do the work, • and the swcmro is not intended or offend Easels (Sec. 7044, Business -
and Professions Code: The Contractor's License Law does not apply to an owner of OUTLET'S -SWITCHES -FIXTURES
-
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
1, Is"
SQ.FTFLOORAREA $/SQ. FT.
sale. IL however, the huildins or improvement is sold within one yearof completion, the '
owner -builder will have the burden of proving that he did not build or improve for put- O
pose of sale.). -
1, as owner of the property, am exclusively contracting with licensed con arrom to TOO it C:D
construct the project (Sec. 7044, Business xad Professions Code) The Camranors Li-
cense Law does not apply in an owner of propeny who builds or improves thereon, and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s) licensed ursuant to the Contractor's
License L. PERMIT ISSUANCE
0 I am exempt under Sed , B & P C for this reason -V--
,
/ � gel, g
Owner Date ALTER - DRAIN&VENT - WATER (EA)
VALUATION
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WORKER'S COMPENSATION DECLARATION, BACK FLOW PROTECT. DE
' 1 hereby affirm under penalty of pe jof m
jury one e following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- DRAINS- FLOOR, ROOF, AREA, ND/
smion, as provided for by Section 3700 of the Lobar Code, for the performance of the
STORIES
TYPECONSTRUCfION
'
work for which this permit is issued.FIXTURES=PER TRAP
U4 Frvd and will maintain Workars Compensation Insurance, as required by Section
'
3]0(1 Labor Code, fonhe performance ofthe work for which this permit is issued..' GAS ._EA. SYSTEM-] INC. 4 OUT
My Worker's Compensation Insurance carrier and Policy number are:
DEC. GROUP
APN
Carrier: Policy No.: GAS - EA. SYSTEM -OVER 4(EA)
-
• CERTIFICATE OF EXEMPTION FROM WORKERS'
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q ti
abecome
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COMPENSATION INSURANCE' GREASFJINDUSTRL WASTE,INTERCEPTOR
(This sacdon need not be completed if the permit is for one hundred dollars ($1110) GREASE TRAP,
or lased -
Icenify that lathe performance of the work fdrwhichthis Permit isisered. Ishall SEWER -SANITARY -STORM EA. 200 FT.
not employ any person in any manner so as m become subject m the Workers' Compen-
cation Laws of California. Date
BUILDING DIVISION FEES
PLANCHECKFEE, \Lb
�y
_\
-
ENERGY PEEiQ
Applicant WATER HEATER WNENTMLECTR .
PP
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certhniae of Exemption, you should WATER SYS'TEMITREATING
subject m the Worker's Compensation provisions of the Labor Code, you most
forthwith cmnply withsuch provisions ar this permit shall be deemed revoked WATER SERVICE
SOILS FEE
PAID
Data Receipt#
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CONSTRUCTION LENDING AGENCY. "NEW RESIDENTIAL PLMB. SQ. FT.
- teethe performanceof
thi that thele issued
ULenders
inLeodu'
rr %
L)
work Seconstruction 097.lendingv.agency
Le work for which this permit Is issued (Sea. 3099, Civ. CJ
Name An ssi 40%
TOTAL:
s
Address ' • - At rL "15l
I wnee that I have reel thirty and court and state ces the above information is
comer I agree to comply with all city end county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
herebyamhmiureptesenmtives ofthiscitylo enter upon the
BUILDING FEE
,
SEISMIC PEE
above-mentioned
above -me e) ogre to save for emnifyian keep ha
e PERMIT ISSUANCE'fur
(We) agree m save, indemnify and keep harmless the City of Cupertino against `
liabilities,judgmentscraing r this eswhlch may many way accrue egainm sail City ALTER OR ADDTOMECH.
m consequence of the granting oof this permit, �
APPLICANV UNDERSTANDS AND W COMPLY WITH ALL ON. CUNT AIR HANDLING UNIT (TO 10,000 CFM)
SOURC GULATIQNS. //s/ /F
�- AIR HANDLING UNIT (OVER 10,000 CFM)
Y
"-TEiRIA/DfT
ELECTRIC FEE \
PLUMBING FEE `
MECHANICAL FEE
CONSTRUCTION TAX
.ODere EXHAUST HOOD (W/DUCT)
Signature of Applin a nRDO
' ARruchin TERI DISCLOSURE
HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT (TO 100,000 BTU)
as defined brim, Cupertino Municipal Cade, Chapter 9.12, and the Hcalth end Safety
-
Code, Section 25532(09 HEATING UNIT (OVER I00t(s00 BTU)
❑Yw ❑No -
VENTILATION FAN(SINGLE RESID), -pme
Will the applicant or future building occupant use equip t or devices which'
emit bezallous air contaminants as defined by the Bay Area Air Quality Management BOILER -COMP CHIP OR 100,0(10 BTU), i
Distort
❑Yes No BOILER- COME (OVER 100,000 BTU)
AIR CONDITIONER
I have read the hvardous materials requirements under Chapter 6.95 ol'the Cali-
media Health & Safety Cade, Sections 25505, 25533 and 25534, 1 understand that if he NEW RESIDENTIAL MECH. SQ. FT.
building does not currently have a tenant. that It is my reapurs unity to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
-
PAID AI tilt4/Yw
- Receipt#
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QI I i e.[65UANCE'DA E"
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ISSUE p BY:
Owner or authorized agent - pate T %
OFFICE