29307 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n O 7
BUILDING PROJECT IDENTIFICATION G
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDATI
16 Stun
OWN 'S AME: jl� PHONIi: TRACTOR'S ME: a LIC NO.
NIC CONTROL#
-.R CHITECAISGINEER: LIC NO: RES ❑
O L / (/
ONTACT. PHONE: n
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) DG ELECT PLUMB MECH
❑ ❑ Cl
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OZ with Section 7000).f Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
Iy� n full tome and effect. PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�WU License Class - Lic.it APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
�,�i Date Contractor
Dy ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
ZO f^C PANELS
1 understand my plans shall be used as public..cords UP TO 200 AMPS ODIFICATION
D El HIMNEY REPAIR
F t,f•'al Licensed Professional 201-1000AMPS IMPROVEMENT
9)d�,'4,l OWNER-BUILDER mDECLARATION
W 44'' << 1 homey affrm that 1 am exempt from the Contractor's License Law for the OVER 10110 AMPS ❑BATH REMODEL/REPAIR 0 DEMOLITION
>(a 6 V following reason.(Semon]03115,Business and Profession,Code:Any city ot'county SIGNS ELECTRICAL - ❑OTHER
Yl LL which reyvirea a permit to construn,alter,improve,demolish,or repair any swcmre
�LLOy prior..is issuance,elm requirestheapplicam for such pcmdn,file a signedsmemem SPECIAL CIRCUUDMISC.
p., thatheishomselp....at to the provisions ofthe Contractor's License Low(Chapter 9
CC (commencing with Section 7000)of Division 3 of the Business and Professions Code)a, TEMP.METER OR POLEINST. COMMERCIAL:
Ld that he is exempt therefrom and the basis for he alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION'
y Section]031.5 byany opplicam for a permit subjects theapplicant too civil penalty of POWER DEVICES 9 ❑TENANT ❑FOOD SERVICE
N Z} not mare thin five hundred dollars($500). V.,
xIMPROVEMENT
"Q r1 owner of the progeny,or my employees with wages as theirs.le compensation, SWIMMING POOL FIXCIX
will do the work,and the .ucsure is not intended proffered for sale(Sm.]B44,Business []OTHER
Professions Cale:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FI URC
N
r property who builds.r improves themon,and who dues such work himself m through
his own employees,provided thin such improvements art not intended or oRered for NEW RESIDENTIAL ELECT
We.If,however,the building or improvement is sold within one year ofrompletion,the SQ.FC FLOOR AREA LSQ.PT.
caner-builder will have the burden of proving that he did not build or improve for put- p� p
pme of sale). F' µ7i
❑1,as owner of the propetiy,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professima Code:)The Contracmfs Li-
se Law does not apply m an owner of property who builds or improves thereon,and QTPLUMBING PERMIT FEE 71996
who contracts forsuch projects with u conductorial licensed pumuairm the Contractor n M - 4,
License Law. PERMIT ISSUANCE
1 am exempt under Sec. ,B&P C for this moron Jr(;
Owner Dam ALTER-pRAIN&VC•NT-WATER IRA) • -VALUATION
1 WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby AW.under penalty of perjury one of the following declarations:
❑Houseemi will mainminaCenificateof Consennoself-insumfor Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
sedan,.Provided for by Section 37M of Nh
e Ler Code,for the p offirt ed.of the STORIES TYPE CONSTRUGDON
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Labor Code forthelmourmimmiffiework for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APE
My Workeror Ipprvnce 01+riaPolic
tr pQ. y numberarc:
Cartier. W.�' La Polic: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
('Otis section mednmbcemnplcred ifthe permit is foram,hundreddollm,H 1W) GREASETRAP
or lcasJ - PLANCIIECK FEC
Icetiify isnot in any
of tsewmkf.r,oich jetttio the Workis ersueglism- SEWER-SANITARY-STORM EA.2W FT.
not employ any petmn in any manner m u m become subject m the Workers'Cnmpen- ENERGY FEE
0Z section Laws of California.Dam WATER HEATER WNENVELECTR
O Applicum GRADING FEE
y NOTICE TO APPLICANT:IL after making this Cenifcmeof Exemption you should WATER SYSTEMTREATING
become subject to the Worker's Compensation Provisions of the Lebo Code,you must SOILS FEE
foMwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
fY Q
(��❑�LLL'
CONSTRUCTION LENDINOAGENCY NEW RESIDENTIAL PLMB. SQ,CF. PAID
UO I hereby which thi Ninth is saed(See ion lending agency for the performance of Date Receiptq
Us Ne work for which this permit is issued(Sec.3097,Civ.CJ '
CJ U Leader's Name TOTAL:
Lendeds Address TOTAL:
0. I certify that 1 have read this upplicifirm and slam that the uh.ve informal am is BUILDING FM-
V) correct.l agree to comply with all city and county ordinances and state laws reining to QTY. MECHANICAL PERMIT FEE
L) z building construction,and hereby authorize representatives ofthiscity meaner upon the SEISMIC FEE
r above-mentimned property for inspection purposes. PERMIT ISSUANCE
(We)agree tosave,indemnify and keep harmless the City of Capetian.against ELECTRIC FEE
IiaM1ilitics,judgmemx,costs and expanses whichnoy m my way name against said City ALTER OR ADD TO MECH.
or asequence of the granting of this pro na. PLUMBING FEE
AT VT UNUBRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CF&D MECHANICALFEE
SOUR:E)EG LATIOP; t a /
P?— XX '(`_J AIR HANDLING UNIT(OVER Io,(Np CFM)
CONSTRUCTION TAX
-Rignato ApplicanVConuacmr Duro EXHAUST HOLD(W/DUC'T) HOUSING MITIGATION FEE
HAZARDOUS MATERIA 'DISCLOSURE
Wiilthe applicant or future building occupant store or handle hazallous material HEATING UNIT(TO 100.0110 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)] 1BEATING UNIT(OVER 100,000 BTU)
E]Yes FIN.
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use ov upmem or devices which Date Receipt 0
mit haunters air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100.00)BTU)
Woo? t❑Yes Fl No
BOILER-COMP(OVER IW.t100 BTU)
I have read the hmrNms wacrials sequiremmmts room Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE EFATE
a Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the
7reb
miNEW RESIDENTIAL MECH. SQ.FT.
uilding doe net currently have a tenant,that it is my responsibility to notify thdoicapunt
therequirements which must Ix met prior to issuance of a Certificate of Occupancy.
wner or authorized agent Data TOTAL ISSUED BY:
OFFICE