29438` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • Use BALL PnIMT PFM nMl v
CITY OF UUPERTINO
BUILDING - ELECTRICAL
- PERMIT NO.
°BUILDING DIVISION APPLICATIONTERMIT
PLUMBING -MECHANICAL'
4J
29438 VX
BUILDING PROJECT IDENTIFICATION
-
B ILDINGADDRESS -
CCnK LK��qq6
-
r
SANITARY NO.
APPLICATION SUBMITTAL DATE
.
NER' . PHONE:'
_
CONTRA AME:,� LIC NO:
e. IF•/t`rf�/
,
TC,
❑
CONTROLN
'
RCHITECT/ENGINEER: LIC NO: I ADDRESS:
,}
-CONTACT. - r - PHONE:
BUILDING PERMIT INFO
❑ COntmiltaint Fuel; Paid by Applicant
BLDG ELECT PLUMB, MECH
(Initial)
t
X. ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
QTY ELECTRIC PERMIT
FEE
$ DESCRIPTION'
affirm that 1 am licensed under provisions of Chapter 9 (commweing
with Section 7") of Division 3 of the Businees and Professions Cole, and my license is
in full forcand effect.
PERMIT ISSUANCEe
RESIDENTIALSOJO
License Class Lich
-
❑SFDWL [I KITCHEN REMODEL
7 Date - Contractor t
APPLIANCES -RESIDENTIAL -
EI ADDITION ❑PLUMBING RE -PIPE
•MULTI -UNIT ❑STRUCTURAL
r ARCHITECTS DECLARATION '. PANELS
1 understand my plans shall he used as public records
.•5 o
"' MODIFICATION
UPT0200 AMPS
"DINTERIOR ❑CHIMNEYREPAIR
Lmenscd Professional � -
OWNER BUILDERm Ce
201-1000AMP5
-
IMPROVEMENT
1 hereby affirm that 1 am exempt from the Conuwtors License Law for the,
Contra,
OVER 1000AMPS
❑ BATH REMODEL/REPAIR ❑DEMOLITION"
following reason (Section 1011,1, Business and Professions Code. Any city or county
SIGNS ELECTRICAL
OTHER
which requires a permit to construct, alter, improve, demolish, or repair any structure
W
prior to its issuance, also requires theupplicant for such permit o file a signed statement—WacoSPECIAL
CIRCUIT/MISC.
; `
that he is licensed pureuanuo the provisions of the Contractor's License Law (Chapter 9
COMMERCIAL
(commencing with Section 7000) of Division 3 of the Business and Pmfesshms Cold)or TEMP. METER OR POLE INS
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
-
❑NEW BLDG/ADDff10N� El DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
POWER DEVICES -
_
not more than five hundred dollars ($500),
[-)TENANT ❑ FOOD SERVICE
01, as owner oRhe properly, or my employeeswith wages as theirsnle compensation.
SWIMMING POOL ELECTRIC
IMPROVEMENT -
i will do the work, and the structure is not intended oroffwed for sale (Sec. 7044, Business
❑OTHER
i and Professions Code: The Contractor's License Law does not apply to"an owner of
OUTLETS-SWITCHES-FI%TURES
property th
y who builds or improves thereon, and who does such work himself or rough
e.
his own employees, provided that such itnptiv arwral ere oat imendeA or offered per NEW RESIDENTIAL ELECTR
sale, If,however, the building or improvement is sold within one year or completion,me
SQ. FT FLOOR AREA
$/SQ. Ff.
ow,ner-builder will have the burden of proving that he did not build or improve for pur.
-
T
:wne T
of the property, am exclusively communing with licensed wntramors m
TOTAL:the
i"`owner �
ProjectISec.7044, Business and Professions Code:) no Contractor's Lf.
F
w does not apply to in owner of property who builds or improves thereon, and
QTY,PLUMBINGPERMIT
FEEracts
for such projects with a eonnaemr(s) licensed pursuant to the Contractors
License Law.
l� ��
PERMITISSUANCE
�/
❑ Ium exam rSec. PC for this reason
Vh
y
-
ALTER -DRAIN& VENT- WATER (EA)
('V% -'e..".
•#
- VALUATION'//I'V -
woe ate
ER'SCOMPENSq DF AGON
BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of pe' a fallowing deulamtions:
7 haveanA will maintain a Certificate of Consent to self -insure mrWorker's Co.,.-
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
sation, az provided for by Section 37(X1 of the Labor Code, for the performance of the
work for which this permit is issued
FIXTURES'- PER TRAP
1 have and will maintain Worker's Compensation Insurance, as requiied by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
GAS - EA. SYSTEM -I INC. 4 OUTLETS
My Workers Compensation Ina cu
mrard currier and
nd Policy number me:
OCC, .
,
APN
Cmdee Policy No.:
GAS - EA, SYSTEM -OVER 4 HDO
CERTIFICATE OF EXEMPTION FROM WORKERS'
11 1-
COMPENSATION INSURANCE -
GRF.ASE/1NDUSTRL WASTE. INTERCEPTOR
BUILDING DIVISION FEES
_ -
(Thixseerionneed not hewmplemdiRhe permit ie for onehundreddollars ($100) -
orlee)
GREASETRAP-
Ice -1171
Nytinthepf o ekin which this isissued' Ishall
PLANCHECK FEE
np
not employ y person in y ui as t become suthe Wbject to the Workers Cumpen-
t
r SEWER SANITARY
ENERGY FEE
anion Laws of California. Date
*^WATER HEATER WNENT/ELECTR
GRADING FEE. -
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
WATER SYSTEM/TREATING
SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with 15th provisions or this permitshall be deemed revoked.
,�•, WATER SERVICE
' CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMB.' SQ. FT.
j„
PAID
Ihereby affirm that, there is a construction lending agency fonheperformance of
Date Raeipt# -
the work far which this permit is issued (Sec. 31)9], Civ, CJ
TOTAL:
Lenders Name
Lender's Address - TOTAL:
and state that the above information is
I certify that 1 have read thirty
BUILDING FEE
and
correct, I agree m comply with all city and county ordinances and state lows relining toa
QTY, MECHANICAL PERMIT
FEE
-
herebyauthorizereoses. Lives of this city to corer upon the
SEISMIC FEE
-
abovengennswctiun,and
for es.
above-Osse)
ELECTRIC PEE
to savecoty an keep
(Wo) agree to save, indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE
agree
liabilities,judgmems, costs and expenses which may in any way acerae against said City
PLUMBING FEE '
ALTER OR ADD TO MECH
in con.sequence of the granting of this permit..
APPLICANT UNDERSTANDS AND WILL COMPLY WITHALLNON-POINT
AIR HANDLING UNIT (TO 10,W0CFM)
SOURCE REGULATIONS.
MECHANICAL FM
'
.. AIR HANDLING UNIT(OVER 10,000 CPM)
CONSTRUCTIONTAX
Stgnamre of ApplicandContr..I.,, Data
EXHAUST HOOD(W/DUCT)' -
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEB
Will Ne applicant or future building occupanfstiie or handle hazardous material
HEATING UNIT (TO 100,00(1 BTU)
-
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 8532(a)1
HEATING UNIT (OVER IOff" BTU)
- -
'E]Yes .. 'tNo
VENTILATION FAN (SINGLE RESID)
PAID
• Will me applicant or future building occupant use equipment in devices which
Date Receipt#
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
BOILER -COMP CHIP OR 1011,(100 BTU) '
District? ' , • -TOTAL:
[3 Yes No -
"I BOILER-COMP(OVER, 100,00011TO,
-
n p
1 have read the hazardous mmcnals r is under Chapter 6.95 of the Cali-
e,
AIR CONDITIONER r
ISSUANCE DATE
Rumba Health &Safety Code, Sections 8505, and 25574. I undersfund that if the
2525533 533
building does not currently have a tenant, that it is my responsibility to notify the occupant
NEW RESIDENTIAL MECH. SQA. FT.
,
of the requirements which mus[be mm prior to issuance nfa Cerlifcate of Occupancy.
'
ISSUED BY:
Owner or euthnnzed agent, ' Data TOTAL:
OFFICE