29562 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES•USE BALL POINT PEN ONLY 11. , 11i-_
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'I'NO. 29562
S 9/S ^ra
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L Vh L
BUILDING PROJECT IDENTIFICATION
BUILDIOO/ ORIiSS: " \ SANITARY NO. APPLICATION SUBMITTAL DAT[
OWNER'S NAME: • nom y5V1'HONE;Q\ iC�`/J COM'RACI'OH:S ME: LICNO:
a b `3 NIC CONTROL a
AR HITECT GINEER: LIC NO: pUDRESS:
L Go s A
PHONE: BUILDING PERMIT INFO
❑ Consultant Pat Paid by Applicant(Initial) BLD ELE PLUM MEC
(AC7ORS 40 DECLARATION
-301
LICENSED CONT'BACnderp DECons of CON QTY. ELECTRIC PERMIT FEE
I hereby affirm tont 1 not heensai ander pmwkmn,.r Chapter 9(commenting JOB DESCRIPTION
OOO th Secrion](XIB)nf Division 3.fthc Busincss anA Rnfe„ionsCWc,and my licenx is
F�� in full force and effnt PERMIT ISSUANCE
W� —,7,D—IW 0 KITCHEN REMODEL
<—U Livens Class Lica APPLIANCES—RESIDENTIAL •OA BION ❑PLUMBING RE-PIPE
lF Q 1 Date Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT 0STRUCTURAL
Z O�Z 1 understand my plim,laill M used us public recons PANELS MODIFICATION
OZ—C UYT'02W AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Pmmssional 201-I0IXIAMPS IMPROVEMENT
ds❑
OWNER-BUILDER DECLARATION OVER IIXp AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
�J 0 w d I hereby affirm that 1 ton exempt from Lha Contractor's License Low for the
�°(' a U following ream..(Station 7031.5.Business and Professions Cade:Any city of county SIGNS ELECTRICAL ❑OTHER
8136,h which requires a Permit to comWet.OR,improve,demolish,or repair any.structure
prior to its issuance,also reclaims the applicant for such permit to file o signed statement SPECIAL CIRCUTUMISC.
E6�} that he is licensed puauant to the provisions of the Convectors License Law(Chapter 9
h0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR PULE INST. COMMERCIAL'
6Mmat he is exempt dismount and me basis for me alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
W^N Section 7031.5by......licanlfor.Net mbjectstheopplicanl m a civil penalty of POWER DEVICES OTENANT OFOOD SERVICE.
TSGnot mom man fee hundred dollars(SSW).
01,as owner of the pmpery,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
(.. will do the oomk,aal mesauctureis not imm�dW antRerW for sale(Sce.7044.Business ❑OTHER
IQyr"m and Professions Code:'Ile,Contractor's Livens Law docs not apply man owner of OUTLE s—SWITCHES—FIXTURES
a 3 progeny who builds or improves themnn,and who does such work himself or through
his own employees,provided that,such improvements are not intended or offered for NEW RESIDENTIAL BLECTR SQ PT.
sale.IL however.One building or improvement is wild within one ycaof completion,the 1 SQ.FT.FLOOR AREA $/SQ.FT.'
ovaer-builder will have the burden of proving that he did not build or improve for the
Ift 1 S { 1 LyT1 , QQ O-
0 I,us pro,of owner of the progeny,am exclusively contracting with licensed conuaaurs 1. I q�2 TOTAL: AS
s 1 I O+Of
construct the project(Sec.7614.Business and Professions Cod, ,,.Contmmor's Ll- 1 3$S � 2 �+•ls
sense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE V
who contracts for such projects with a contractor(.)licensed pursuant to the Contraatra
License Lew PERMITISSUANCE
0 1 um exempt under Sec. .B&P C for this m.sm
ALTER—DRAIN&VENT—WATER BEA), VALUATION
Owner IJam
WORKERS COMPENSATION DECLARATION BACK FLOW m PROTECT'.DEVICE 1 2��
I hereby affirunder penalty of perjury one of the followi ng declarations: �J �r
n .
I have and will maintain a Certificmc ofCoownl to self-insuin for worker's Compete DRAINS—FLOOR.ROOF,AREA,CON . S'TORIFS 'TYPE CONSTRUCTION
sutiun,as provided for by Section TRX)of the Labor Code,for the performance of the /^1
work for which this permit is issued. PI%TUHE,S—I'ER'FRAP •`t ' 1,'
0 I have.,at will mnimmin Workers Compensation Instorm.,as inquired by Section
3700 of the Labor Code.for(be performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS / pCg¢ ,ROUPI� MIN
My Worker's Compensation lnsururcecamicrand Policy numberim: jb
Cartier. Policy Na: GAS—HA.SYSTEM-OVIiR 4(-A) 1V!, 1(T
CERTIFICATE,OP EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE.INTERCEPTOR /^- Is7
COMPENSATION INSURANCE q BUILDING DIVISION GOES
This sectlo.nccalma be completed ifthe pc man is femme hundred dollars(5100) GREASETRAP
or Icss.) I'LANCHECK FEE `k7CL LOG
I verify that in the performance ofthe work for which this permit is issued.[,hall SEWER—SANITARY—STORM EA.200 PT.
nareasplo,any penun in anynmme,,ci:a to beeomesubjecnn the Worker,Contpen- P.NERGY FVE zctlz
,Z anti..Laws of California.Dae WATER HEATER WNENT/ELECTR
z C) Applicant GRADING FEE
pJ NOTICE TO APPLICANT:IL after making this Certificate of Exemption,youshould WATER SYSTEhVfRFATING SOUS FEE
become subject to the Workers C pensaion provision,of the L.hor Code,you most
fodhwBb comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
a �
C(lN5'TRUCTION LENDING AGENCY NEW RF;SIDENTIAL PLMtl. SQ.IT. PAID
U I herebyalHrmtha rhetelsa construction lending agency for me poffomrance of Date Receipt#
U. 0 the.,,,it for which this permit is issued(Sec.31197.Civ,C)
0 Learn s Name TOTAL:
W Lender's Address - TOTAL: I
Ail-
I certify that I have reel oris application and state ma the alrove information is BUILDING THE
TZ) travel.I.grcem comply ,In all city and countyordl...ce.,:mload,laws Tclad.g to QTY. MECHANICAL PERMIT FFE
V Z building construction,and hereby authonic repm
rewarives of this city to enter upon me SEISM IC FEE 1
above-mentioned property for in,pcai.n purpose, PfiRMI f ISSUANCE ELECTRIC FEE \ 1
(We)agree to save,indemnify and keep hamdess the City of Cupertino against
Iishillties,judgmentx,costs anti expenses which may in anyway aceme against sold City ALTER OR ADD TO MECH.
in consequence of me grunting of this permit. PLUMBING FEEASAJ
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ILL l, POINT AIR HANDLING UNIT(TO 100)(()CFM)
SOU��LJyJNS. /��a.0�� MECHANICAL FEE 3s
-((--�^II / (,`�' AIR HANDLING UNIT(OVER Io,(pO CFM) CONSTRUCTION TAX
Signature of ApphcanV ontmcho Da EXHAUST HOOD(W/UUCP HOUSING MITIGATION FEE
H ,ZARUOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defrval by the Cupertin.Municipal Code,Chapter 9.12,and the Health and Safe,
Calc,Section 25532Bd? HEATING UNIT(OVER 100dM0 BTU)
Yes 0 No
VENTILATION PAN SINGLE RPSID) PAID
Will the applicant or lumre building t use e t or devices which Dam Receipt a
pp dbvthevn Area
n BOILER—COMP OHP OR IW,(MA BTU)
emit hazallous air cnnmminwts as def nW by the Ray Arta Air Quality Management
1Y)Tph:
District! BOILER—COMP(OVER 100.000 BTU)
0 Ye, ❑N.
I have real me hdeardous materials regelmorna under Chapter 6.95.1 the Cull- AIR CONDITIONER ISSUANCE DATE,
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understood that ditto NEW RESIDENTIAL MF,CH. SQ.PT.
building doe,not currently have a mnanl,mm it i,my m,Ixmathd ty m notify me decup:mt
of the inquimmmnts which must be met prior m irm nce of.Cealistae of Occupancy.
Owner or authorized agent Dae 'f01'AL: ISSUED BY:
OFFICE
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