29483APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CINITY OF CGUPERTINO BUILDING - ELECTRICAL
BUILDDIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDEM
PHRMH NO.
A O �i
29483 4 o JrIFICATION G
BUILDING ADDRESS:
SANITARY NO. -
APPLICATION SUBMITTAL. DA'I'12.
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OWNFB NAME. PHONE:
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CONTRACTOR'S NAME
IC : /{"M rLIC NO:
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CONTROLM753
RCHITEC /ENGINEER: LIC NO:
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ADDRESS:
w.S/WP-,lca.l talk, d<lrP d-AI44:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial)
BLDG ELECT PLUMB MIiC
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LICENSED CONTRACTOR S DECLARATION
I hereby affirm thin I um license unJar previsions of Chapter 9 (o carton
wiN Stttion]OOU)of DivisionlM,he Buin<s send Professions Code, and my license is
in full fare
f-Zo • (/�DY(-(off
License Lm.n
Contra
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑KITCHEN REMODEL
[]ADDITION (3 PLUMBING RE-PIPEaM
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEIIREPAIR ❑DEMOLITION
El OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCH("TFCTS DECLARATION
T understand my plana shall be used as public records
PANELS
UPTO 200 AMPS
Licensed Pori ... I
OWNER -BUILDER DECLARATION
I hereby affirm ilia, I'am exempt from the Contractor's License Law for the
fallowing remain. (Stt,inn ]1131.5, Business and Professions Cak: Any city or county
which requires a permit le mnnmm, alter, improve. Demolish, or repair any shucwm
prior to its issuance, also requires the applicant for such permit to file a signed smmmem
20l-1000AMPS
OVER I(MM)AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
f �Ny
�QO
C. a cry
SSnot
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F
L'3 m
that he is licensed pursuant to the provisions of the Continuities License Law (Chapter 9
(commencing with Section 700))of Di vision 3 of the Business and Professions Cole) or
Lha, he is exempt therefrom and the basis nor the allege exemption. Any violation of
Section ](131.5 by any spineumfor apcordisubject, theippliamuo a civil penalty of
more than five hundred iki (5500).
❑Lis ownecof Ne mmmeny, or my employees wiN wages as their sole cnnamens:vii,,
will do he work,ee the,commrc is nit intended mattered for to Sm. 70a4. Busineex
and Professions Crwc: The Contractor License Law dons not apply ,o as owner of
property who hands or improves thereon, and who docs such work himself or through
his own employees, provided tom such improvements are no, intended a, offered for
sale lLhawever. the building orimprovement is sold within one Yeu. of Co...... gthe
TEMP. METER OR POLE INST
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑FOODSERVICE
IMPROVEMENT
[I OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FI ES
NEW RESIDENTIAL ELF
SQ. FT. MOOR AREA
S/SQ. FT.
l
ow mer -builder will have the burden of proving that he did not build or improve for pur-
pose of owner
❑ Las owner of the pmpery, ant
and contractingfesswcxdcth licensed)TheCuommoors m
.� �I nes
'ear
Business s U.
o thermmamd
mum La the project (Seca ]Bio Resines ane ray s ho bei Cider) The elm hereon, and
mum tons whobulldsrmann
es
IWAR
QI'Y. PLUMBING PERM( FEE
a cdpmpcny
for%whplro
tothe
seweimmna errsacn mrojeru witnarimmaarra>Reem,ed pirsaam mane cimtme,ir,
with
1
IYI/'1R y 1996
PERMIT ISSUANCE
Urease law.
❑ I um exempt under See. ,B&P C for this mown
ACIER- DRAIN &VIiNT-WATER (EA)
Owner Date
-' sa'VALUATIQNu
WORKERS COMPENSATION DECLARATION
BACK FLOW PRO TEC.. DEVICE
I hereby atiir under penalty of perjury one of me following declarations:
STORIES
TYPE CONSTRUCT ION
El I have and will maintain aCenificamof Consemuoself-imure fir Workers Compen-
-,am, as provide for by Section 3700 of the Labor Calc for the performance if the
work far which this menu is issued
DRAINS -FLOOR. ROOR AREA, COND.
FI%TURES - PER TRAP
❑ I have and will maintain Worker's Compema,ien Insurance, as require by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
OCC. GROUP
APN
GAS - EA. SYSTEM.] INCA OUTLETS
GAS - EA. SYSTEM -OVER 4(EA)
My Worker' S,Compen.a tion Insurance currier and Policy numpg� �S,�
Carrier. `T ,ATF Policy Nu: fGY57DB3-
GREASP/INDUSTRL WASTE INTERCEPTOR
CFRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
('This wiction turnout be complc¢d If Thr Permit is for one hundred dollars (SIM)
or loss.)GRIiASE
TRAP
PLANCHECK IFF.
SEWER -SANITARY -STORM EA. 200 FF.
ENERGY FEE
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1—'
0
7zCONSI'RUCTIONLENDINGAGENCY
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I minty that in the performance runic work for which this peril is issued, l shall
not employ any person in tiny manner so as to become subject to the Workeri Compen-
safirm laws of Celifomin. Dim
Applicant
WATER HEATER WNENT/ELECI'R
GRADING FCE
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become wbjeouo the Worker's Commensntion previsions if the Labor Corte, you must
forthwith comply with such provisions or this peri,shall he deemed revoked.
(hereby affix construction is a consction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
WATER SYSTEMUNLAT ING
SOILS FEE
WATER SERVICE
PAID
Dem Reoeamtp
NEW RESIDENTIAL PLMB. SQ. FT
TOTAL.
TOTAL:
U
Lender', Name .(",4 s
Q.
.F -a pi
UZ
Lenders Address
BUILDING FEE
I cendy that I have read this application and state that [be above nomination is
correct. l agree to comply with all city and county announces and state laws relining In
building construction, and hereby amhodie represenmtives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
aN ve mentioned primary for inspection purposes.
(We) agrte m save, itch m tidy and keep harmless me City of CuMnino agaimi
PLUMBING FEE
hattilities,judgments, costs and expenses which may many way wemengairidand City
in mnICthe grantingof this peri,.
ALTER OR ADD TO MECH.
AIR ❑ANULING UNIT rTO I0.000 CFM(
MECHANICAL FEE
APPLICANTANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S(IIIRCE REGULA'f10N5. / 9
3-2l•/G
AIR HANDLING UNIT (OVER 10,(X1l1CFM)
CONSTRUCTIONTAX
Signature of Applicant/Confracrnr Date
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION PER
I IAZARDOUS MAI 'ERIN S DISCLOSURE
HEATING UNIT (TO 100.000 BTU)
Win the applicantinmurre building em.,camsmmor handle huanom ricamil
as define by the Cupertino Municipal Coec. Chapter 9.12, and the health and Site,
Code Section 255321,)^HEATING
UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RISID)
❑yes No
PAID
Ua¢ Receipt
/
Will the applicant or future building acupam ux equipmcm or Jevitts which
mit haeatdous air conuminants as delinW by the Buy Area Ah Quality Manugement
BOILER - COMP (IHPOR IW.O(p RTU)
AI.
BOILER -COMP (OVER ((0,1](0 BTU)
District'
E] Yes 0<o
AIR CONDITIONER LA
unr Chapter 6.95 of me Cali-
I have mad Ne hazardous materials mquimmen¢de
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT
futons Health &Safety Csxle, $tt,iim 25505. 25533 and 25534. 1 understand that if 0c
building dons na curcnlly have a tenant (nut it is my no pomaibiloy ti notify the accupan,
of en n v�iicn meal I poor m i„uance ora cenificmr a"Ce try.
Ictu-
3 -�I y
TDTAL:
ISSUED BY:
Owner or:mthnrizeJ agent Dan
authorized
OFFICE