29062 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMONO, 29062
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S ME: HONE: CONTRACOR'SNAML: I LIC NO: NIC CONI'NOI.a
r cr Db�riv :ric �s3�6 391 f �mvslT—uaroa� ❑
\NCI11'1 tCp/ENGINEER: LIC KO. ADDRESS:
M7 Gt5 S 1 5 'rWJAJ G10
L * TF ymmm
CONTACT, PHONE: - BUILDING PERMIT INFO
r tcTl� Mr/� C+&p) m -:2j))
: ff) ❑ Consultant Fees Paid by Applicant(initial) �>p. LE r PIA 11 MECH
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PI7RMIT FF 'j--(' `
1 hereby affirm that I oro licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
0�Z th Section7M)of Divisimn3ofthe Businea:o d n easW my license is RESIDENTIAL:
IaOO wt en PERMIT ISSUANCE
full(area soil effeuL ❑SFDWL ❑KITCHEN REMODEL
s F- to YY
aUV L¢cnmtl6g_�Ls"a APPLIANCES-RESIDENTIAL ❑ADDITION [1 PLUMBING RE-PIPE
ti Q L Uatc Contractor
ARCHITECTS DECLARATON ❑MULTI-UNIT E3 STRUCTURAL
z 077, I understand my plans shall he used vs public¢cords c/ PANELS MODIFICATION
/
f�
Oz`y'-a0 - UPT0200 AMPS 2 a ❑INTERIOR 1-1CHIMNEYREPAIR
UN Licensed Ponessimat 201-HgNtAMPS IMPROVEMENT
�42� OWNER-BUILDER DECLARATION OVER IIXIUAMPS ED BATH kEMOUEUREPAIR [3 DEMOLITION
I hereby affirm that I am exempt front The Commenr's License Law for the
XK :a. following reuaon.(Section 7031,5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL EI OTHER
which acquires a Permit to conswct,.]'a,improve,demolish.oimporter,sWctme a
F,�.0 prior to its issuance,also requires the applicant fur such permit to file a signed outerwear SPECIAL CIRCUFUNIISC.
f ot7
that he is licensed pursuant to the provisiotnof the Contractor's License Law(Chapter 9
W 00 (commencing with Section 7")of Dirision 3 of the Business bad Professions Cale)or TEMP.METER OR POLE INST. COMMERCIAL:
d L c hat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑PEMOLITION
ern
Section 7031.5 by any applicant for a Pewit subjects the applicant to a civil Penalty of POWER DEVICESTENANT ❑FOOD SERVICE
m more Wan five hundred dollars(5500).
F z Y IMPROVEMENT
f � ❑ Laa owner of the property,or my employees with wagesm their sole compensation, SWIMMING POOL ELECTRIC
will do(be work,and thesure is not intended oroRcred for depice 70,W Business ❑OTHER
wn
�•3m and Pmtcssiuns Gale:The Contractor's License Uv,dues not apply to en owner of 1UTLIi I'S-SWITC .-FIXTURIiS
property who builds or improves thereon,and who does such work himself nr Waugh
his own a Ianyces,provided thin such impmvroorm,ore not intended or nlYv¢J for NEW RESIDE)II'1'R SQ Fn
ole,It,however the building or improvement it add within ane Year ofmmplelinn.tha SQ.FT.FLOOR AREA S/SQ.ET.
owner-builder will have he burden of proving that he did not build or improve for Pao
a sa
of ma.).
OI,as owner of Ne property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.704T Business and Professions Cade:)The Conameri r.x Li- 60 00,an
cane Law does not apply m an owner of pmpeny who builds or improves hemon,and QTY. PLIJ ER IT FEE �4f�,.�,
who contracts for such project with a comramitO licensed pursuant to the Commemh
Limine Law. PERMIT ISSUANCE 199
C]1 an exempt under Sec. .B&P C for this reamn ,
ALTER-DRAIN& -WA 1 A) vf- LUI' VALUATION
Owner Dam C /W J C9 U
WORKER'S COMPI par,,on DECLARATION PACK FLOW P OTE T.D1iVICli b
1 heathy uftion under penalty al perjury one nl'the I'ollnwing Jwlaatium".
I hove enA will maimoin uCorifieum ol'Cnmcnnu mlf-insure for Worker's Cnmpcn- DRAINS-FLO .RO( BA,COND. STORIES 'IYPECONSTRUCfION
Nation,as provided for by Section 3700 of"the Labor Code,for the performance nl the
work far which his permit is issucd. FIXTURES-PCR TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the Performance of the work for which Lots permit is issued. GAS-FA.SYSTEM-II O T 5 OCC.GROUP APN
My Workers Compensation Insurance corner and Policy number me:
Carrier. Policy Nn: GAS-EA.SYSTEMOVER J 1
CERTIFICATE OF EXEMPTION MOM WORKERS' GRF.ASMNDUSTRL WASTE INfERCE R
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thnsectioa naednol be completed iffle pewit is finesse hundred dalsrs($100) OR CASE TRAP
i or less) PLANCHF.CK FEE
I cenify that in We perfonnoncenfthc work for which his permit isi.cmcJ.l shall SEWER-SANITARY-STORM F.A.300 FT.
am employ any person in any manner so as to Fee nnte subject m he Worker,'Cnmpcn- ENERGY FEE r- O
Oz Notion LtwenfCullforom Dam WATERHEATERW/ViiIsGUELECTR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:If,after making this Cenilicum 01 Exemption,you should WATER SYSTEM/TREAt ING
F '�^ hecomesuhject to the Workers Compensation provisions of the labor Cute.you must SOILS FEE
Ly+ forthwith comply with such Provisions or this permit shall be deemed revoked WATER SERVICE
y Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ.FT. PAID /2-I5-'/Y
U O I hereby.(firm that there is a caesura; coding agency(oohs Performance of /� Data Rcceipta ��3/.�V
D. f' the work for which this permit is mood(Sec.3097,Civ.C.) C
U Leaders No. dilTOTAL:
I<nJer'I AJJreaa {J
} W� BUILDING FEE Lt
1 cenify t a 1 read this application and sac¢shut the strove infowaion i.
F h amcm,l agree comp s wiW all city and county ordinances and sate laws relating m QTY. MECHANICAL PERMIT FEE -3.00
U z huilaing agree ran.an arc ad aathmiie repormatovesof this city to enterapttn the SEISMIC FEC
an aa
ptopeny t inspection purpmcs, PENMITISSUANCF
(Weft eemsavAenvtily and keep herinlvsx We City of Cupcdino ugaino 1 ELECTRIC FEE
liahilhia,ju g mots,wnl a exp-1awSvhich may In anyway accmeagainat said City ALTER OR AUU TO MECH.
PLUMBING FEE
Attu
nscque - afore an my dthispcnnil.
APP1. A 1' IND F ST VISAyD WILL COMPLY WITH LL NO POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL PEE
SOLY 4.G)LAI YS
' 91 AIR HANDLING UNIT(OVER 10,000C FIND CONSTRUCTION TAX
goamm pplicent(Conuas 4J to EXHAUST HOOD(W/DUC ) HOUSING MITIGATION FEE
HAZARDOUS MAI'RIALS DISCLOSU E
W theapplicamorfumrebuilding re, pantsmreorhe dlehicadousmaterial HEATING UNIT 00100.000 BTU)
a e6n by the Cupcnino Municipal Coale,Chapter 9.12,and the Hulth and Safny
Code,Section 255321a)? HEATING UNIT(OVER 100.0110 BTU)
YcsEl No
VENTILATION PAN(SINGLE RESID) PAID
Will We applicant or future buildin•occupant use equipment or device'which Date Receipt M
PP 6 Atm ywpr Qua
u
� BOILER-COMP(3HP OR IIh1.tIfN1 HTU)
m hmmdnw or,cmntaminame to Jetinal by Ibv tray Arca Air Quulhy Management TOTAL
Oisricfl es Fl BOILER-COMP(OVER IMOM BTU)
❑Y
I have read the hemsdaus mamrials acquimants under Chapter 6.95 of the Cali.. AIR CONDITIONER ISSUANCE DATE
toms Health&Safety Code.Sections 25505,8533 and 25534.1 undersand drat if the NEW RESIDENTIAL MECH. SQ.ET.
building Joex nm currently have a¢moot that it Ia my responsibility to tmtify the occupant
of he recommends which must be met prior to h uunce of a Cenificam of Occupancy.
Owner ur au0motsad agent Data TOTAL: ISSUED BY:
OFFICE
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