29927 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING I LECTRICAL PE UAITNO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 29927
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRHSS: 11 SANITARY NO. APPLICATION SUBMITTAL DATE
OW R'SN MC:a e `PHUN CON' NAhfE inot) �, LIC NO:
NIC CONTROL N
CHITEC'UEN EOR: Also/, L'c O: I^ M X90: ,1_o �D.NE SS. CtSl3b � g0
CONTACT: a.A PHONE: V J,yyl" , BUILDING PERMIT INFO
Consultant Fels Paid By Applicant(Initial) _ �.IQ BLRO E_ LFjT pLug1B MCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE`
I hereby affirm that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
E��GCz with Seatinn]00(O of Divi'on3 of the Business andP fesnions Code,avdaalicensees
O Y. PERMIT ISSUANCE RESIDENTIAL:
in full force and effort. n
�U�[[[1 License h �� Lie is � ��Z ❑SFDWL ❑PLUMBIKITCHENREMODCI.
y�a De,a Cuntmdor APPLIANCES-RESIDENTIAL ❑ADDITION 11 PLUMBING RIYPIPF,
FOoe ARCHITECTS DECLA TION PANELS ❑MULTI-UNIT ❑STRUCTURAL
.Z.Z j2z- 1 understand my plans shall be used as public records MODIFICATION
UPT02MAMP5 ❑INTERIOR [I CHIMNEY REPAIR
F N., Licensed Prrfessinnal 201.1"AMPS IMPROVEMENT
'�hl]
OWNER-BUILDER
non the RATION OVER 1000AMPS C BATH REMODEUREPAIR [I D17MOLITION
CCGG I hereby affirm that 1 1. uxmnpl I ad I' C,owme o e:An,city o far the
LLO FUF following rums,..(Section 7031.3.Business ad s,de t.li Crede:Any city or manly SIGNS ELECTRICAL []OTHER
C ya which requires u permit re coma the alter improvu,demolish,or repair any awmere
n.] prior to issmntt,also rtquirts the applicant for such permiuo filcasignW statement SPECIAL CIRCUIT/MISC,
y thatmencccmed purction1 )previsions 3 Ne Contracmrand Pruelsw(C Coda)
i 0 (commencing with Section TOf10)of Division3 of the Business end Patfessiov Cale)or TEMP,METER OR POLE INIT. COMMERCIAL:
a c z that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C DEMOLITION
"^ Smtion]B3 LS by any applicant fora pemtit suhjecm the applicant l,ecivil penally of PUWE ❑ ❑F
DEVICES _
res TENANT OODSERVICE
yactmam than live hundred deltars($5M).
Q C 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
_O will do the work,and thesuucmm is not intended or offered for sale(Sec.]0i4.Business []OTHER
v t Professions Code:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If,hmooar,the building orimprovement is sold within one yearofcompletion,the - SQ.PT.FLOOR AREA, VSQ.FT.
rivner-builder will have the burden of proving shat he did not build or improve for par- , g 91,�
Pose of sale.). - D
C 1,as owner of the fertility,am exclusively contracting with licenced contractors to T
construct the project(Sm.7041,Business and Professions Code:)The Contractors Li. `r
cense Law does not apply to an owner of prepeny who builds w roJC
improves thet
n,and QTY, PLUMBING PERMIT FEE
who contracts f,rsuch patterns with o connections)licensed pursuant to the Contractor's _
License Law. IPERMIT ISSUANCE. -
❑ I am exempt under.Sec. B&P C for this reason
Owner Data ALTER-DRAIN&VENT-WA VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DBVI I `� Y �^s
I herebyaffirm under penalty of peduuone of the following declarations: ' b7 LP
•C I have and will maintain a Cenilicom ofC,nsevt to self-insure for Workers Competr DRAINS-FLOOR,ROOF,AREA,COND.
sation,m provided for by Section 3700 of the Labor Ctrl,for the performance of the STORIES TYPE CONSTRUCTION
w kfor which this permit is issued FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Immau 1,as rational]by
Satin.
i00ofthe Latam Code.far the performance,fine work far which this Permit is issucJ. GAS-EA.SYSTEM-I INC. OUTLETS OCO GROUP, APN '
.My Workers Compensation Insurance camerand Policy numberam: r ,
Cartier. Policy Nr.: GAS-EA.SYSTEM-OVER 4 HA)
By — FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR
(This section need nm be completed ifthepennit is foione hundred dollars($10() BUILDING DNISION PEE$
or less) GREASETRAP
°I certify that in the peformanceol the workforwhich this permit is issued l shall - PLANCHECK FEE
not employ tiny petro.in an manner an es m become sub'ml m the Workers'Com em SEWER-SANITARY-STORM EA.200 FT.
Y 1 P ENERGY FEE
0Zsationlawsof Califomia.Date WATER HEATER WNERT/ELECTR '
Z Applicant, GRADING FEE
ry NOTICE TO APPLICANT.IL after making this Ccnificam of Exemption,you shouldWATER SYSTEM/1'RFATING -
-a became subject to the Worker's Compensation previsions of the labor Code,you mum SOILS FEE
W f,Mwith comply with such provisiom'or this pemotsiml be deemed revoked. WATER SERVICE
Q -
CONSTRUCTIONLENDINGAGENCY NEW RESIDENTIAL PLMIL SQ.FI. PAID
U O I herehyaRrm that there is.cunawNrn lemb., gency for the perfmmma'd - Om RealiltIt
us F-1 the work for which this return is issued Iger.319],Co.C.)
p F" Lenders Name 1 TOTAL:
LU11 Lenders Address i
p, 1 certify that I have mad this application and state that the above information is BUILD[ HE ss�s
N comet.l agree to comply wird all tiny and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U� building cmidOmlon,and hereby..then.representatives of this city to enter upon the SEISMIC FN
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and kap hmmless the City of Cupenino against PERMIT ISSUANCE ELECTRIC
in conkcquence
liabilitiesuemm�entscmnandexpcnuswbich mayinany way accme egaissst said Ciry of the gmntingof this phrmil. ALTERORADDTOMECL PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL C LTH, LL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEF.
1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicarmiContreclm Dat ' 3 EXHAUST HOOD(W/DUCD HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building,ccu not snore or handle hmallous ramcm l I[EATING UNIT(TO 100,000 BTU)
as dalmod by the Caperton Municipal Code,Chapter 9.12.and the Health and Safety
Cock,Section 27532on? GRATING UNIT(OVER IW,0(10 BTU)
❑Yess " VENTHA'1'ION FAN(SINGLE RF.SID) PAID
1'` Date 1 Receipt#
(
Will the mit com est or furore building occupant vu equipment or devices which BOILER-COMP(3HPOR 100,010 BTU) -
Dun'hazardrus air contaminan¢m defined by the Bey Amu Air Quality Management TOTAL:
DteWnE BOILER-COMP(OVER 100,000BTU)
El Yes ,
I have mod thc hazardous numrmis requirements under Ch.pter 6.95 of the Cull AIR CONDITIONER - ISSUANC DATE
frond.Health&Safety Cade,Sections 23505,25533 and 25534.1 understand that if the NEW HIiSIDENTTAL MCC({, SQ.PI'. -
buildingdoesnel ureal] ealenu yth.lit's my rcspmsibility to notify the occupant
of to mgaitements w t at p' II usuwce of socIOcme f Ocev
Data c.
Owneroreuthrr a _ ISSUED By.
OFFICE