29648 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'FNO. /� (�� /1
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L J 4 a
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
Coo MwT1FRL',I C-i
ON R'S NAME: PHONE: C RACTOR:SNAME: LIC NO:
IONA �N%Ct F�,-nopi N." r g N/C CONTROL#
RCHITLCT/ENGINF.P.R:I LIC NO: ADDNI?S5: C
�
/
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hneby affirm that 1 am licensed s under Iuxvisimof Chapter 9(commencing JOB DESCRIPTION
G a'2 with Secti.m70pp).f Division 3uf the Business end PmfevionaCode,and my liccmeis
RESIDENTIAL-0PERMIT ISSUANCE
in full force and eff _
.tUV License Cl Lic.N1511317"1160SFDWL O KITCHEN REMODEL
I-�w Dam4 Convector s APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBING RE-PIPE
,:D on ARCHITECTS DECLARATION
d
❑MULTI-UN ❑STRUCTURAL
ZOyZ s lunemmndmYPIns shot[be usedas Publitreams PANIi1S
MODIFICATION
O Z r UI'7O 2110 AMPS
W Licensed Professional ❑INTERIOR 11 CHIMNEY REPAIR
�d •i OWNER-BUILDER DECLARATION 20I'100TIIAMPS IMPROVEMENT
yfK Q I hereby affirm the,I ren exempt from the Chanceries License Lew for the OVER[000 AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
x 3 6 U following reason.(Section 7031.5,Business and Professions Code:Any city or county OOTHER
which requires a pectin to construct,alma improve,demolish,or repair any ewaum
Y1 LL SIGNS ELECTRICAL
priortoiniss...m,olso requires theapplicaut for such Permit o file.signed smtemrnt SPECIAL CIRCUIT/MISC.
vvWW11"y that he is licensed pursuant to the provisi.m mthe Conitacmes License Law(Chapter 9
COQ (commencing om
mmcing with Secti70knof Division 3 ofthe Business and Professions Cale)or TEMP.MILER OR POLE INST. COMMERCIAL:
a c y Nv he is exempt therefrom and the basis for be alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
..,[L Section 7031.5 by any applicant fora permit mbjecu the applicant to a civil Penalty of POWER DEVICES
L,Z} not more than five hundred IMPROVEMENT
dollars(55010. D [I FOOD SERVICE
^� C O Las owncrof property,or my employwith wages as their sale compensation, SWIMMING POOL ELECTRIC NIPROV
y. o will M The work,erW the stricture is not intended oroffered for sale(Sm.7014.Business OOTHm
Wand Professions Code:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a 3.. property who builds or improves thereon,and who does such work himself or through
his own emplhyma,provided Nan such improvements am not intended or offered for NEW RESIDENTIAL ELECI'R
sale.If.however,the building or improvement is sold within one yearafcompletion,the SQ.FT.FLOOR AREA $/SQ.Fr
owner-builder will have the burden of proving that he did not build or improve for put
pose of rile.).
0 1,as owner of the property,am exclusively contracting win licensed contractors to TOTAL:
construct The Project(Sec.7044,Business oil Professions Cale:)The Contractor's Li.
m.m law doesamapply man ownerofpmperty who builds.,improves thereon,end QTY. PLUMBING PERMIT
who contracts for such projects with o contracmr(s)licensed pursuant o the Commoner Q
License Law. PERMIT ISSUANCE WAY (y
❑ l eta exempt under Sec. ,B&P C for this reason 2
Owner Data ALTER-DRAIN&VENT-WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE a�!/ Uf- UUf-�f(I)jy
1 hereby affirm under penalty of perjury one of the following declarations: U
I have and will maintain a Certificate of Consent to self-insum for Worker's Compcm DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the pertommum of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workees Compensation Insurance,us required by Section
37M ofthe Inbar Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.)INC.4 OUTLETS DCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number art:
Came' P.l icy No, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BURRING DIVISION PEES
(This section nod not be completed Ifthe pemtit Is for one hundred dollars IS 100)or lase.) GREASE TRAP
PLANCHECK FEE
Icenify oat in the perf.nnance of rte work lire which This permit is iss'C.... h. SEWER-SANITARY-STORM EA.2i0 FT.
care arson in any manner sec ue m banana auhjem no the Wnrkcrn'Cnntpem ENERGY FEE
O s
PPI I f t i .'1,)ate WAl Ell BEAT BE W/VENT/ELECfR GRADING FEE
NOTICE TO APPLICANT If,aper making this Cenifcam of Exemption,you shnuN WATER SYSI UNIITREATING
become subject 1.the Worker's Compensation Provisions of the Labor Code.you omen SOILS FEF.
fonhwin comply with such provisions or this permitshall M deemed revoked. WATER SERVICE
�O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby affirm that here is a construction lending agency for the pmlarrounce of Date Receipt IT
D4Hthe work for which this permit is i...ad(See 3097,Co.C.)
c U lenders Name TOTAL:
Lender',AddressT
[J Rs 1 certify that 1 have read this application and state thin the above information is BUILDING FEE
V71 correct,1agree to comply with all city and county miduances and slide law,relating to QTY, MECHANICALPERMIT FEE
UG1 building conswctom.and herebyauthorm reprcummivc.ofihis city in enteroponthe SEISMIC FEE
above-mentioned propeny for inspection purposes. PP.RMIT ISSUANCE
(We)agree m save,indemnify and keep homeless the City of Cupertio nagainst ELECTRIC FEE
liabilities,judgments,costs end,.pT.scs which may inuny way memeaguimt said City ALTER OR ADD TO MECH.in consequence of the graining of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AUR HANDLING UNIT(TO I0.0g)CFTH
SOT MECHANICAL MECHANICAL FEE
AIR HANDLING UNIT(OVER IO,(KK)CFM) CONSTRUCTION TAX
Signature. plicent/Comoscror Date EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score orhmdle humdme material HEATING UNIT(ITT 100,000 BTU)
as defined by The Cupertino Municipal Code,Chapter%IZ and the Health and Safety
Code,Section 2553200? HEATING UNIT(OVER 100,IXIa BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Wadme.ll the sur eli moron.a building by the BayA.Aid use r ealhrdMiceswhich BOILER-COMP(3HP OR 100!100 BTU)
emit hermdnus a"v contaminants as def ted by the Boy Area Air Quuliry Management TOTAL:
Divi
❑Yes ONn BOILER-COMP(OVER 100.000 BTIH
I have reed the hecNous materials"iirements under Chapter 6.95 ofthe Cali. AIR CONDITIONER ISSUANCE DATLF
Tania Health&Safety Code.Sections 2M5,25533 arW 25534.1 undemmnd that if the NEW RESIDENTIAL.MECH. SQ.FT.
building does not currently have a nine d,that it is my responsibility to notify the occupant
of the requirements which must be met prior ri issuance of a Cell of Occupancy.
Owner or authorized egem Dam I ITOTAL: ISSUED BY: vw
OFFICE
i
NATE P.O. BOX,420807,SAN FRANCISCO. CA 94142-W7
COMPpN3/¢,'tAN
INSURANCE '
FU'N D'. CERTIFICATE OF WORKERS';CpMPENSATION INSURANCE-,- .t f
MMAY 1, 199b +.•.,
.:. ... .
r ,.nouev'rturiaeri�, 1 �7Gf,'G2�o6
r 11' ' OCRTIFICATE Bri15rFlE6: 0'1-O'�:-9�
SMITH, SENNY LAVON a PR60F OE.`'I'NSURANCE CERTIFICATE
APEX. ROOFING,.'.,. r ' r
460'NORTHERN
SAN JOSE'; CA '95125',"
This is to certify that we,'have issued a valid Workers'Compensation insurance poficydn a.form 3pproved�by the California
Insurance Comnliesloner to the employer named below foi the policy period indicated.
This policy is not aubjeet to;cancellatlon by the Fund except upon,ten days',advanee riritten:notice.to the gmployor.
ft ON Who NVn YQW.I 1;N tlNul.',rlu.,n nulinu Wt ALIILI 1P.:_ W-,, 6.ounoaio.t n w Iw nulmai.eRplfatlon.•.
This certificate ofI'insuranoe is net an i eurnnnn. policy i+nd doet'nyt umcnd;ektond nr.'ellmr'the covoraga aitorCed by the '
polities,listed lierein. Notwltnstanoing any, requlremerit,,term, or condition pf,eny cohtract 'orother documenbyth6
respect to which this'certificate of insurance mpy,pe;i ,su'd^Of, may nPrtialp,.1ha inRirrinhn 'AWad.bv kl+? ,,,II„;�. _
rlA6iuil�;uJ haralF.lh,b..�)wlt..uu Uir�crms exuwowttaand'Condifon of
' .re, , L ;f •, 1 1I 1 1, f ', l+ N,I b`n ' ' 1 I" `
' t'n ,' " A"' .. u '. •..'' ,.. ;,�.fM t.r "r,: ✓H PRe51�FNT.. •
P d•
EMPLOYERS' LIABILITY LIMIT INCLUDING DEFENSE COST': '$1'.,000,0.00.00 ' ,
PER OCCURANCE.
FMDLOYER', ,'.r •, ...
� .;�' ;•." e•, . . 0 •. .� ..�•' •ir' nr`: + "C . r� .r�.
NNY• LAV
ON
SMLTH; BE
APEX ROOFING -
460 NORTHERN RD
SAN .JOSE,"CA 95125
i ,.