29916APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
RESIDENTIAL:
PERMITISSUANCE
BUILDING - ELECTRICAL.
PERMITNO.
9916
BUILDING DIVISION
APPLICATIONlEERMIT
El MULTI -UNIT
PLUMBING - MECHANICAL.
L
MODIFICATION
❑INTERIOR
DCHIMNEY REPAIR
IIUII,DIN'G PROJECTIDENTIPICA'riON
WATER SERVICE
BUILDING ADDRESS:
MOLITION
.F:.PQ�
D OTHER
SANITARY NO.
APPLICATION SUBMITTALDATE
ISSUAN
DFN
TANT
DF00
IMPROVEMENT
CJ((AO 7lJV
OWNERS NAME:
PHONE:
CONTRAC'1'OR:SNAME
LIC NO,
NIC
E]
COM 'ROL4
IQ
_ O
RCHITECT/ENGINEER: LIC NO:
ADDRESS:
COM'ACT:
PHONE:
BUILDING PERMIT INFO
LICFNSED CONI RAC]Ok;S DECLARATION
I hereby oflina that I am licensed coder prmisinns of Chapter 9 (conmenem,
yOy100 witcene.7000b.f Division 3ofthe Bmilaosond Professions Code, andmy license is
FI�h Sin full tome and cffmt. C
.it_u V License Claes Lic. is V J O
+n 66 Datc—j-Jr 2(n— Contra5 eT �d�
ARCHITECTS DECLARATION
zo,OZ Iumlcrsmnd my plans shallhusW as public records
�
OZ—�
Licensed Professional
Q O WNE W Iexempt,fr DECLARATION
C Q I hereby .(limon that 1 1. exempt from the Cssions Cos License Low for the
AC�L( O m U following tures.. (Section 7031.5, Ruxitass Tod improve.
dr ions Code: Any city st structure u13 a 1 which Rquias n permit re conswct, alae improve, demolish, ore a sig ed suucure
F LL•OQ prion e. y h applicant tor s is signed
ppK;!�a (hath I" Wpursuant t Ih p Division
lin Contractor son I Chapter
W C O
(commencing th Section ]Ba) f D"is for 0th a em J Professions . ENO or
a a e (Bat he r. pt therefrom J theba for the alleged emit Any violation of
y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
>ynot more than five hundred dollars ($500.
FSC [ I, as owner nfthe property, or my cmployees with wages as thein ole cunipennatimn,
F. will do the work. nit the structure is not intended oroffered for sale (See.]OU, Business
W and Professinrt Calc: The Contractor's License law does not apply to an owner of
property who builds or improves thcaon, and who docs such work himself ur through
his own cmployees, provided that such impmvc ncn(s are not intended or offered for
sole. If, however, the building or improvement is sold within one yew of completion, the
owner -builder will have the burden of proving that he did not build or improve for awl
poseoLs.IcJ.
D 1, as owner of the property, am exclusively contracting with licensed contractors to
I construct the project Sec. 704E Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of propeny who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Lo,
D 1.m exempt under Sec. ,B&PC hrz this rt.son
❑ Consultant Fees Paid by Applicant (Initial)
101 Yl ELECTRIC PERMIT I FEE I
(honer [)tireWORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
❑ I havicend will maimuina Ccnifcam ofConumto self-insurcforWwkxv.,Compen-
saton, ns pmvid d Int by Section 3700 of the Labor Code, for the portent ...... (f the
work for which his permit is issued.
D I have said will maintain Workers Compensation Insurance ....... mad by Scene.
37W of the Labor Code, for he poodr nwce of the work far pw�hM1mic,ha wth:is permit n is n
My Wo,,IW�e CryElav' "tion Insurance came, and Policy /UC�JS/ �
Currier: f�Q fLli:�/ f..T/l 71116bc, Nn.. �UC� J
CEKI'IIBCATF, OP EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted ifrhe permit is for line hu alraddollars ($100)
less,)
1 certify that in the performance of the walk fur which this pemtit is Issued. ,.hall
not employ any person in any manner so is to become subject to the Workers' Cumpcn-
Z sat ion laws of California. Date
Applicant
NOTICE 10 APPLICANT It, atter making this Certificate of Esemption, you should
a become subject to the Worker's Compensmion provisions of the Laltor Code, you most
forthwith comply with such provisions or this permit shall he deemed Ranked.
0. CONSTRUCTION LENDING AGENCY
L) 0I hereby afirm that there is a constmction lending agency for the perfirmance of
the work far which the 1f sw d (Sec. 3097. Civ. C0
OULenders Name µ las
} Lenders Address �✓
1 certify that I have read this application and slam that the above in olood, n is
FUO corcc0 l ugrccm comply with al) city and county ordinances and state laws Rioting to QTY.
U building construction, and hereby vuthdiu npresenrativesnf this city to enter clam the
above-mcmiottW property for inspection purTo..'.
(We) affect to .save, irtdctmtify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in etroo oencc of the grunting of this permit.
APPLICANT UNDERSTANDS ANI) WILL COMPLY WO ALL NON-POIN I'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store m handle haau aus material
at defined by the Cupcnin, Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(.1"
C3 Yet 7 N
Will Ne applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Area Air Quality Management
District] /
❑[jYes Nn
I have real he hvardas material, magrircmems under Chapter 6.95 of the Calm
four. Health & Safety Cole, Sections 25505, L5533 and 25534. 1 understand that if the
building docs not currently have o anane than it is my responsibility to notify the occupant
mOhoeyuirements which trot met pymrm i.,nytee of a C_ngiente stQ apaay.
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
UPTO 200 AMPS
2014000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES —FIXT
JOB DESCRIPTION
RESIDENTIAL:
PERMITISSUANCE
❑SFDWL
D KITCHEN REMODEL
❑ADDITION
DPEUMBINGRE-PIPE
El MULTI -UNIT
[]STRUCTURAL
DRAINS — FL, EA ,A. GOND.
MODIFICATION
❑INTERIOR
DCHIMNEY REPAIR
IMPROVEMENT
WATER SERVICE
D BATH REMOW
MOLITION
.F:.PQ�
D OTHER
BOILER — COMP (OVER 100.000 BTU)
COMMERCIAL•
0NEW BLDG/ADDITIONEM
ISSUAN
DFN
TANT
DF00
IMPROVEMENT
❑ OTHER
NEW RESIDENTIAL F,LECTR b
SQ. FT. Il.00R'AREA
Vr sJV
PERMITISSUANCE
T
PLUMBING PERMIT FEE
PERMIT ISSUANFE\\�
ALDER —DRAIN VENT—WATER LA)-
VALUATIO
BACKFLOW .DEVICE+
DRAINS — FL, EA ,A. GOND.
STOR IUS
GAS—EA. SYSTE INC. as
OCC. GROUP
PERMITISSUANCE
GAS—IiA. SYSTEM-OVE 4(EA)
GREASIPINDUSTRI. WASTE INTERCEPTOR
BUILDING DIVISION Fl?ES
GREASETRAP
PLANCHECK FEE
SEWER—SANITARY— STORM HA. 200 PT.
ENERGY FEC
WATER HEATER WNENT/F,LF.CTR
GRADING FEE
WATER SYSTEMR BEATING
SOILS FEE
WATER SERVICE
PAID n.,.. .--,^• x
NEW RESIDENTIAL PLMB. SQ. FL
MECHANICAL PERMIT FEE
SEISMIC FEL
PERMITISSUANCE
E cm(
ALTER OR ADD TO MECH.
PLUMBINUTE
AIR HAN DLING UNIT (TO 10JXXI CPM)
MECHANICAL I2
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTION AX
EXHAUST' 110(1[) (W/DUCT)
HOUSING MI'1'IG IGNITE
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
Date Be,
VENTILATION BAN (SINGLE RESID)
BOILER—COMP (3HP OR 100,000 BTU)
BOILER — COMP (OVER 100.000 BTU)
AIR CONDITIONER
ISSUAN
NEW RESIDENTIAL MECH. SQ. IT.
OFFICE