29006 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29006
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECI'IDENTIFICATION
BUILDING ADDRESS: ryt. SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS NAME PHONE: CONTRACT'OR'S NAME: LIC NO: h--21-Ci 5
NIC C NTROLN
ARC TECVFNGINEER: LI N0:• ADDRESS: ❑
. EJ.I L,1 !Fl iRN NiUNte iA 'IYLO Ak-1'IJ V
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECU
CK (�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Section]OIXBofDivi,sion3ofrhe Business and Professions Cock,and my license is RESIDENTIAL
4100 wn PI7RMIT ISSUANCE:
CWF m full force and if t ❑SPDWL ❑KITCHEN RIiM(1DEL
FR-U License Class Lic.N
NGL Dale �t,_ Contrar APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RFPIPE
to'N —ttr* ARCHITECI'S DECLARATION PANELS C3 MULTI-UNIT ❑STRUCTURAL
Z p Z 1 undcnead on,plan,shell he used os public records MODIFICATION
0Z—p UPI2W AMPS C1 INTERIOR ❑CHIMNEY REPAIR
F��41 Licensed Professional 2014000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IWAMPS E3 BATH REMODEIIREPAIR El DEMOLITION
Pg d I hershy affirm that 1 um exempt from the Contmcmr,License Law for the
W 3 o..F following reason.(Section 7031.5.Business and Profession, axle:Any city sur county SIGNS ELECTRICAL. �OTHF,R
y which requirts a permit m ennrvct,alter.improve,Jc sh,at repair any suvcmre V"LISTIQ4I 2DPL LI
F�'OQ prior to its issuance,also requires the applicant for such maimfilc o signed statement SPECIAL CIRCUIT/MISC.
�y the he is licensedpursuunnnlhr,prov �nsofMcC tmcmr',IJ,mseLmv Chupter9
4C�O (commencingwilM1 Secti,,n]INNI)af Divi,i,,n3of elfu,ine.andl'rnfesxionsCMgor TEMP.METER OR POL1i INS'I'. COMMERCIAL:
E.ly o K That he is exempt Nerefrum and Ih<bu.is fur c alleged escmpla Any violaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
4Xl 1a• Section 7031.5 by my applicant for a p=rom subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
so sl more than five hundred dollars 6 Las owre,oi he I.ar laces with wants as Inti,eats cont mtmtion, SWIMMING POOL ELECTRIC IMPROVEMENT
lX [] pmpery my player, b P
F d dolhewon;Cde:The o ,,li License aw do=ssotal of apply to an,Business ❑O'T'HER
W 3 and Professions Code:The Cu a ooh License Lew docs not apply In an owner of OIITLLTS-SWITCHES-f9%TURES
progeny who builds or mapro x thereon,and who does such work himself or through
his own employees,prnv that such improvements are not intended or ofRred for NEW RESIDENTIAL ELECfR SQ FT.
mlelfhoweveetbebui n ng or improvement is sold within one year ofeampletion,the SQ.FT.FLOOR AREA VSQ,FT.
owner-builder will h the burden Of proving that he did not build or improve for pur-
ine re sale).
❑ I,Yawner the property,um exclusively contracting with licensed contractors to TG
construct the eject(Sec.](W4,Business and PrnE'asians CadeO The Contractor's Li-
cents Law does ant apply to un come,of progeny who build.,,,improvcsusioem.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant to the Compactors
License Law. PERMIT ISSUANCE DEC 20 1995
I am exanpt under Sec. .Bic inr this reran
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner
I Y Ur L UrtH I INU
WORKER'S COMPENSATION DECLARA ON\,A,.il�dScr
i BACK FLOW PROTECT.DEVICE
• Iherenyoflirmtodr,seraltyotpe,my one.1 he followinI S10Dp
n I have and will maintain a Ccmficam ofCorwolm sdLiamre to DRAINS-FLOOR.ROOF,AREA,COND. STORIES 'I'YI'E CONSTRUCTION
ration,as provided for by Section d. of the Ichor Csde,for thework for which this permit is issued. FIXTURES-PLR TRAP
E have and will maintain Workers Compensation Insurance,us —`3]W of Ola Labor Code,for Ne performance of the wark for which GAS-EA.SYSTEM-I INC.n OUTLETS OCC.GROUP APN
My Workery ymge yvuon In ranee Cartier and Policy u
Carticc �`�C-0M Policy Na: (;AS-EA.SYSTEM-OVER O(EA)
CF.RTIVICATE OF EXEMPTION FROM WORKERS' GREASFIINDlISTRL WAST[INTERCEPTORCOMPENSATION INSURANCE BUILDING DLV 1 ION FEES
(This,reionncW flat be completrdfflhe pcnml is mron=hundred dollars(Slg)) GREASETRAP
or less) PLANCHECK FEE ►�
IcmiFy Nmin tit=p=rforman Dhe work for which this permit is issucd,IshaB SEWER-SANITARY-STORM EA.200 H.
nm emgl,,y any person in any yw.r cn o.c m hsenna mmftd m the Workers'Camper-
of.
amper- ENERGY FEL
OZ mtion Laws.1 Califif;;; WATER HEATT:R W/VENT d;LECTR GRADING FEE.
Z Q Applicant
NOTICE TO AP .CANT:IL after making this Certificate of Exemption,you should WATER SYSTEMRREATING
become subject m the Worker',Compensation provisions of the Labor Code,you man SOILS FEE
W > fonhw'ithconaply war such provisions nr(his person 1,,Il be decmedoo,oked. WAI'f:RSERVICE
n' CONSTRU ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V I herebyaffirm that t Bacons. inn lending agency for the performance of RanplN
f-+ Thu work for which tit' Inil is ismed(Sec.301 Civ.C.)
L Lender's N TOTAE,:
U Leader',A s l 1 kTl
W 1 certify Ill.,L nave mad this application and state that the above information is BUILDI E
(z) com:caEagre.l,,comply wim all city and county ordinance,and stare laws relating to QTY. MECHANICAL PERMIT FEF,
U building construction,and hereby authorize representatives of this city m enter upon the SI?ISMICFE
.hove-mentioned property,for inspection purposes. PERMIT ISSUANCE
(We)agree m rove,indemnify and keep burmlms the City of Cuprrtino agrest ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway rector,against said City ALTER OR AUDIT)MECIL
PLUMBING FEE
inconsequence of the gu
rnting m,hls pconah.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLE NO UNIT(TO 10,000 CPM)
MECHANICAL PEE �
SOURCE REGUI TIONS.
�� �� 1..g �`Ar
S'i� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
of ApplicamCommem, L Dole EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAE S DISCLOSURE
Will the applicant or future building occupant store or handle hamNous material HEATING UNIT(TO 100,000 BTL)
as defined by the Cupertino Municipal Cede.Chapter 9.12,and the Health and Safety '
Cede,Serfim 25532(x)? HEATING UNIT(OVER 100.100 B'T'U) tAo
Yes S do
z- VIiNT1fAT10N FAN(SINGLE BESIDE PAID Dam RmcigN
Will the applicant or furore building mcupa t use equipment or devices which
emit hazardous air conuoninants as defined by life Boy Area Air Quality Management BOILER-COMP f3HP OR 100,000 BTU) A
Dioner? BOILER-COMP(OVER 100.000031-U)
❑Peso
I have read the hazardous mutnriuls requirements under Chapter 6.95 of the Cid, AIR CONDITIONER ISSUANCE DATE
forma Health&Safely Cole,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ.IT,
building des aoemrcnd a lenanl,that it is my resporuibility l,,notify the occupant
thertqui hj9 tl`mel prior,.moans ofa Cenilieftef'a�
hnnuJagent—'
Owner or rutagen IIY— 1l GD aa¢ T ISSUED BY: ��+� - •
OFFICE