29429 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES_USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONJPERMIT PLUMBING-MECHANICAL. A /� Q
BUILDING PROJECT'IDENTIFICATION J't J
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMI'ITAL DATE
� e1� �� 0�c�
O 'NEWS A ' ^ PHONIi: —� CONfRACfOR'S NAME: LIC NO:
J SIC CONTROL#
ARCHITECI'/ENGINEER; LIC NO: ADDRESS: ❑
CONTACT. . PHONE: BUILDING PERMIT INFO
• ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR
under;S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby,Efate the I an licensedander provision:of Chapter 9(commencing JOB DESCRIPTION
OoZ with Scction]000)of Uivision3uf the Business and Professions Code.and mylicense is RESH) NTIAL
WOO . PERMIT ISSUANCE
in fall force and effect. OSFDWL [I KITCHEN REMOUEI.
�ul Liomw Class Liao APPLIANCES-,RESIDENTIAL ❑AIlDIT10N ❑PLUMBING RE PIPE
F W hale Cnnllwlor
FOh ARCHII'ECPS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCIORAL
Z O-Z l understand my plans shall be used as Public records MODIFICATION
OZ=c UPT0201AMPS C1 INTERIOR [I CHIMNEY REPAIR
F
H!:Inpetard Prrfcui...I 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
OVER I(MIO AMPS O BATH REMODELiREPAIR [I DEMOLITION
K C Q I hereby affirm that 1 am exempt from the Contractor's License Law far the
i�� L V I'nllowing remnn.(Sweden 703 L5,Rumness and Profusions Core:Any city or county SIGNS ELECTRICAL ❑OTHER
1+13 LL N which require,a permit to construct,ohm,improve,demolish,or repair any yrvewre
��c� prior east....mce.alsorcqumsthc.PPlicam lar sacM1 penninnlil,a,igned stut...or SPECIALCIRCUIT/MISC. r-
f, y the he is licensed pursuant to the provisions stills,Contractors License Law(Chapmr9
t�i]�00 (commencingwiNScehun]0XUofDivi.sion3 ofthe Business and ProfessionsCM,)or TEMP.MEI'ER OR POLE INST. COMMERCIAL:
a d e Beat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEN'BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permiesubjecd the applicant to a civil penalty of POWER DEVICES A ❑TENANT ❑FOOD SERVICE
^�yt more than five hundred dollars($500) IMPROVEMENT
O (] 1,as owncndihe pmpeny,or myemployceswieh wages avthcirsnlccompennaeinn, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended oroffeecd for sale(See7 4 ,Business OOTHER
pj m and Prolessien.s Code:'P a Contractors Liecnsc Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
d 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nor intended or offered for NEW RESIDENTIAL ELECTR S
sale.If.however.the building or improvement is sold within one year are
SQ.FT.BOOR AREA LSQ.FT.
"sacr-buildve er will hathe burden of proving that he did not build or improve for par- "1
e ifsme.). 'r E*
I,as owner all the properly,am exclusively contracting with licensed contractors to TO
consumer the Ionic,(Sec.70U,Business and 14nfes.tons Core:)*1 he Contracrn's Li. MAR 1
wase Law does not apply to an owner of property who builds or improves thereon.and Q1 Y. PLUMBING PERMIT FEE 1 199
ho contracts for such pmjecn with a comnctogs)licensed pension to the Comea:aer s a
License Law. PERMIT ISSUANCE C/ y
C] lamexempeunder Sec .B&P C for this aasom Ur
ALTER-DRAIN&VENT-WATER(EA) VALUATION r r V
r
Uae
meWORKER'S COMPENSBI'ION DE.LARATION BACK FLOW PROTECT.DEVICE
1 hereby atf.ne trader penalty of perjury one of the following dwelwmionc.
I have and will maintain a Cenificam of Consent o self-insure for Workers Couper. DRAINS-MOOR.ROORAREA,GOND. STORIES TYPECONSTRUCHON
sation,as provided for by Section 37W of the Labor CM,,for the performance of the
work for which Nis pman is issued. FIXTURES-PER TRAP
1 have and will maintain worker's Compensation Insurance,as required by Section '
37M o(thelose,Code,for the polormancc ofthe work for which Ni,Permit is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance cooler and Policy number tare:
Caricr. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CEIGU'ICATE of:I!XEMITION FROM WORK17RS'
COMPENSATION INSURANCE. GREASEANDUSTRL WASTE IN TERCEPTOR BUILDING DIVISION FEES
(This,tckarnced not becnmpleted ifthe pcmtis is funme huadreddellan(SI(MI) GREASE'I'RAP
or less. PLANCHECK FEE
I certify that in the perfomnnce Ufthe work forwhich this permit is issued,i shall SEWER-SANITARY-STORM EA.200 FT.
not emPlny any person in any manner so as be become,objecuo the Worker:Camper- F:NHRGY FEE
,Z sullen Laws of California.Dan- WATER HEATER WNENT/ELECI'R
Q Applicant GRADING FEE
NOTICE.TO APPLICANT:If,aRcr making this Cenificale of Exmnpoon,you should WATER SYS 1'EMaREATING
F' become subject to the Workers Compensation provisions of the Labor Code,you most SOILS FEE
forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
0
� Z CONSTRUCf10N LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receipt#
U O I hereby offimt that there is a construction lending agency for the performance of
the work for which this it is issued(Sec.3097,Civ.C)
O perm
U Lcndcrs Nam, TOTALTOTAL:
Lender's Address :
1 Gentry that 1 have read Nis application and stat,Thal the above information is BUILDING FEE
E' y
correct.I as=to comply with all city and county ordinances and seam laws relating to QTY. MECHANICAL PERMIT FEE
U Z mildingcnnnwdinnend herebyzmhonre eepracardea esstfthixehymcnterupon else SEISMIC PEE
atzwe-mentioned property for inspection purpous. X PERMIT ISSUANCE
(We)agree to save,indemnify and keep hdess the City of Cupecom against ELECTRIC FEE
am
liabilities,judgments.cants and I.,rses,deb may in any way acme againrtsald City ALTER OR ADD TO M ECH.
in PLUMBING FEEmequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) ICONSTRUCTION TAX
Signature ofApplicauCtueacmr Dae EXHAUST'HOOD OMMUCO HOUSING MITIGATION ME
HAYARDOUS MA'T'ERIALS DISCLOSURE
Will thca,licante,furore buddingo¢,onit aereor handle hatrin smaerial HEATING UNIT DO 1W.000 BTU)
us defined by the Cupertino Municipal CMe.Chapter 9.12,and the health and Safety
CMe,Section 15532(.)^ HEA'T'ING UNIT(OVER 100,001 BTU)
❑Yes Fl No VENTILATION FAN(SINGLE R&SED) PAID
Will thea ileum m town buildin a tau e t or d,vices which Date Receipt#
Pp gby mean Area
n BOILER-COMP(3HP OR 100,101)BN)
mit hazardous air contaminants as definN by the Bay Arca Air Quality Management TOTAL:
Diseinl
❑Yrs Fl No BOILER-COMP(OVER I00,0g)BTU)
I have readthc hazardous maenals requirements under Chapter 6.95 of the Cal i- AIR CONDI I IONLR ISSUANCE DATE
fomia Health&Safety CM,Sections 25505.25533 and 25534.1 understand But if else NEW RESIDENTIAL MECH. SQ.FT.
In ildingdocs mor currently have a evneat,that it is my responsibility to notify else occupan
of the recommend,which mss be mer,prior a ismarec oL Cenifica,of Occnpdey.
Owner or umhorued agent Date ISSUED BY:
OFFICE