29777APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
❑ KITCHEN REiMNDEL
CITY OF CUPERTINOBUILDING. - EI,ECI'RIC'A I.L.
- -i•-- NULL PLUMING BING . MECHANICAL
RUILDINGDIVISION -g �I ) ATIONIPRRMIT ROJF.CI'IDENTIFICATION
El PLUMBING RE -PIPE
BUIL'-NOL-1R,,:.
�_ .. -.
❑STRUCTURAL
OWNER'S NAME,, /
LL PHONE: c- 3 -01?9
CONTRACTOR'S NAME: LIC NO:
�)RCHITECT/ENGINBE LI NO:: v
t G
ADDRESS
IMPROVEMENT
CONTACT: PHONE:
,
h
woowith
F W S
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y Q c.
FNZ
O N
. P•• U t�� —VH 7
El consultant Fees Paid by Applicant (Initial)
LICENSEDCONITACfO 'S DECLARATIONQTY.
I herehy . inn that 1 am liccn.md under provision, of Chapter 9 (commencing
Section 7)ol' Dion 3ofthe eusinessmid Pndcasfons Code'tad.oy l mucosa is
1R0Division
in full force and effect.
License Class l.ls'.N
Dam Carteret
ELECTRIC PERMIT EEE
ef"i PHRMI'IISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
1 understand myplansshell beusedas Public .,ad,
PANELSZ
UPT0 2M AMPS
Licensed Prnlc,,smol
201.100AMPS
�Wi� mt OWNER-HUILDER DECLARATION
SS�� 1 hereby afOthat 1 am exempt from the Contractor's License Law for the
kO6 UF- following reaxm. (Section 7031.5. Business and Professions Code: Any city or county
: LL N which mlai. a permit m mw
coct, alter, improve wre demolish, or =pit any setu
LLO1 prior to its issuance, also requires the applicant for such permittofileasigned statement
OVER TWOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/M INC.
y�that he is licensed pursuant to the provisinexofthe Contractors LicenxLaw (Chapter 9
L'(commenei as with Section 7000)ofDlvf,ino3orthe Btu'ine,x and Profewinn, Code) or
S X e f� that he is exanpl therefrom and the basis for the alleged exemption. Any violation of
y Section 703.5 by any applicant for a perrmitsubjects the applicant to a civil Penalty of
t more than five hundred dollars 055(X)).
=�0Las owner of the pvpeny, nr my employees with wages as their solerompensauan.
will dothe work, and the structure, is not itnended proffered for sale (Sec. 704,1, Business
Ly+1 m and Professions Cafe: The Contractor's License Use does oat apply In an owner of
I HMP. METER Olt POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
prapro, who hui lis tar improves shcrenn, and who does .such wark himscll'or through
his own employm,, provided that such fmproveroend accent intended or oPded fur
N17W RESIDENTIAL. ELEC'IR SQ FT.
sale. If, however, the buildia, m urproventent i, w4d within mic yem of Oundetiom, the
-
o nesbuilder will have the burden of proimprove ving that he did not build or impve for pun55-
Q
psseafsale.)
❑ L us owner of the prepeny, am exclusively contracting with licensed contractor, to
TOTAL:
onswct the project (see. 7044. Business and Professions Code:) The Contractors Li.
case Law docs not apply to an owner of property who builds or Improves thereon,and
Q'T'Y, PLUMBING PERMIT ,� •
who contracts for such pmjecty with a contractor(,) licensed p ... arm to the Contractor's
PERMIT ISSUANCE
Liccnm Law.
❑ l tan exempt under Sec .B&PC for this res»n
ALTER- DRAIN & VENT- WATER (EA)
ownerDate
BACK FLOW PRO' 1' ECT. DEVICE
OR KF,R:S COM PENSATLON DECLARATION
I hereby nffirn undo penalty of perjury mac of the following declamtiom.
.
❑ I nsvitud willmafntain a Cerileth, of Cnn,ent toself.insure I., We'ker, Cnmpm-
DRAINS- FLOOR. ROOF, AREA, CONI ACII
stairs, as provided lits by Section 3701 of the Labor Calc, for the performance of the
work for which this Nmtit is issued
FIXTURES - PER TRAP
❑ L have and will maintain Worker's Compensation Insurance, as required by Section
37W ofthe Labor Code, for the performance ofthe work for which this permit is issued.
GAS -EA. SYSTEM' -I INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
My Workers Compensation insurance carrier and Policy number arc:
Carrier Policy No.:
GRFASMNUU5'I RI, WASTE INTERCEPTOR
CHR 'I'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
(This section need not be completed ifuse permit is for one hundred dollars (SHAD
or less.)
NEWER - SANITARY - STORM EA. 200 FT.
' I cenify that in the performance ofthe wark for which this Permit is issued.I shall
not employ any person in any manner so ev to become subject to the Worker.: Compen-
WATER HEATERW/VENT/ELECTR
Z sat ion laws of California. Date
OO
G i/)
Applicant
NOTICE TO APPLICANT: If, alter making this Cenilicate of Exemption, you should
WATER SYS'I'EM/TREATING
0
UO
U0
�
OU
L[1
G
m
become subject to the Worker', Cmnlarmation provisions of the Labor Code, you must
forthwith comply with such Provisions or this permit shall be deemal revoked.
CONSTRUCT
ac[ON LENDING AGENCY
I hereby whichrmthat pernat isuccd(See 3097,on Cie agency fmthe perfnmmnec of
'he work lite which this pmtit is issncd [Seo. 3097, Cie C.)
Lender's Name
WATER SERVICE
NI7W RESIDENTIAL PLMB. SQ. FT.
p
TOTAL: / .
r's ldm,,
LcndcA
I certify that 1 have read this application and Stam that the above information is
corned l.,. to comply with all city and county ordinances and state laws relating to
QTY. MECHANICAL PERMIT FEE
V Z
buildingcm,wome, and hereby authorise representatives ofthis city meas upon the
/ PERMIT ISSUANCE
them mentioned pnspery for inspection purposes.
(We) agree to ave, indemnify orad keep hamae,x she City of Cnpenina uga rvt
ALTER OR ADD TO MECH.
habilities,judgmena, costs and expenses which may in any way areme against said City
in co iVaPena of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT(TO I0.000CF14)
SOURCE REGULATIONS,
AIR HANDLING UNIT (OVER IQOW CFM)
Signumruof Applicwe/Contractor Data
EXHAUST HOOD(W/DUCT)
HAF,ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazankastmnered
HEATING UNIT CFO 100.000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code Section 25532(a)'!
_
HEATING UNIT (OVER LOB." BTU)
VENTILATION FAN (SINGLE R&SID)
❑Yen C1 No
Win the applicant nr finure building occupant use cent proem or devices which
nageent
,mil hamrdous air contaminant, m drImed by the Bay Area Air Quality Mam
HoII.LR-COMP (3111' OR 1011.001 BTU)
BOILER - COMP(OVER 1W.OW B'TU)
Dismal
E3 Yes C] No
AIR CONDITIONER
Ihavem:ethehauNwsmamdalso uim=ntsunder Chaper695of Ne Cali-
NEW RESIDENTIAL. MECH. SQ. FT
forma Health & Safety Cod, Sections 25505.25533 and 25534. 1 understand that if the
holding doe, nos c merely hove. mama, Not it k my m,,op,diddy m ratify the nccupam
of me regnimlmnts which matt be met prior to issuance (da Cenihcam of Occupancy.
TOTArl—
Owner or thommmd agent Dam
OFFICE
IN
29777
_i9- 9G
BUILDING PERMIT INFO
5%VDWL
❑ KITCHEN REiMNDEL
❑ADDITION
El PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
GRADING FEE
MODIFICATION
O INTERIOR o,.•
p�, ❑CHIMNEY REPAIR
IMPROVEMENT
Q D
❑ PATH REMODEL/REPAIR ❑ DEMOLITION
❑OTHER(
U
ELEC CF
mg
.20
PLUMBING FEEp
COMMERCIAL(;UYLh i (IVU
❑ NEW BLDG/ADDITION
❑ DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
Is
❑ OTHER
2
SQ. FT FLOORAREA
til .7- 4,
,ff Y.50
BUILDING DIVISION FEES
c
PLANCHECK FEE
9'AP
ENERGYFGE
w
GRADING FEE
1,3 5V
SOILS FEE
/ A eon
PAID
Damiii
c
o
AIJ
TOTAL:
Gi�Oro
BUIL E
SEI, IC JE
ELEC CF
z 7.
.20
PLUMBING FEEp
MECHANICAL 'E
t /
• 70
CONSTRU(7TI NTAX
Is
HOIISINGMITI ATIONFEH
2
`� C)
PAID
Dam
Or,
TOTAL:
ISSUANCE DATE