29778 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILIIING-ELECTRICAL. PERMIT NO.
BUILDINd DIVISION APP IC TIONlPERMIT PLUMBING-MECHANICAL 29778
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2-0
OWNER'S NAME: PfiONE: CONTRACTORS NAME: LIC NO:
G COQ _ NIC CONTROLp
ARC II'1'ECIYEGNGINEER: LIC NO: QQ ADDRESS ID
CONTACT: PHONE: i. BUILDING PERMIT INF
S Lo, W K 3 7.oaf ❑ Consultant Fees Paid by Applicant(Initial) BLDG E PI CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
0y �Z with Section 7000)of Division 3ufine Buammoand Professions Cade,sed my license is
Flop PERMIT ISSUANCE RESIDENTIAL
�� nfullfal.,a eget. SPDWL ❑PLUMKITCHENREMODEL
a—u hittnse Clens IJc.p -
Q U APPLIANCES-NIiSIDENTIAL CA ON
-1 PLUMBING RIiPIPE
mel Uec TSDE I-
WW ANC?{I'fECT'S DECLARATION ❑MULTI-UNIT ❑S'1'RUC'fURAI.
F.D h PANELS
, 1unJemm�J my plans shall he used es puM1llc records MODIFICATION
oz—,OZ— UPT02WAMPS ❑INTERIOR CCHIMNh:Y REPAIR
F 4)t:ul Licensed Professional 201-10(NlAMPS BATHIMPROVEMENT
MOD17
OWNER-BUILDER DECLARATION OVER1000AMP5 ❑BATHftEMODfiUREPAIR CDEMOLITION
C C Q 1 hereby affirm that I am exempt from the Contractor's License Law for he xax O a U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL COTTER
W 3 k4ya which requires a permit m construct.altar,improve,demolish.or repair any structure
co prior to its issuance,also requires the applicant for such permit to file a signed mm
nment SPLCIALCIRCUITJMISC.
ythat he is licensed purstand in the provisions of the Contrecmrs License Law(Chapter 9
p0 (e..... ing wim Section]000)nf DivislonJ of the llusiness and Pmfcasinnx Cada)or TEMP.MIi I'ERORPOLEINST. COMMERCIAL_
d p,m c thin he Is exempt mueGum and the basis our he alleged exemption.Any vialmion of [-1NI7W BLDG/AUDITION C DEMOLITION
�..m Section 7131.5 byany applicant for a proton subjectsthe applicant to.civil penalty til POWER DEVICES CTENANT CPLO])SPRVICI:
est more Than live hundred dollars 1551X0.
F.y i- SWIMMING POOL ELECTRIC IMPROVIMPROVEMENT=Q Lus owner ol'the propeny.mmy employees with wages as their sole cnmpensmion,
sE p.O will Jo the work,andthe structure is not intended uroffcred for sale(See 7044.Business CQTHER
Wand Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3� pmpcny who builds or improvcx thereon,and who rices such wok himself m through
his own employees.Provided tha such improvermcros arc not intended or offered for NEW RESIDENTIAL M EC IR SQ Ff.
sale.IL live e building or improvement is sold within one year ofcompletion.the SQ.FT FLOOR AREA LSQ.FT.
ncrbuildcr will have the burden of proving that he did not build or improve for put-
pose of sale.). (7
71 1,as owner of the property am exclusively contracting with licensed contractors m T
sro'wa the project(Sec.7044,Bmimess and Professions Code:)The Conmotor,Li-
cense Law does not apply to an ownerof property who builds or improves mcmon,and QTY. PLUMBING PERMIT FEE
who umnmeLs for such projects with a contractors)licensed naman 0 the Contruemrs
License law. PERMIT ISSUANCE IIIA( Q
Cn Iraexempt under Sce. .B&P C for th'rsremJUN an O
F Dam
ALTER-DRAIN&VENT-WATER WA) VALE TI
Owns �
WORKERS OMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE• /Iheabyaffirm antler penalty of perjury one of the following declarations: r�IY Llf (;Ur
CT11B
❑I have and will maintain a Certificate ofComent to self-insure for Worker's Coalition- DRAINS-FLOOR.ROOK AREA,COND. STORIES T;P'CONSJ'R1tCUClti
smian,as provided for by Section 371X1 of the Later Calc,for me performance of the Ie S i/� Y�
work for which this permit is issued. FIXTURES-PER TRAP T F
C 1 hove and will maintain W'orker's Compensation Insurance,m required by Section
3700nfthe Labor Cole,for the perfommncc of the .,it for which this permit is issued GAS-EA.SYS TEM-1 INC 4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSIEM-OVER 4(EA)
CERTIFICATE,OF EXEMPT ION FROM WORKERS' GREASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Ilhis section need not be compldW ifthe permit is loran,hundred dollars GREASETRAP L
or less) PLANCHECK PEE / 6O
Icetify tha inthe,domanceofthe work forwbichthispennit isi...ad,Lhall SEWER-SANITARY-STORM EA.200 FT.
not employ any From.in any hourter su as to become subject to the Workers Compcn- ENERGY FEE to 4"
Z cation laws of California.Dae WATER HEATER WNENVELECTR
O Applicant GRADING FE-13Q O
Z NOTICE TO APPLICANT:If,alier making this Certificate of Exemption,you should WATER SYSTEMG`REATING
a
Hj SOIL S FEE Fa become subject to the Worker`s Compcnsoeon provisions of the Labor Cela,you most
W Iimhwilh comply with such provisions or mix permit shall be deemed rcvuked. WATER SERVICE
ps CONSTRUCTION LENDING AGENCY NEW RGUDIiN'1'IAI.?'LMR. SQ.Fr, PAID:D z Dae n
U O I hereby affirm that there is a construction lending agency for the fermnaunce of ',^
f-' the work for which this permit is issued(Sec.301 Civ.C.) TAI 440
Q U lenders Name
Lenders AJJress Ro
y I rectify that I have mad this application and sour that me above information is BDILDIN FF: kokIs
r�
h corect.I agree to comply with all city and county ordinances and state laws miming t0 QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby authorise representatives of this city to enter upon the SEISMIC EF
mro,ro mioned property for inspection purposes PERMIT ISSUANCE
(We)agree m use,indemnify unit keep harmless the City of Cupertino uguimm ELECTRIC FEE
liubilitics.judgmm�q costsand experaes which may many way acerae against said City ALTER ORADDIOMECH.
in ueoequof the gn ming of this perms. PLUMBING P
enca
07t39;
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECIIANICA. 'iE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IB,IXXICFM) CONSTRUCTIONTA
Signature ofApplicanoCmannem, Data EXHAUST HOOD(W/DUCI) HOUSING MITIGATION E -Q
HAZARDOUS MATERIALS DISCLOSURE
Will meapplicant or future building cccupanwmte rehandle haeardaos ma¢rial HEATING UNIT(TO UXLXX1 BTU)
as defined by the Cupertino Municipal Cele,Chapter 9.12,and the Health and Safety
Cede,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
C Yes F1 No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt a
Willthe.,applicant mantra bullmng by he
use equipment itdaviceawhich
I most hnnndnus uk mmmaminnnd as defined by the Bay Area Air Quality Mnnngcmcnt BOILER-COMP IMP OR IW,0W BTU) TA L:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes CNo
I have mad the hmmdous thamdmsp AIR CONDITIONER
reyuircrtwna utWer Chapter 6.95 of the Cali- ISSUA `CE DATE
marks Health&Safety Cole,Sections 25505.23533 and 25534.1 undaroand this if the NEN'RESIDENTIAL MECH. SQ.EL
building does nm coat Poor a Icnuut.that it is my responsibility to ramify the aecupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner in aumnrittd agent Umc T 155UIiU BY:
OFFICE