29883 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 2 9 8 ^3
BUILDING DIVISION APPLICATION/PRRMIT PLUMPING-MECHANICAL
L J4 lXJ VX�KJ
RIIILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'. SANI'I'ARYNO. APPLICATION SUBMITTAL DAL I'.
,vo 0 3 9 ib�1 1.v� 3 S
OWNER'S NAME: PHONE: CONTRACTOR'SNAME: LIC NO:
NIC COMROII.��kp
'f •4RCH I ECL'/ENGINEER: LIC NO, ADDRESS: ❑ t-t 1
CONTACT; PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) fl .kG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DOZ with Satins]0Nry oTDivision3af the Business xnJ PmfessionsCode,and my license i. �rTI ,I„
WOO PERMIT ISSUANCE
HWS in full force and effect. FOWL ❑KITCHEN REMODEL.
K U F License Class Lic.M
Q U APPLIANCES-RESIDENTIAL AUDITION [I PLUMBING RE-PIPE
y G S Date Comforter
ARCHRECT'I DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z p n Z 1 understand my plans.shall he used as public records PANELS MODIFICATION
OZ-C UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
F-HFW Licensed Professional 201-IIXI1 IMPROVEMENT
`,eatOWNER-BUILDER DECLARATION OVER IOOIIAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
W Q 1 hereby affirm that I am exempt from the Contractor's License Law for the -
KO L U following remon(Section 11131.5.Business and Professions Code:Any city or county SIGNS IR.ECfRICAL ❑OTHER
W 3"i which requires u permit to crawruct,alter,improve,demolish,or repair any svuci us,
I-la.
prior mise issuance,almmquireathe applicant fnr.such pcnniuofilcn signal smmment SPECIAL CIRCUIT/MISC. /nIIIA
f �. that he is licensed pursuan to the prae
ovisions of the Commors License Law(Cher 9
W:Y�p (corunencingwifhSation1000)of Division3ofthe Businessoad Pmfessiom Ccal I r TEMP.MFT ER OR POLE ISIT. COMMERCIAL:
Q. c y that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Section 1031.5 by any applicant for o Permit subjects the applicant to a civil penalty of POWER DEVICES
❑TENANT s ❑FOOD SERVICE
Z p. t more than five hundred dollars(3500). IMPROVEMENT -� 1" V
�=Q ❑ Las owner of the propeny.nr my empnyccx with wages as theinnlc rnmpen.wdnn, SWIMMING POOL ELECTRIC
l- will will do the work.and the svucmre is not intended or offered for sale(Sec.9041,Business ❑0 THER
ad m and Professions Cede:The Courtrai License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves income.and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement is sold within one year ofcompletion.the SQ.FT FLOOR AREA S)SQ.PT.
ovain,thmicc,will have the harden of proving 11,11 he did not build err improve for pert-
pose of ymone t1'�"10
❑1,construct owner of the propeny,oat exclusively nmessions wird IicenseC cmnvannrs to i
veLathe project(Sec.plyto a 4.Business and property
who
ds or imIpro Convenors Li- Ct
cense taw does not apply a an owner of t mpeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who camruns for such Prnjccu'whh a comranor(x)licensed pursuant to the Confrocmrra
License law. PERMIT ISSUANCE
❑Ium exempt under Site .B Ps 1'C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Ow ar Date
WORKER'S COMPENSATION ofcipa,on DECLARATION BACK FLOW PROTECT.DEVICE 337
1e and w alias under Penalty of perjury one of the following declarations: ((
•❑ Ihavc and will maintainbye Cerril ofConseni Code,sure for Worker'sce ofth- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPECONSTRUCTION
ration,av pnrviJed for by Senior 9900 of the Lubar Coda for the peAormanec of the
efar which this permit is issued. FIXTURES-PER TRAP
have and will maintain WorkcA Compensation Insurance,us required by Section
3100 of are labor Cade.for performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS (KC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEMOVER 4 RDG
CERTIFICATE OP EXEMPT ION FROM WORKERS' GREASI%INUUSTRL WASTE IN'IERCE14pR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe permit is forone hundred dallaa(SI01) GREASE TRAP
It
or less.) PLANCHF,CK FEE Tj
Iverifythatin Ne pentmor aaceofthewmk fnreshich thispersed is issued,Ishall SEWER-SANITARY-STORM EA.201 FT.
not employ any ps,c m in any manner no m to become subject to the Workni Compete ENERGY FEE
Z safion law"d Califnmia,Dam WATERI{EA'TER WNENI'/IiL[CTR
Q Applicant GRADING PEE
NOTICE TO APPLICANT:If,after natking this CeniGcute of Exemption,you should WATER SYSTEM/BEATING
1•-' ; both
booms,subject to e WmkeA m
Compensation provisions of the labor Code,you an SOILS PEE
forthwith comply with such provisions or this permit shall be deemed avoked. WATER SERVICE
Q
= z CONS'BUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SO.tT. PAID Dia Receipt d
L) O Ihcrchy affirm thvuhcrc ix nconxfmnlnn landing agency torr the perfommvnm of
E~- the work for which this permit is issued(See NAG.Civ.CJ
Lender's Nance TOTAL:
!U Lenders Address A r
y 1 ttrtify for I have read this application and state that the shove information is BUILDING FEE
.F. Ud correct.l agree to comply with all city and county ordinances and slate lmwsrcmti ,m QTY. MECHANICAL PERMIT FEE
U � building cousrction,and hereby mahoriurepresentatives offlikerty m initiation the SEISMIC PEE
m
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(W cros • indemnify and keep harmless the Cayof Cupertino against ELECTRIC FEE
liabiliti .jud coos nd expenses which may in anyway accrue again said City ALTER OR ADD TO MECH. PLUMBING FEE
inco of theg ng of this perrou.
APE.1 UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00O CFM)
MECHANICAL FEE
SO - F,GULA NS. -
Pabi• Q. AIR HANDLING UNIT TONER IO,INIBCUM)
CONST Rl1CT10N'1'A%
pphimm Cimmar DartEXHAUST HOLD(w/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wi lthenpplieenfor(wart building acap.,smreor handle hanNous material HEATING UNIT 00101.(1(10 BTU)
s eine by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
1 ,
tion 29532(0)? HEATING UNIT(OVER 100.000 BTU)
❑Vcs ❑No VENOLATION FAN(SINGLE RESID) PAID
Date Raeiptp
Will the applicant or future building occupant use equipment or devices which
remit haaandone au contaminanu,as defined by the Bay Area Air Qualify Mmagcmcm BOILER-COME E3HP OR 100,010 BTU) TOTAL:
District? BOIL1iR-COME POVER 10),010 BTU)
❑Yea
I as ehazardou materials reyuiretncnL.under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma H .arety Calc, tions 25505,25533 and 25534.1 andervand that if the NEW RESIDENTIAL MECH. SQ.FT.
haddur mcuncedy ea tenant thata is my respomihilbyta nturfy the occupant
ofthe mentswh' mustbemetprionoissuanceofacenificaa oftkcuganc.
m Jagenf me ) ISSUEDBY:
rt OFFICE