29885 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RE'ECI'RICAL PERMITNO.
HUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 29885
BUILDING PROJECF IDENTIFICATION
RUIhDBiGOADIO F� r Lot— � SANITARY NO. APPLICA'T'ION SUBMI'ITAL DATE
OWNERR'SNAME: PHONE: CONTRACTOR'S NAME: LIC NO:
N/C CUM ROL#
ARCHITECT/ENGINEER, LIC NO; ADDRESS', ❑ e)c -
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I berenr arctrm nm I am E..mea anger provisions of chapter 9(«,ntmendng JOB DESCRIPTION
C=Z wi'hSm'ion]IXNp ofDivininn3nfthe Business and Professions Gdc,and myli¢meis I
WOO VlikMl'1'ISSIJANCL
F-w= in full force and effect. 'FOWL ❑KITCHEN REMODEL.
, u License Class Lic.k APPLIANCES-RESIDENTIALADDITION ❑PLUMBING RE-PIPE
H 6 6 Dom Contractor
nRCHITECP5 DECLARATION E)MULTI-UNIT El STRUCTURAL
zCco,z Iundc....nd my plan,shell be.,ad.,public....rds PANELS MODIFICATION
OZ=O UP TO 20)AMPS C1 INTERIOR [I CHIMNEY REPAIR
rtnl u, LiccnsM PRofroimd 201-IOW AM1I PS IMPROVEMENT
SYS;
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODELIREPAIR C2 DEMOLITION
LL C w d I hereby admit that 1 am exempt from the Contractor's License Lnw forma
a.owV following mason.(Sectito 703 L5.Bovines,and Professions Code:Any city or county SIGNS ELECTRICAL ❑OfHER
RI 3 0 N which rtqussu n e,also re roma ffic atm.,improve,demolish.ore pair any stmelum
Ipp"�r/�r/�a6 pinnoi¢issmnce,also requires the vpplicam for such Permit to atigneJ ma'emtm SPECIAL CIRCUIT/MISC.
2 yzi that hens lieemed,ma...Ito(be prnekiall.f the Commllul's License Law(Cm,,r9
OO (commencingwilh Sectian70(abof Division Sol'be Buvinessond Professions Coda or THMP.METER OR POLE INST COMMERCIAL'
a a c C that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F-Z> nut more than live hundred dollars($30(b. . IMPROV17MENT
f=� ❑ T,as owner of the prup.ry,or my enspluyces with wages as their ale compensation, SWIMMING POOL ELECT RIC El OTHER
p.. rt
will do e work.and the sauctme is am intended oroffemd for sale(Set.WED.Business
cat
3 w and Professions Ede:The Coname oh License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who fiend%or improves thereon,and who does such work himselfor through
hi,own cmPloyee,,pmvided In.,such impre,emem,arc not intended or offered for NI?W RESIDENTIAL ELEC'I'R SQ FT.
vale.If.hOwncr.the buildingor Improvement issold wind.one year ofcnmpletion.the SQ.h1'.FLOv.R/q�NIiA SISQ.PI'.
r-builder will have the fiuNen of pmvingthat he did not build orimpmve for per- LO 1 '1{/G' Q
prow of sale.), lY /6 9
❑ 1,as owner of the property,am exduxively comm,ning with licensed contnmtom to /, 9C
construct rte project(Sec.7046.Business and Prolcsions Code:)The Contractors Li. , +� s r - k99
ceaw Law docs mm apply to an owner of property who build%or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a c(intmetoos)licensed pursuant to the Contractors r,I
License Law. PHRMIT ISSUANCE
❑ T um exempt under Sec. .B&P C for this mumm
ALTER-DRAIN&VENT-WATER HA) VALUATION
Owner Due 1 0
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE IL
1 hereby iimaffirm under penally of pepuD one of the fnsum rt)g decWorkee ions �r
0Ie,as provided
forbyneCion 3700 of Ce Labor Calfle.further Worker,Co of the DRAINS-BOOR.ROOI',AREA,GOND. STORIES 'TYPE CONSTRUC'HON
xmiom,as pmvided for by Section 3]Ip of the labor Code,for the performame of the
work for which this panni'i,issued FIXTURES-PER TRAP
❑ I have and will maintain Worker's Cnmpensme w rkfor which
as this
required by Section
37(X1.(the(ober Code,for the perfommnce afthe work for which xis permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC,GROUP AI'N
My Workers Compenxaion In,amnae carrier and Policy number are:
Cartier: Policy Na.: GAS-EA.SYSTEM-OVER Y(EA)
CERTIFICATE OF FXEMPTON FROM WORKERSGREASFJINDUti FRL WAST'13INTERCEPTUR
COMPENSATION INSURANCE BUILDING DIVIS101%kEES
Mis,eUmaneednm becomplabi ifthe permit is prime humbaddnllan:(SIM) GREASETRAI'
or Itva) PLANCHECK FEE
leerily that in the perlirmmme ofthe work for which this Permit is issued.I shall SEWER-SANITARY-STORM En.2W FT.
nosubject t employ any Peron in any manner ma as to become subjecn the Workers' pen-Com1iNERCY I IiIi
O Z .tion Laws of California.Data WATER HEATER WNENT/ELECfR GRADING HE
Z Q Applicant
.N. Nf ITICE TO APPLICAM':If,after making this Ccnifcam of Exemption,you should WAFER SYSTEM/1'REATING SOILS PGB
> become subject to the Worker's Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this perms shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PINS. SQ.FI'. PAID
VQ T hereby ulfirmthal there iso construction lembagagency liutheler(immune of I, utplM
w ,r the work for which this permit is issued(See.3197.Civ.C.) TOTAL:
C)U Lenders Name
Lender's Mims,
I cenily that 1 have lead'his application and state that the above mourn ifian Is HUI G PEE �•
[" N correct.1 agree to comply wdh all city and enemy ordinance,and one laws ielaing in QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authnme reprewmatives of this city no enter upon the SEI. FE
above-mentioned propertnspection purposes. PERMIT ISSUANCE.
(We b and mot'y and keep humde,s rte City of Cupertino against ELECTR .FE6
lmmi'ie- g s,cons an expnacs which may many way acerae against said City g1:1'F:R OR ADD TO MECH.
damn. Rthe great of'his petted'. PLUMB NGPEE
APP CYe UNDERS NDS AND WILL COMPLY WITH ALL NON-POINT ATR HANDLING UNIT(TO 10,000 CFM) MECHA AL FEE
SO EGULATI , S.
I AIRHANDI.INGUNIT(OVHR Id,IKKICPM) CONSTRUG'F NTAX
ppluanVConrdcmr bra EXHAUST HOOD(W/DUCT) HOUSING MITI TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wil 'hcupplinnd or future building oempam%oreor handl IF...Natortmenal HI:ATINGUNIT(TOIW,IXN)BTU)
v -fin y the C.,er ina Municipal Cade Chapter 9.12,and rte Health and Safety
tion 255121x1, HEATING UNIT(OVIiR 100.000 BTU)
❑Yc, ❑No PAID
VENTILATION FAN(SINGLE RGSID) Date Receipt p
Will the applicant or future building oecupanl use equipment or devices which
emit hazeNous air contaminants as defined by the Bay Area Air Quality Management BOILFR-COMP IMF OR I00,000 BTU)
TOTAL:
District? BOILER-COMP(OVER 100,01(a)BTU)
❑Ye, ❑No
I have read the huallous mancri.],na moncnts.tele.Chapterfi95of the Cull AIR CONDITIONER ISSUANCE DATE
fount Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building docs not currently haven temem,,thus it is my respponsihil'ny to notify rte occupant
ul the rtyuimments which must be nact prior to issuance cars Cenllleale of Occupancy.
Owner.,mumn,ed.gent Date _AIq- ISSUED BY,
OFFICE