29013 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29013
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
,JJWILDINGADDRESS: - ��
SANITARY NO. APPLICATION SUBMITTAL.DATE
/ 0/,5z P¢o�asu/� VII,
WNC �N"AME: 'I PHONE p CONFR C'IOR:NAME: LIC NO:
�e I 4Y704� 40k_7i{l— Y(� � Ll .,h NIC CONTROL.#
•IRCIfI'IECf[ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
9 N`
El Consultant Fees Paid by Applicant(Initial) BLDG ELPLUME MEC
LICENSED CONTRACT OH;S DECLARATION QTY. ELECTRIC PERMIT FEE ErLJ !J
QW, I hereby affirm that l ten licensed under provisions of Chapter 9 Rommearm, JOB DESCRIPTION
wo, with Section 7001oI Division Solna,Business and Professions Cnde.andmylimmo is
PERMIT ISSUANCE
FOO 'y
nE— in full tome and effm. «ea� FDWI, C1 KITCHEN REMODEL
a—U License Class Loc'IT / APPLIANCES-RESIDENTIAL
z W Date Contractor
y L/, ❑ADDIT109 E:1 PLUMBING RE-PIPE
ARCHIT[CTS DECLARATION ❑MULTI-UNIT []STRUCTURALg,D m PANELS MODIFICATION O�Z I understand my plan,shall he recd as public records
CZ—, UP 7021X1 AM PS ❑INTER R []CHIMNEY REPAIR
Licenced Prnressional 201-10N)AM11. 1 VF:MF;NT'
zYm.4 OWNER-BUILDER DECLARATION OVER IIXAMPg ATHREMODEUREPAIR ❑DEMOLITION
C C 6 I hereby affirm that I am exempt from the Contractor's License Law for the
W O W U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHEyR���'
which requires a permit m constmct,alteq improve,demolish,or repair any orous ure �¢7iS< /c�iXXrtn4 1
F•�O priormin issmnce.also requires Ne applicant for such permit to fileasigneJ stammrnt SPECIAL CIRCUIT/MISC.
} that heir licensed pursuanuothe ptxicnionsnrthe Cnmractors License Law(Choate,9
�Qp (commencing with Section 70X10)of Division 3 of the Business and Profusions Cowl TEMP.METER OR POLE INST. COMMERCIAL'
a cy that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BI,DG/ADDITION ❑DEMOLITION
W Section 70315 by applicant for a permit whjie s the applicant lou civil penally dPOWER DEVICES IO ❑TENANT' (_1 17001)SERVICE
rn not more than five hundred dollars(8500), IMPROVEMENT
01.as owner of the property,or my employees with wages as meirsole compensation, SWIMMING POOL ELECTRIC
F will unite work,and Ne structure is not intended or offered for of,(See 70,14,Business ❑OTHER
ad m and Professions Code:The Cm uactors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a 3 property who builds or improves thereon,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.
sade If,husever.the buildingbr improvement i,,.Id withinone year ofcumplctim,dre SQ.FT.FLOOR AREA ASQ.F1'.
'AcrvbmIder wAI have the hurder of,wing thin he did not build fir improve for per-
nl solcJ.
f7 h as boner of the property,am exclusively cmuractlng with licensed enmractora m TOTAL: 37 O O
construct the project(Sec.70,14.Business and Professions Cxde:)The Contractors Li-
c sc law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE \
whoconuacts for such projects with a contracmKs)licensed pursuannn Ne Commacer s
License Law.
Iomcacmpt under Sec. .B&PCfor this reasPERMIT ISSUANCE
on
ALTER-DRAIN&VENT-WATER(EA) ALUATION
Dater O
WORKIiR'S COMPE ATION DECLARATION BACK FLOW PROTECT.DEVICE TaO�k�n
fie (hereby aflinn under penalty of erjnry fine bl the following decla tion: `I00
.Fl lhaveand will maimaina Ccnircae of Comm�uoself-Ensure fm Workers Campos- DRAINS-FLOOR,ROOF,AREA.COND. STORIES 'rY PI:CONSTRUCTION
sation,as provide for by Section 37M of the Lidor Code,for the performance of the
work far which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain workers Compensation Inmomm,sea required by Section
37M of the Under Code,fes the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrico Policy Na.: GAS-IEA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS: GREA5IJINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE OUILDING DI V ISION PliliS
(This uctionneN bbl he complete iflhe permit is for one hundred dollars(5100)
In less.) GREASE'I'RAP
7•S S s S'0 PLANCHECK FM
porbacturne
dre
ch
Icenify lhminthe anymnnero as
ware fiv%objectto The W rkesaCmpton'hull SEWER-SANITARY-STORM EA.200 FT.
not employ any perste in any manner m us to became mbject m the Workers Compton- ENERGY FEE
OZ sation Laws of Cidlomia.Date WATER HEATER WNENDELF.CTR GRADING FEE
Z O Applicant
NOTICE TO APPLICAN'1':If,aBcrmaking this Certificate of Exemption.you should WATER SYSTENUTREATING
av) become subject m the Worke,Conium tin.provisions of the Lamm Code,you must SOILS FEE
W forthwith comply with such powisiansor this permit sued be dmoned revoke, WATER SERVICE
CONSTR LENDINGAGENCY NEW NESIUENTIALPCMB. SQ.FT. PAID
UO IhertbyaIDrm flotation,isis.comminution leoding agency for the perfbmmbnm of Dare ReceiptX
W P the work for which this proart is issued(Sm.3097.Civ,C.) TOTAL:
0 U Lenders Name
} W Lender's Address TOTAL: 9
ns Icenify that 1 have mad this application and state that the above information is BUILDING ITE 9��
HN correct.I agree to comply with all city and county oulumerecs and state laws rolmingm QTY. MECHANICAL PERMIT FEE
U . building eotsvmsetlnn,and hereby amhotdze rept,wntutives of this city to caner upon the SEISMIC FEE
alnrvc-mentioned property liar inspection p rpnses. PERMIT ISSUANCE37-for J
(We)agree m save,indemnify and keep hamiless the City of Cupertino agmoo -lam ELECTRIC FIiE
liabilities,judgments,cosh and expenses which may many way accme against said City ALTER OR ADD TO MECH,
in consequence of the swung of this permil. PLUMBING PIiIi
eqrunvs
APPLICANT UNDERSTANDS AND WELL COMPLY WITH ALL NON-POINT AIR HANDLING UNLT(TO 10,000 CFM) MECHANICAL ME y
SOURCE REGULATIONS. a
",Loffg1Aj )I( 11 1Q AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
tiignuwrc of AppllcanVCmmomamr Dam F.%11AUS'1'110011(W/DUCT( HOUSING MITIGATION FES
HAZARDOUS ERIALN DISCLOSUIdm
Will tbeapplieanlnf ramie hu Eng occupied none or handle hrlasdouxanatenal HEATING UNIT(TO 100,000 BTU)
as define III Cupertino Municipal Code,Chapter 9.12,and the Health end Safay
Code,Section 25532(u)'I HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SING LE RESID) PAID L
Date Receipt Is
Will the applicant or future building occupant use equipment or devitts which BOILER-COMP(3HP OR 100,M)BTU)
mit hazardous air contamiruds as defined by the Buy Arca All Quality Managemcar
District? BOILER-COMP(OVER IINBTU) ( s Co
TOTAL
❑Yea ON. \� \( {r V 'N'dzy
:
1 have¢ad lhehazardousmatcrialsmquiremenls under Chapmr6.95afthc Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understood Na if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a tenant.that it is my responsibility to notify The occupant
of e9nium eau which mast Ic pnm m issuance of a Ccniro to ora upai!�y V
/
owner mauthamIcd agent Of Das, TOTAL: ?, ISSUEDBv. AA�71Oc-uCCe
OFFICE