29433 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. �,�
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT'LDP.NT'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
All
33 G a
0 NI$'S NAME: PHONE:
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CO ACTOR'S NAME: /ate IC NO: N/C NTROL
OWN?
�ARGHLTLiL /liIS 67 MER: LIC NO: AURS: bf
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CONTACT. PHONE: OF BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DF.CLARA'1'ION QTY. ELECTRIC PERMIT FEE
I hcrchy uffrm that 1 um licensed under provisions of Chapter 9(cmairmaing JOE DESCRIPTION
fr�a2 N Section Matter Division 3ofthe Business and Professions Craf my license is RESIDENTIAL:
OO with PERMITISSUANCE
full force and eller q
l-Z� Litten Lic,N�� D SFDWL ❑ THEN REMODEL
yu Date Commctor a APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RI'sPIPE
ARCHITECTS DECLA ATION ❑MUI,TI-UNIT ❑STRUCTURAL
Z O >> PANE"
`r'q 1 understand my plans shall Bebused as public records MODIFICATION
OZ— UPTO HIO AMPS C1 INTERIOR El CHIMNEY REPAIR
FBF'; Licensed Professional 201-1000AMPS IMPROVEMENT
X�,a
OWNER-BUILDER DECLARATION e onteonnenots License OVER 1000"PS El BATH REMODEUREPAIR El DEMOLITION
C Q 1 hereby affirm that 1 am exempt from the Law forum
following maker.(Salim.7071.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER fl
W'314 y which acquires a permit to connect,alter,improve,demolish,or repair any structure
0 pricrto its issuance,also requires the applicam for such permit to file o signed statement SPECIAL CIRCUEDMISC.
} that he is licensed pure onto the provisions of NC Contractors License Law(Chapter 9
sa0 (commencing with Section 70001 of Division 7 mile Business and Pmfitoomas Coal or TEMP.MBE CDR POLE INST COMMERCIAL:
sa
a z Net he is exempt Ihemfmm and the basis for the alleged exemption.Any violation ofad
NEW BLDG/ADDITION ❑ ITI
DEMOLON
ter• Section 7071.5 by any applicant for a permit subjects the applicant to v civil penalty of POWER DEVICES
} sol mare tban live hundred dollars(5500). TNT ❑FOODSERVICE
FabI,us owner of the norm loees with woes vs their sole con nation, SWIMMING POOL ELECTRIC NT
C ❑ property, YemP Y 8 pe
of Il do the workund the aromatic is not intended or o0cmd for sale(See.7044,Business ❑0 F.R
63 m and Profession,Code:The Contractor's License Law deal net apply ,,an owner of OUTLETS-SWITCHES-FIXTURES I'
property whir builds or improves Thereon,and who does such work himself at through
his ewe employees,provided that such improvements are not intendc i nr offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however.the building or improvement is sold within one year ofcomplednn,The SQ.FT FLUOR AREA s/SQ.FT,
owner-budder will have The burden of proving that he did not build or improve for pur-
pose mf sale.).
❑ I,as owner of the preparty.am exclusively contracting wird licensed Capt.".,. TOTAL: • t/
connect The project(Sec.7014.Business and Professions Culex)The Connector's Li-
waste
i-c se Law does not apply to an owner ofpmperty who builds or improves thereon,and Q'ry.. PLUMBING PERMIT FEE ®�
who contracts far such pmj¢Ts with a cam cions)licensed putsuaafit)Ne Contractors �T
License law. PERMITISSUANCEC'l/r 28199,6
C] I am exempt under Sec. ,B&P C fm This mason s7
Owner Dv¢ ALTER-DRAIN&VENT-WATER(PA) VP'LV,///TION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE MU
I
hereby uffrm under penalty of perjury one of die following declarations:
❑I have and will maintain a Cmificam of Consent m self-insure for Workers Compeer DRAINS-FLOOR,ROOF,AREA.COND. - STORIES TYPE CONSTRUCTION
cation,as provided far by Section 37W of the Labor Code,for the performance of the
work for which this lamr,is issued FLXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section 0
37M of the Labor Code,for the performance of The work for which this permit is issued, GAS-M.SYSTEM-I INC40UTLEfS - OCC.GROUT' APN
My Worker's mansminal a olecnrriervnd Policynamherate:
Currier. - policy Ne.: GAS-M.SYSTEM-OVER 4(EA)
9:I2'1'IFICATE OF EXL'MPfION FROM WORKERS'
COMPENSATION INSURANCI3 GREASEfaIDUSTRL WAST'F,INTERCHVTO1t
('Otis sermon need not he completed if the permit is for one hundred dollars ISIW) BUILDING DIVISION FEES
less.? OR BASE TRAP PMNCHGCK PEIi
I verify that in the radmitancen oro work far which this permit is issued.I shall
not employuny person in any manner ser as To become subject In he Worker,'Compos- SEWER-SANITARY-STORM HA.200 Fr. ENERGY FEE
cation Laws of California.Date
O Applicant WATER HEATER WNENT/13LEC1'R GRADING FEE
r~N. NOTICE.TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TRMTING
C•" , becmne subject In the Wado,a Compensation pmvisinn,ria the Labs Code,you most SOILS FEE
� u.c forthwith comply with such pmvisinnsar chis Permit shall be deemed revoked, WATER SERVICE
ow
0
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ IT. PAID
(� Q Iherthy uffrm Neuherc is nconstmdion lending agency(ante performance of Data Receipt
Oti the work for which this permit is issued(Sec.3197,Civ,C.)
I-'' Leaders Name TOTAL:
ul Lender's Address TOTAL:
Ga 1 certify that I have mond This application and state that the above infornmtion is BUILDING ME
W correct,I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF.
V P, building construction,and hcrchy unitarian representatives of this city to enter upon The SEISMIC FEE
above-mcntinncti prnpery for inspection purposes. PERMIT'ISSUANCE
(We)agree mav
se,indemnify and keep hurmless the City of Cularlimn against ELECIAIC FEL?
linbilities,judgmenls,vests and expenses which may in any way aceact,,shul.said City ALTER OR ADD TO MECIL
in censequc enf The grunting of this permit. PLUMBING FEE
APPLIC UNDERS ANDS AND WI MPLY WITH ALL NON-P01 AIR HANDLING UNIT(TO 10.00r,
OUR t UL O MECHANICALFEE
AIR HANDLING UNIT(OVER 10j")CFM7
t• - CONSTRUCTION TAX '
Sign um of pp canUCemmctnrstriate
EXHAUST HOOD(W/DUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will beapplicvncorfar..buildingottupantiaosomhaadle baaurlmus mmenal HMYING UNIT(TO 100,(g)O BTU)
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code.Section 25532(aTl IfMTING UNIT(OVER 100,000 BTU)
❑Yes ON. VENHMTION FAN(SINGLE RISID) PAID
Will the applicant or antra Building bt use equipment or devices which
Date Receipt
emit um air contaminants as deteg by the Bay Ana Air QualityManagement BUTLER-CUMP(3HPOR 100,000 BTU)
District!
TOTAL:
❑Yu No BOILER-COMP(OVER 100,000 BTU)
I have mad The huallous materials rements under Chapter 6.95 of the Cul I. AIR CONDITIONER
requi a ISSUANCE.DATE
amnio health&Safety Colo,Sections]5505,is my and 25534,1 i ndenund that if theItuildfiNEW RESIDENTIAL.MECH. SQ,ItE
ofthe re Anes not currently lawn mount,p for o is my psinace ark Cer iy ca notify The xccy
of the r<quircnems which nun he met pnnrmissuunce nfa Certificate of Occupancy
Owneror matured agent Data TOTAL: ISSUED BY:
OFFICE