29680 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^ ^ C HO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDINI:PROJECT ILIP.NTIPICAI'ION L JM v
ILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATI
o1 S6 1VoR'rm I pmyi Ave.
N 000LC REVER P��E: _ S 9 I ONTRAC OR'S NAME: LIC NO:
K 1 NIC CONTROLp
RCHI I ECHENGINEER: LIC NU ADDRESS: CD
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE ❑ ❑
O a Z 1 hereby affirm that I am licensed under provisions of Chance 9(commencing JOB DESCRIPTION
with Sation]000)of Division 3 of the Business and Professions Cade.¢Bay ro license is
�00 I.full forcePERMIT ISSUANCE RESIDENTIAL:
� s effect..U(E� Licrnm Class Lic.p ❑SFDWL ❑KITCHEN REMODEL
Ful Date Contractor APPLIANCES—RESIDENTIAL []ADDITION PLUMBING RCPIPE
m 0. ARCHITECTS DECLARATION
p,Or>>n PANELS ❑MULTI-UNIT
❑ I URAL
Z O I underamndmy planhall heuxdas public reordMODIFICATION
OZ UP T02W AMPS
O ❑INTERIOR ❑CHIMNEY REPAIR
[sis3 ¢I Licensed Pmfessi mal 201-INM�AMPS - IMPROVEMENT
9 44 OWNER-BUILDER., ia DECLARATION OVER["AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
I hereby affirm on I n empt from the Contractors Cas License Lew for the
3 a 1v following reason(Section)031.5, t,aaeBusiness and Professions demolish,or Any city or county SIGNS ELECTRICAL ❑OTHBR
F O} whichrequiresne..1.to.a.no,,,licimprove,n pormitor repair anyomment
...777 cture
poor at he isrcensets locroore to the I..vino. afthe Contractors file.
Law,
agriter9 SPECIAL CIRCUIT/MISC.
yWy
that pumuom m0knolDisionsn with,
Llceoso Law(Chapmr9
(commencing with Section]Oggaf DivisionJof the Business and Pmfessians Cude7 or TEMP.MILLER OR POLE INS[ - COMMERCIAL,
0. n CC that he is exempt therefrom and the basis fmdhe alleged exemMion.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
4• Section]031.5 by any applicant for a pemtit subjms the applicant m a civil Penalty al POWER DEVICES
stn []TENANT ❑FOOD SERVICE
7�p. not more than five hundred Jnllms y amp.
O ❑I,oas the work,the pe cometor my employees withwagesfor sale
compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
.will duthework,and thexo Coatis not intended oraw dolor sale IStc.toan Business ❑OTHER
W0.a and Professions Code:The Contractor's License do does not apply s if owner of OUTLETS—SWITCIIGS—FIXTORES
property who build.or entedtimproves thereon,and who nts such work himself or through
his own employees.peaviJW that such Improvements arc Bol intended or offered for NEW RESIDENT'IAI.IILECI'R SQ fT. -
sale.If,however,the building or improvement is sold within one year of completion,the SQ. F1.00 AREA LSQ.FT.
owner-builder will have the burden of leaving Out he did not build or improve for par- '01 L
Plain of cath).
❑ h m owner of the property,am exclusively contracting with licensed convectors to TOTAL:
constructe,"the project(Sec.7N4,an,Business pandroperty
Professions Cade:)The Contractor'seLi- 211996
who coawdoonouch plymrn with
ofpeapeny who licensed
fortune".
the thereon,anJ QTY. PLUMBING PERMIT FEE
who contracts for such projects with a umtmcmr(a)licensed pursuant to the Contrecmr's
License Law. PERMIT ISSUANCE I Y UI' vk#rCIl1 nw
Ium teemcrS ,B&P C forthisreason
Owner_ ~ Date `I ALTER—DRAIN&VENT—WATER(LA) VALUATION
)RKE fS COMPENSATION DECLARATION BACK FLOW PROTECT D17VICII
1 hereby. vm under penalty of perjury one ofthe following declarations:
•O l have end will mainwin.Cenificateaf Conmmto sell-now.,for Warker's Compo- DRAINS—FLOOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTION
nion...v provided(or by Section 37M time Labor Code,for the performance of the
work for which this Mman is is,.M. FIXTURES—PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3'/00of the labor Code,for the perfatmance of the work for which this Permit is issued. GAS—EA.SYSTEM.I INC.J OUTLETS
My 's Compensation Imumnce cancer and Policy number ore: OCC.GROUT' APN
Carrier: Policy Nu.: GAS—F.A.SYSTEM-OVER 41EA7 ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASrANDUSTRI.WASTE INTERCEPTOR
(This section need not be completed lithe permit is rerun,hundred dollars($100) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE
I certify that in the performance ofthe workforwhich this permit is issued l shall SEWER—SANITARY—STORM EA.200 ITT.
not employ any Arson in any manner so as to become subject to the Workers'Compen- ENERGY FEE
OZ anion Laws of California.Date WATER HEATER WNEMIELEC(R
Applicant - GRADING FEE
tiNOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMaREATING
a ' become subject to the Worker's Compensation provisions of the Labor Code.you must SOILS FEB
{i7 forthwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
U 0 Thereby affirm theuhere is aconawninn lending agency fnnhe performance of Data Receiptp
IL t•t the work for whichthis parrot is issued(Sec.3097,Civ.C.)
Q FF'' Lender's Name TOTAL:
Lender's Address I
0. I certify that I have mad this application and state that the above information is BUILDING FEE
VJ correct.l agree in comply with all city and county ordinancea and scam lawarelating to QTy MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize repreacnmtives of this city to enter upon the I SEISMIC FEE
shove-mentioned pmpeny for inspection pmpeacc. PERMITISSUANCF.
(We)ogres m boundlesspen
save,indemnify land keep boundless the City of Cuinu against FLECTRIC FEE
liabilities,judgmema,coats and expenses which may in any way merue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ(100 CFMI
SOURCE REGULATIONS. I MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTIONTAX
Signature of Applicam/Comrecmr Dam EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicanmr future building metapantsmreor handle hazardous mated.[ HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Heabh and Safety
Code,Section 25532(x)' HEATING UNIT(OVER 100.000 BTU)
❑Yes MNo VENTILATION PAN(SINGLE RISID) PAID
Will the applicant or trout¢building occupant use equipment or devices which Data Receipt#
it hazardous air common.....as actual by the Bay Acta Air Quality Management BOILER—COMP(JHP OR 100,01)(i BTU)
Disvin] TOTAL:
FI Yea ONO BOILER—COMP(OVER 100,0010 BTU)
I have real the hazardous materials requirements umler Chapter 6.95 of the Cali- AIR CONDITIONER
825533 a p ISSUANCE DATE
formaHealth gdoes&Softly CWe,Semens255115.is myre.425534.1 undewand thatifthe NEW RESIDENTIAL MECH. SQ.FT.
building does Boas which
have a tenant,that o is my c responsibility Ceccarelli,
notify the Occupant
of the requirements which must be met prim m iswance of a Cenilitule ol'Occup.ncy.
Owner or amhadzeJ.geat Dale TOTAL: ISSUED BY:
OFFICE