29521APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
PERMIT NO. a
-11.
BUILDING DIVISION APPLICATION/PERMIT, PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
29521 � � �
UUILDINGADDRESS:�
SANITARY NO.
APPLICATION SUBMITTAL DATt
39Pore v�
OWNER'SNAME: � )RI(INE:
5
C RACT'ON'SNA E: L NO:
NIC
CONTROL#
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❑
SRCHITECf7ENGINEER: LIC NO:
ADD E'S:
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CONTACT. PHONE:
BUILDING PI7RMIT INP
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT U MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby ufOrm that I am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCM PT ION
with Section 7000) of Division 3 ofthe Nosiness and Professions Cede, nit myli.meis
in full force ondcfle # (/�p
License lad Lie#
Date canlracmr
PIiNMI'1'ISSUANCC
RESIDENTIAL :
❑SFDWL ❑KITCHEN REMODEL �p,(
❑ADDITION 2 PLUMBING R&PIPE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
❑MULTbUNIT ❑STRUCTURAL
MODIFICATION
PANELS
UP TO 200AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODEI/REPAIR �DIiMOLITION
❑ OTHER
Licensed Professional
OWNER-RI111,DIiR DECLARATION
I hereby ufrom that I am exempt from the Carmelites License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
201.1000 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
which resquires a permit to construct, alter, improve, demolish, or repair any auucture
prior to it issuance, else requires the applicant fm such permilto file. signed nuramal
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7001 Division 34the Bmineas.od Profession Code) nr
SPECIAL CIRCUIT/MISC.
TEM#'. MUTER OR POLF. INST. se
COMMERCIAL;
that he is exempt lienefmm ane the basis for the alleged exemption. Any violaimr of
Section 7031.5 by any applicant for a permit subjects the upplieunt 1..cisit perallyof
m more than five hundred dollars ($50p.
I, as owner of the property or my employees with wages as their sale compensation,
will do the work, and the someone is not intended or offered for sale (Sec. 70,41, Business
❑ NEW BLDC/ADDITION ❑ DEMOLITION
[]TENANT C:1 1700D SERVICE
IMPROVEMENT
❑ OTHER
- POWER DEVICES
SWIMMING POOL ELECTRIC
and Profess]... Code: The Contracmr's License law does not apply m an nwrer of
OUTLETS - SWITCHES - FIXTURES
property who builds or improves Ncmon, and who does such work himself or through
his own employees, provided that such ]mprovemerm arc not intended or normal for
sale. IL however. [lie building or improvement is sold within one year ofcomplei in the
NEW RESIDENTIAL ELECTR SQ Fr.
SQ. IT. FLOOR AREA
$/SQ. Fr.
owner -builder will have the burden of proving that he did not M1uild.r improve for poo
pose of sale.).
❑ 1, at owner of the property, am exclusively contracting with licensed commmon to
# n
TOTAL:
e nswe the #reject (Sec. ]044, Business end Profeasiora Code:) The Conocmh Li-
401?-
ewdoanoapply m an owncrorpropcny, who builds or improves thereom aad
memLe
QT -Y, PLUMBING PERMIT EE
-#
who contracts for such projects with a contractor(s) licensed pursuant o the Conlructor's
License Law.
I am exempt under Sec. ,B& P C for this remon
4•/�� �i �9Q(
Gh r r WU
PERM17 ISSUANCE
Owner Dae
ALTER -DRAIN & VENT- WATER EA)
VALUATION
r77y�U
iNSATION DECLARATION
Wm
BACK FLOW PROTECT. DEVICE
1 hereby affirm under penahy of perjury one of the following for declarations:
order'par
Worker'sCoupon-
❑(have and will maimassaCenifc.mof the Lim, Codi, for the if I he
smirk, as Provided 1'Pe by Section 3]1X1 of the Lahr Code, for Ne performance nl the
DRAINS -FLOOR. ROOF, AREA, GOND.
STORIES
STORIES
TYPE CONSTRUCTION
]hi
which this permit is issued.
I'IX'fUNiiS - PER TRAP
have Worker's Compensation Insurance, required by Section
❑ I have ami will ode,
for h
My of the "Nor CodaionNcprancecancer anMwnrk fnu which this permit is based.
My Workers Compensation Imomnm eerier and Policy number arc:
Carier,Policy Nu.:
CAS -fiA.SYSTEM-I INC. 4OUTLETS
(XC. GROUP
APN
GAS- HA. SYSTEM -OVER 4 (EA)
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisrection necdnm be completed litho permit is for ora hundred delluca X Its))-
or less)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
OREASH TRAP
PLANCHECK FEC
SEWER -SANITARY -STORM EA. 200 FT.
I certify Nm in theperfomanceofrhe work for which this permit is iswal,]shall
not employ any Person in any manners �o pelpmc�upjecyto the Woheri Compen-
ration Laws of C. o�n Dec L s7 f0
APPlicam #1��� t
ENERGY FEE
WATER HEATER WNENTM.EM
GRADING FEE
NOTICE TO APPLICANT If. after making this Cerificam of Exemption, you should
become subject m the Worker's Compensation provisions of the Labor Code, you amat
WATT; R SYSTEMr RRAI I N 0
SOILS FEB
forthwith comply with such Provisions or this Permit shall be deemed revoked
' WATIiR SERVICE
#
NEW RESIDENTIAL. PLMFI` SQ. FT.
CONSTRUCTION LENDING AGENCY
I hereby union Nat there is a construction lending agency for the performance of
PAID
Data Receipt is
the work for which Nis permit is issued (Ser. 3197, Civ. C.)
Lenders Name
TOTAL:
Lcat ers Address
L:
BUILDING PCC
n and state that the above irmation is
I certify that 1 have read this oppiiemianfo
creel l agree to comply wit all cityand county ordinances and state laws miming to
building construction, end hereby mormize represenatives of this city to enter upon Nc
QTY, MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
E=RIC nil!
uMrve-mentioned pmpcny for inspection purposes.
(We) agree m save, indemnify aad keep hvmlees the City of Captain. against
ALI'17R OR ADD TO MCCI 1.W.
Iiabilides,jidgmenw, costs and expenses which may many w.y.cemc.omras.id City
in consequence of the'reating of IN. permit.
PLUMBING PEC
AIR HANDLING UNIT (1014(00 CFM)
MECHANICAL. FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RE
REGULATIONS. ^ -��
A4A -_ #�_/ `
7
AIR HANDLING UNIT (OVER 10,00) CFM)
CONSTRUCTION TAX
Signature of Applicam/Conavcmr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD UMMULT)
HOUSING MITIGATION FEE
HEXrING UNIT,(TO I otuan ETD)
Will the applicant or future building occupant slurp or handle hazmdous material
as defined by the Cupeni no Municipal Cale. Chapter 9,12, unit the Health and Safely
Code, Section 255321u)"
HEAT]NO UNIT (OVER 100,000 BTU)
Oyes ON.
equipment or devices which
Will the air cortmorfulura building by the rat use Bay
Droit hazardous air, conmminams as dcfined by the Boy Arca Air Quality M.nagemem
District?
❑Yea 0 N
PAID
Dam Receipt #
VENTILATION FAN (SINGLE RESID)
BOILER- COMP(JHP OR 10(,080 BTU)'
TOTAL:
BOILES - COVE (OVER 100,000 BTU)
AIR CONDITIONER
I have read the hezadous meted.11 requiremeaa under Chapter 6.95 of the Cali-
DATE
SSSUUAA
NEW RESIDENTIAL MECH, SQ, FT.
frrnia Health & Sufny Cade. Sections 25505, 25533 and 25534. 1 umkrsamd that if the
building does not currently have a tenam, that it is my responsibility m nmify the occupant
INCE
R
\V\ /U\
of to rcqire
umems which must be met prior to issuance of a Cenificam of Occupancy.
ISSUED BY:
Ownermnilloco adugont - (late
TOTAL:
OFFICE