29388 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMII'NO. 2 9 3
BUILDING DIVISION APPWCATION/PERMIT PLUMBING-MECHANICAL L�../131XJ VX
BUILDING PROJECT IDENTIFICATION
BUILDOUR • SANITARY NO. APPLICATION SUBMITTAL DATE
(W 'SAt.1 PHO E: CONTR ON'S N 'LIC NO'.
/ N/C CONTROLN
�I A
I.R:
LIC N
AUURE• S. _ ❑
CONTACT: PHONE: r BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ A ❑
Lmthat FDCONTRd under provisions
QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 oro licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
00 with Senion]Ogl)of DivisionJof the Business and Professions Cade,and my license is PERMIT ISSUANCE RESIDENTIAL:
in PoII farce and eft
Coda .L ❑SNWI. El KITCHEN REMODEL
a U 1 License C s Lic,g
'�<a Date a tactor APl'LIANCPS-RISIDEM'IAL ❑ADDITION � ❑PLUMBING RE-PIPE
I.as 0. AR Tf $DECLARATION PANELS ❑MULTLUNIT []STRUCTURAL
Z 1 used n cords MODIFICATION
s re UPT0200AMI:S I ❑INTERIOR ❑CHIMNEY REPAIR
CPES OWNER-BUILDER DECLARATION 2014000AMPS IMPROVEMENT
y affirm that I um enerept from the Comrselors License Low for the OVER I"AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
b 0=0 Bdlnwi ecolor.(Section 7031.5.Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑01'HEiR
tna]l O
which rtquiree a Permit m construct.slier.improve,demolish,or repair any strucmm
0 pricam asismance,also requires the uppliennt forsuch Permit o rdc usignedstatcment SPECIAL CIRCUIT/MISC. \
Q� Nat he is licensed pursuant a the provisions of the Connector's License Law(Chapter 9 e
GAO (cammencingwish Section]OW)af Divin.r3ofthe Bminessnod Professions Cale)or TEMP.MLTI?R OR POLE INST. COMMERCIAL:
6 n that he is exempt therefrom and the basis for the ullcged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]0313 byany IPplicamfara permit subjects theepplicam macivil'maby of POWER DEVICES ❑TENANT ❑FOOD SERVICE
z�y not more than rive hundred do]].6500). IMPROVEMENT
a0
01,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the wurk,and the structure isnot intmaltal ralfered for sole(See704PI,Business ❑OTHER
and Professions Code:The Convector's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Pat who builds nr improves theame.and who does such work himself ar through
his own employees,provided that such improvements arc not intended or offend for NEW RESIDENTIAL ELELTR SQ E-n
sale.If,however,the building or improvement is sold within one yearofcompletion,the SQ,FT.FLOOR AREA VSQ.FT.
owrmr-builder will have the burden of prnving that he did not build or improve for Pur- r LV k )
Potentiate.).
❑1,as owner of the property,am exclusively contme ing with licensed amtmetom to TOTAL:Li- MAR
onswct the project(Sec.]fH4,Business and Professions Cate.,The Co o—olrs 7 1996
cense Law does not apply to on owner of prepeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE O
who contracts for such Projects with a contractors)1lcensal pumuanfto the Convucmrs I
L��Y Ur
License Lew. PERMIT ISSUANCE 4urcn I I14C
❑1 nm exempt under Sec. ,B&P C for this mason
Owner
AI.TF.R-DRAIN&VENT-WATER(EA VALUATION
Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby M.under penalty of perjury one of the fallowing declarations:
❑ [have and will maintain a Certificate of Commeun self-insure for Workers Counter- DRAINS-FLOG, ROOF.AREA,CORD. STORIES TYPE CONSTRUCf10N
station,its provided for by Section 37W of the Labor Cate,far the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
37W ofthe Labor Code.for the performance of Ne work for which this Pitis issued GAS-EA.SY.SIF.M-I INC.4 OUTLETS Oso DEC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier, Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREiASFIINDUSTRL WASTE INTERCEPTOR
(This section need not he completed Hthe permit is far one hundred dollars is 100) BUILDING DIVISION FRES
or less) I GREASE TRAP
PLANCHECK FEE
Loy my thaperm Ne perfnrmner of thesend for which this per Woo issued per-shall SEWER-SANITARY-STORM EA, FT.
not employ any parson in any manner so as m become suhjecnn eche WorkerF Cooper- ENERGY FEE
Z z plLias.of California.Dam
Applicant WATER HEATER WNFM/BLELTR � ��
Z O ApplGRADING FEE
y NOTICEAPPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM?RFATING
f-a; become subjbj ect to the Worker's Comas or this provisions of eche Lobar Cate,you must SOILS FEE
� rw forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE:
Q
CONSTRUCTION them is a c10N LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.Ff. PAID
14 I for by affindwhich
thauhereisncdiSce,ionlenCie.agency forthe performance of Data Receipt
14 OF the work for which this permit is issued(Sec.3119].Civ.CJ
0 Lender's Name TOTAL:
44L Lender's Address TOTAL:
1 certify that 1 have mad this application ami strum that the about information is BUILDING FEE
N aomrcct.l agree to comply with all city and county ooinarues end struma laws rtlatingm QTY. MECHANICAL PERMIT FEE
V building communion.and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE.
obave-mctionnod property for inspection purposes. PERMIT ISSUANCE
(We)agree to serve,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
hahilities,judgmems,casts and expenses which may in any way accrue against mid City ALTER OR ADD TO MECO.
incomAPPLICANT of ERmndn"ANDStAs Wa9l.COMPLY WITH ALL NON-P INT PLUMBING FEE
AIR HANDLING UNIT(TO 10,000 CEM) -:5370
SOURCBI S. MECHANICAL FEB
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
gna anVCanhwzmr Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLO E
W I eapplicant mouton,building occupant samen ninlehazerdousma¢tial HEATINGUNITGO IW.000M)
as dcfin y the Cupenino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? HEATING UNIT(OVER 100,1101 BTU)
71 Yes -7 No PAID
VENTILATION FAN(SINGLE R[SID) -
Will Ne applicant r future building antpant use equipment or devices which Data Receipt Is
•emit hormones air commentators as defined by the Buy Area Air Quality Management BOILER-COMP GHP OR I0n,000 BTU)
UisricYt BOILER-COMP(OVER IM W BTU) TOTAL:
❑Yes ON.
I have read the"Ideas materialsAIR CONDITIONER - ISSUANCE DATE
rtquirtments order Chapter 6.95 of eche Cali-
fornia Hcalth&Safety Care,Sections 25505,25533 it 25534.1 undermand that if the NE W RESIDENDAL MECH. SQ.Pi'.
building docs not currently have a tenant,that it is my responsibility to notify the twcupaut
of the mouircments which must tutnet dorm issuance of a CeniOcate of Occupancy.'
Owner ar anthodzcd agent Data TOTAL: ISSUED BY:
OFFICE