29389 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29389
BUILDING DIVISION' APPLICATIONIPF.RMIT PLUMBING-MECHANICAL.
BUILDING PROJECT 0HISG Ih'ICATION
BUILOf GADDRE.SS: SANITARY NO. APPLICATION SUBMITTAL DATI
ODER 5 NAM P ONP CONTE R'S NAME: LI 2
( I I NIC CONTROL of
A E f?F: UiPid , 11 LIC NO: ADORISS �� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
1 hereby affirm and I am licensed under previsions of Chapter 9(commencin QTY ELECTRIC PERMIT FEE
s JOB DESCRIPTION
D00 o.mwire Sx c (10)of Division3 of the Business and Professions Coda and my license is RESIDENTIAL:
Cl) info ll forenode c 1'13RMD'ISSUANCE
�k.UV Lic lase Lic.p ❑SFDWL C]KITCHEN REMODEL
PZW Ip or APPLIANCES RESIDENTIAL
❑ADDITION ❑PLUMBING RE-PIPE
2 L=)q ARC[ ' TCP XLARATIUN ❑MULTI-UNIT ❑STRUCTURAL
5 1 1 plans sed uspublic record, PANELS MODIFICATION
OZ�O LI' t UPT02001AMPS ❑INTERIOR ❑CHIMNEY REPAIR
m ' ' 201-10WAMPS IMPROVEMENT
,ej y S,'4j OWNER-BUILDER DECLARATION ' OVER I000AMPS ❑BATH REMODF.UREPAIR C 1 DEMOLITION
CC L'm U 1 ecu .(Flan on 1 13 exempt from the Contractors o e:A.,.Lew for the
d U fol owing mason(Seaman 703 13,Business and Rvfesinoa Code:Any city nr countySIGNS ELECTRICAL ❑OTHER
a.F which requires a permit a comwct,I ler,improve,demolish,m repair any structure
promo its almanac, requires the applicant forsuch,conto 1.Ile asignedssumenl SPECIAL CIRCUITIMISC. �� —
a� that he is licensed pursuant to me provisions of the Contractor'sLvCm,CLaw(Chapter 9
GC (commencing with Section 7000)of Division 3 ofthe Rosiness and Professions Code)or TEMP.MIII R OR POLE INST. COMMERCIAL:
a c C Not he is exempt therefrom end the basis Por the alleged exemption.Any vmitift r of ❑NEW BLDG/ADDITION ❑DEMOLITION
.�q5'^
Section 703L5 by any applicant fora permit subjects the applicant in u civil penalty of POWER DEVICES
sn^y ❑TENANT ❑FOOD SERVICE
I„Z} amore than live hundred Jollors($500). IMPROVEMENT
�C ❑Lshe vorofmlme sury,mmyo,i eyeeswithwaga asweirsnle compcmmion, SWIMMING POOL ELECTRIC
o will Jothscions and a The mre is moisenense Law due,xil rof apply to
an Business
ner of
❑OTHER
^m and Professions Codin improves
themes License Law s such
nrn apply m if owner of OUTLETS-SWITCHES-FIX]'URCS
6 a^ hpropertyis own who builds pr improves thereon,and who ans such wnrk himself or through
his own employeese provided ohm such improvements a2 not intended m offemd for NEW RESIDENTIAL ELLCI'R SQ
soleer-buihowever,r will moc ill,hu m of perces is at he i min nne ilL,mprwoftxn•m. SQ.FT FLOOR AREAS S/SQ.PT.
,anc
owner-builder will have the boNen of proving that he Jid not build ncu improve for pury
❑1,as owner of the property,am exclusively convecting with licensed conBun.rs m TOTAL. MAR 7 199%
construct he project(Sec.7M4.Business and Profession,Ce..,II-C.n..... s Li-
ambeLawduesnotapplytoanownerofpropmywhobuildsorimprovesthereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a comucmrts)licensed pursuant to the Cmuracrrs UI r Ur uurCrtl III L)
License Law. PERMIT ISSUANCE d
El Iamexmnplunder Sec. ,B&PCformis reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSAI ION DECLARATION BACK MOW PROTECT.DEVICE
1 her.hy affiran under penalty of perjury one of the following declarations:
❑I have and will maintain a Cmtificom of Coment to self-insure for Worker's Compact- DRAINS-FLOOR ROOF,AREA.COND.ro00 STORIES TYPECONSTRUCTION
saner,as pvided for by Section 3] of the Timor Ca e,for me performance of me -
work for which this permit is isamcd Iq STUBBS-PER TRAP -
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the lsMr Code,for the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS LL 00 OCC.GROUP APN
My Workers Compensation Insurance currier and Policynumhr am:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRRASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
section need two hcamp,ned if the permit is for be hundred dollars(5100)
or less) ! GREASETRAP PLANCHECK FEE
I certify that in the performamceofthe work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM FA
not employ any person in any manner so as m subject become subjeco the Workers'Compen- .200 Fr. ENERGY FEE
OZ Italian Laws of Cnli(omia.Date WATER HEATER W/VENT/ELECIR
z Q Applicant is ZC GRADING FEE
y NOTICE TO APPLICAN'I:If,atter making this Catifcate of Exemption,you should WATER SYSTESETREATING
a ; became subject to the Workers Cmin,mantian mwitions of me Labor Code,you must SOILS FEE
Til fonhwim Comply with such pmviam's or this permit shall he deemed revoked. WATERSERVICE
Uz CONSTRUCTION LENDING AGIiNCY NEW RESIDENTIAL PLMB. SQ,Ff. PAID
L) I hothi mmemisamnswctianlending agency forth,performance of Dee Receiptp
W 1-�
the work forr which
this permit is Issued(Sea 3047,Ci,C.) TOTAL:
Q F^ Lenders Name,
P. L.mler1 Address i TOTAL:
P. certify moo I have read this y and
un and swan ordinances
the shove itate ws rmutinn is BUILDING FCIi
Z? Correcttaildo irmarem,andcon,sy wcebyin ha ernuntymdinexciftnd ityormsre,singe QTY. MECHANICAL PERMIT FEE
U z building ttmsaraion,and hu.by aulhoriu represenmivn of pis city on enter upon me SEISMIC FEE
.hove-madmi ed property for inspection pm,m a t.
(We)agree I.save,indemnify and keep hmnd,x she City of Cupenima against PERMIT ISSUANCE ELFCfRIC FEE
Iimi,inct,jud,ramp,casts and expcnse,w bingy'aany way acemeogdnssaid Cioy
JJyy ALTER OR ADD TO Mf:CH. PLUMBING FEE
in Ezff
APIL . MPLY WITH ALL.NON�'OI AIR HANDLING UNITCf0 Ig00OCFMI MECHANICALME
SOS.
AIR HANDLING UNIT(OVER IB(MM)CFM7 CONSTRUCTION TAX
nsu o Cosracer D EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
t HAl RDOUS MATERIALS DISCLOSURE
Wil plicano.r fume building uccupaal shirt or haMle hound as material HEATING UNIT(TO 1011.000 BTU)
as define ere Cupertino Municipal Code,Chaplet 9.12,and me Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER I00,(NN)BTU)
[I Yea ❑No VENTILATION FAN(SINGLE RFS ID) PAID
Date Receipt Is
Will m,.,If omanl nl future building cby the IT use co Air equipment or dM..which BOILER-COMP(3HP OR IOq(NI0 BTU)
emit humrdnns air cnnwminums as ddined by the Bay Arca Air Quality Munagcment
DTOTAL: (�
1vin?
E]Yet, El No BOILER-COMP(OVER 1110,001(ft PTU)
I have,read the horNoas mmerialsrequirements under Chapter 6.95 of Of.Cali. AIR CONDITIONER ISSUANCE DATE a
forma Health&Safety Ce.,Sections 2.5505,2-1533 scud 25534.1 mademand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a terman,that it is my responsibility to notify me occupant
of me requinancros which nest h mu print a issuance of it Cenificule of Occupancy.
Owner or amhoriud agent Dam TOTAL: ISSUED BY: 41
OFFICE