29720 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'I'N029720
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �4J L
I3UILBING PRIURCT IDEN'Tlh'ICA'I'ION
BUILD CARESS: SANITARYNO. APPLICATION SUBMITTAL DATI
OW {y/ryl? .�_ I PHONE'. CQKf Np
ACfOR'1 E: LIC :
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COrNNPAICCe I\`rtt � PHONE: - ��,H��ay,.J, BUILDING PERMIT INFO
,u ��DUOQ�t7 q{r7•�01,%6) Consultant Fees Paid by Applicant(1nlBap _ BLDG ELE PLO MECH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Ihm I ran licensed under provisions of Chapter 9(commencing JOB D SCRIPTI N
❑CCz wim Section 7IXI0)efDivision3ofthe Business and Prnfessian Coda,anJmylicenuis RESIDENTIAL-
- in full force and cRe PERMIT ISSUANCE --y—=�
WG et. n� Z ❑SFDWL ❑KITCHEN REMODEL
MSUp License ux Lic.k gpPLIANCF..S-RLSIDI!NTIAI- ❑ADDITION ❑PLUMBING RE-PIPE
;+� Dmex Contractor
�p,n RCHITECT'SDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z Z 1 uaJmmusJ my Pa.,hall be used m public records MODIFICATION
O Z IIP TO 200 AMPS ./
❑ I El INTERIOR C1 CHIMNEY REPAIR
�,� Y1 Licensed Professional 201-I(IOIIAMPS - IMPROVEMENT
••T OWNER-BUILDERm the Com ION OVER i"AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
eW;CE ,4
K J 1 hereby.(Sero that 11. exempt from the Conuacmrs License Law for she
3 a uF Following reason.(Section 70]1.5.Business and Professions Code:Any city nr county SIGNS ELECTRICAL ^ [I OTHER
Ooo which requires a permit In enmwcl,alter,improve,demolish,or repair any nmeurc l�
{n� primi.io issuance.also requires theopplicantforsucin permirto file a sig.ULIrtementSPECIAL CIRCUITIMISC.
} that he is licensed pursuant to the Provisions of the Contractors Licenu Law(Chapter 9
I+1 ❑O (commencing with Section 70p)of Division 3 of the Business and Professions Cartel or TPMP.METER OR POLE INST. COMMFRCIAL:
6{y m Nm he is excmpl Nerefmm end the basis far Ne ollcged exemption.Any violation of - EW BLDG/ADDITION ❑DEMOLITION
{itCl Seminn]03LS by any applicant fora permit subjects Ne applicant macivil penalty of POWER DEVICES
^'m NAST ❑FOOD SERVICE
F-Zanot mom Nan five hundred dollars(SSW). I ROVEMENT
❑Lnownerof the pmpeny,mmyut employees wimwmges ricile(Site 044,Baannn, SWIMMING POOL ELECTRIC
yqZ' ❑ will dnfeniamk,ande: he mreisonl,Lice sur nffe does,
(SecJl144,Business []OTHER
Lel and property
elms Cafe:The Contractor's License law dnas not apply m un owntt el U'LEI'S'-SWITCHPS-FIXTURES
his o nY who builds or improves t such improvements and who does such work himself of through
his own employees.he provided shat such oldw are not intended or pBeren,for NEW RESIDENTIAL C:LCCfR SQ FT.
sale.ILhewev will
have the bur en of p mens issoldhe ithinone yearoftbildori improve for
SQ.FT FLUOR S/SQ,W'.
owner-builder will have the harden of proving that he did not hail]or improve far put �-
pose of rale.). A
❑1,as owner of Ne property,am exclusively contracting with licensed contractors to )
construct the project(Sec.7(W,Business and Professions Csxlc:)The Contractor's Li-
cense,Law alms not apply loanowner olproperly who builds or improves lhcreot.and QTY PLUMBING PERMIT FEE
whommosets for such aroma with acomractor(s)licensed pursuant tome Contractor's ass elf, 1996
License law. PERMIT ISS NCC r
Ellam exempt under Sec. ,13 R P C for Nis reason k/y f
Owner Date ALTER-D AIN 1!NT-WATER(E ) VALUATION
WORKER'S COMPCNSATION DECLARATION BACK IRO Cr EVICE D• / ���
I hereby affirm under penally of pcei ry one of the following declarations:
❑ Ihave and wilrommum a Certificate ofConsenuo self-insure far Workers Compen DRAINS- OR, EA.COND.
sation,res previded for.by Section 37M of the Labor Code,for she performance of the TORICS IYPE CONSTRUCTION
son-1,for which this pcmdt is issued. PIXTG - RTR
ay�.ls�t have and will maintain Workers Compensation Insurance,as reyuireJ by Section
3]IXlnl'Imance
he Labor Code,for the perforof the work for wbich,hi,point is issued AS'EA.SY. INC.40U'METS OCC GROUP APN
My Work ompcnsationl nit c7�a carrier ad Policy...I a, S-EA.SYSTEM- (EAl
Carim c No.:
FROM TCR '
COM PENSATION INS U RANCE C H S W STE INq .R'EPfOR BUILDING ISION R!IS
(This section need not he completed if the permit is for one hundred dollars($IW) GREASE.TRAP
or less.) PLANCHECK FEE
Icerify shat in me performance ofthe work for which thin permit is i,sued,lshall SEWER-SANITARY-S'f .2 FT.
not employ any Iwrxon many manner m as m beemne subject in me Workers'Cnmpen. ENERGY FEE {�
O ,z sation lawsof Culifomia.Date WATER HEATER WNF.NT/ELEM
Z 0 Applicant GRADING FEE
(A NOTICE TO APPLICANT:If,after making this Cerifeme of Exemption,you should WATER SYS'D?MaREATING
abceonte subject it,the Wnrwex Compensation provisions of the[.,,bar Cale,you most SOILS FEE r
forthwith comply with such provisions or this permit shall be,deemed revoked. WATER SERVICE
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID !�1
UO Ihereby ifimvhat there is a construction lending agency for the performance of Date
IL Hme work for which this permit is issued(Sec.30)7,Civ,C.)
U Lenders Name
OTAL:
D-I Lender'sAddress
1 cerlify Ihnt 1 have rend this upplicmion end nam thm Ibc above inlimmmion is JHOUSINGA
r•
ciel correct.l agree to comply withal)city amt county ordinances and nate laws mixing to QTY. MECHANICAL PERMIT ••E
U z building construction,and hereby immunize representatives of this city to enter upon the G
TJ
above-mentioned properly,for inpatinn purposes. PERMIT ISSUANCE
(We)agrce msave.indemnify and keep harmless the City of Cuparlino against O
liabilities,judgments,costs and expenses which mayin anyway acerae against said City ,TCR OR ADD I'O MECH. Vnet ��in consequence of the grouting M this pmnit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT pIR HANDLING UNIT(7n IO,Og)CI'M)SOURCEREGULATIONS, Jr.-I�/'/I AIR HANDLING UNIT(OVER 10,0(10 CFM) AXol'ApplicaMConwcmr Data EXHAUST HOOD(W/DULT) IONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building eventual store or handle hazardous material HEATING UNIT(TO I00.0%)BTU)
as defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER 100,000 BTI)
❑Yes y'n VENTILATION PAN(SINGLE RESID) PAID
Dote R7r,,m M
Will the applicant or(mare building occupant use equipment or devices N'ant BOILER-
emis hazardous air contaminants as defined b Ne Ra Area Air COMP(3HP OR I W,I]W BTU
Bay Quality Management )
District? 'TOTAL:
❑Yes $CNo BOILER-COMI'(OVER 100.00(i BTU)
I have read the ha omfouuss materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANC D E
fomia Health A Snlcty Cole,Sections 2.5.503,25533 and 25534.1 mohmtand duct if the NEW RESIDENTIAL MECH. SQ.1-7.
hullding does nos currently have a tenant,that it is my mepnnsmility to notify me cmapant
of Ne requiremenu which must be met primto issuance of a Cenificam of Occupancy.
Owner nr aumorreJ agent UumTOTAL: ISSUED BY:
OFFICE