29235 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/I'ERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEN'T'IFICATION JM L
BUILDINGADDRESS:/J-�� / SANITARY NO. APPPLLICATION SUBMITTAL DAL'E
04,1
O R'S NAME: fp //�O ^ �1 .'LO// COyTRAC R' NAME: LIC NO: ❑
/. / a 1 S J T R NIC CONTROL x
RCHITECTIENGINEER: LIC NO: ADDRESS:
C ACI PHONE: BUILDING PERMIT INFO
/ ^/r'- �J///y��// ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED'CONTRACTOR'S iDECLARATION QTY ELECPRICPERMIT FEE
1 hereby off that 1 sm licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CZO with Smiim,70m)). oflhe Bminesso Prdassmt dny I mmeia 1 IgiRM1'I'[ss 11n NCE RESIDENTIAL'
F mfull force onJ 1g�ur i. < 1
UH Licrn la L � � ❑SFUWL [3 KITCHEN RCMODF:1,
rr�� yam- APPLIANCES-RESIDENTIAL
W� Dam�sCx�/ Contraclo - ❑ADDITION ❑PLUA1BING kE-PIPE
[.ay ARCHITF,-I':S DECLARATION PANELS ❑MULTIUNIT ❑STRUCTURAL.
xpH� ' Iurdandmid my pitim,dall be madvio oleic recmda MODIFICATION
0Z�O UPTO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
h4tnl Licensed Professional - 201-1000AM IMPROVEMENT
�6'�.' OWNER-BUILDERDECLARATION 201-01000 ATPS 4s W a I hereby affirm mal 1 am exempt front the Com non's License Law for the o❑orrrBr..ATH RRMODCURF.PAIR El DEMOLITION
dU fallowing reason(Section 7131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL J ssTHER [
sR 3
P''00 ya which requires a permit to construct,alter,improve,demolish,or repair any structure ��l
.1 prior its issuance,also requires the applicant for such Permit fiPEC
le a signed statement SIAL Cl RCUIT/MISC. 7-
d� (hot he is licensed pnrsnantmlot poo,West,of Commoner's U.dw Law(Chapter 9
(commencing with Section]000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLF,INST. COMMERCIAL:
a m C
that he is exempt merefmm and the basis for the reneged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
R• Section]031.5 by any applicant for a permit subjats the applicant to a civil penalty of POWER DEVICES
�+ sn ❑TENANT ❑FOOD SERVICE
2 nal tome than fivethe pyredty,rrsyempl.
O ❑Las
otheowner k.the mesomemmycmptended oithwages:nalei(Sm.compensation, 'SWIMMING('DOLELECTRIC IMPROVEMENT
will do mesons,ands: he Contisto intended or coweredfor talc(Sec.](aa,Business ❑OTHER
06 and Profession Cede:The rnex therean License taw does not apply m if owner of OfIfLE1'S-$WITCHF_5-ITXTURPS
propeny who builds or intpmves merenn,and who Joel such work himself nr through ,
his own cmplayees,provided Ina(such improvements are not intended nr oRbred for NEW RESIDENTIAL ELIiCfR SQ t1'.
sale.IL however he building or improvement is sold within one year ofcompleaom,me SQ.IT.FLOOR AREA $SQ.FT.
owner-builder will have the burden of poising that he did not build or improve for put.
p sc of sale.).
❑ Lies owner of the propeny,am exclusively contracting with licensed conhaams to ' TOTAL:
conahuct the project(Sec.7144,Business and Professions Code:)The Comrvmm's Li. W fl
ceras,Law Jus not apply to an owner of propeny who buildsor improves thereon.end QTY, PL MBIN IT FEE
who marinas Bn such projects with a commands)licensed punuanr an the Commune,
License Law. I d PERMIT ISSIIANC i4
❑ I who exempt under Sec. B&P C for this
Owner Dam reason
ALTER-DRAIN& - TER(HA) VALUATION
KER
ram ad, rand,it] thor, no.1
PACK FLOW PNOTF.0 1'.OE E C (24S
Ihercby efftrm under penally of perjory one of Ne following declumtinnn: 2 'f' OVL/ �!
13700
Iheve and will mainaina Ceniftcaa nfConunua self-insure for Workers Compen- DRAINS-FLOOR,RDDIE,AREA,C D. STORIES 'TYPE CONSTRUCTION
sodium,as provided for by Section 3700 of the Iabnr Cade,forme performsnc<of the
ork for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker Compensation Insurance,s required.by Section ofineLaborC e,for the perfommnce of the work for which this permit is issued. GAS-EA.SYSTBM-1 INC.40UTLG'1:5 OCC.GROUP AI'N
My War ut I .0 nee artier and l'o tr�� /`ir.r GAS-EA.SYSTEM-OVER 4(EA)
Cam Policy / /(]�
CERTI9C OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. � GREASFANDUSTRL WASTE INTERCEPTOR
(This cation need not becompined ifine portal is forms,hundred dollars F1RILE
BUILDING DIVISION FP.85
or Iass.) GREASE TRAP PLANCHECK FEE
Icenif,dadirmmperfammuuol'(hework bnwbich in,permit is isnuaLl,hill SEWER-SANITARY-STORM EA,.20B FT.
not employ any person in any manner so as to become subject it)the Workers'Compcm ENERGY FEE
Zwlioulaws of California.Date
z O Applicant WATER HEATIiR W VF:N ER
LEC GRADING EEE
a-iy NOTICE 10 APPLICANT:IL after making this Ccnlfi,sw of Exemption,you should WATER SYS'I'EM/I'REATING
a hcemna subject ,,the Worker's Compensation provisions mf m,Labor Code,you must SOILS FEE
fonhwim comply with such provision in this pormashall be deemed revoked. WATER SERVICE
�L 0
CONSTRUCTION LENDINGAGENCY NEW RESIDL'NTIAI.PLM(. SQ.IT. PAID
Up I forwhichimuhunhcreisaco (Sec.ion leading7.Cagency l'nr the perfnnnonceof Oma Receiptp
U. f' hework fnr which this pcmlit is issued(Roc.3(19],Civ.C.) -
C U lenders Name TOTAL:
'y W Leadds Address TOTAL:
f.. 04 1 sanity that 1 nice read his uppllen(imn std sale Jett the above imnrtnmion Ix BUILDING F8E
i..rAA correct.I agree(ocmmply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FPE
U z huilding cunstmetion,and hereby atuhuriu reprexenmtives of this city to enarupun the SEISMIC FEB
above-mentioned property for inspection purposes. 0 '
(We)agree(m save,indemnity and keep harmless the City of Cnpen'mo against PERMIT ISSUANCE ELECTRIC FEE
lixtedities,judgments,costs and expenses which may in any way acme against said City
ALTER OR ADD TO MEC(I.
in consequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT AIN HANDLING UNIT ITO 10,000 CFM)
SOURCE REGULATIONS. MECHANICALFEE �•
AIREANDLING UNIT(OVER 10,INX)CFM) CONSTRUCTIONTAX
Signature of Applicam/Cmmracar Dale EXHAUST GOOD(W/DUCI') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore huilding occupant more or handle hasunlous material HEATING UNIT fin 100,k)O BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and me Health and Safety
Code,Section 25532(x)'! If RATING UNIT(OVER 100,000 BTI))
❑Ycs 'AN,) PAID
VENTILATION FAN(SINGLE RESIU) Data Receipt#
Will the applicant or future building use equipment or devices which
nit hazardous air contaminants as defined by by the the Bay Arca Air Quality Management BOILER-COMP(3HP OR IW,OfN)BTU)
` TOTAL:
14Dialran?, a
Cl Yes I HOILER-COMP(OVER 100,000 BTU) -
I I have read me h nnexim s materialsuirements under Chapter 6.95 of the Cali AIR CONDITIONER
req ap ISSUANCE DATE
forma gHealthdoes&Safety Cala ealimvs 25505,25537 and 2553).1 understand that if the NEW RESIDENTIAL MGCH. SQ,fT.
building does not currently have savant,that itiorto is my our
of.Coniymmail ythmpancy.m
I of me�uirtmenls whish muni be and prinrm ixnuance ofa Cenificare of Occupancy. .. '
I Owner or unmarred ug con Data TOTAL: ISSUED BY:
/ OFFICE