29798APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/IaERA4IT PLUMBING-MECHANICAL
• BUILDING PROJECT IDENTIF'ICA'TION
PERMIT NO. 2 9 7 9 8
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�ARCHITECT/ENGINEER:
B ILDING ADDRI�ESS:- +
Y
7SS 47�1�i �!5 i63 .
SANITARY NO.
A1PPLICATIONSUBMITTALDATE
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C RACTOR'S NA/M�E� LIC NO:
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CONTROL
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LIC NO:
M1CWA _ WLI.r 1 Gi 7/60 ` L
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CONTACT: 4y PHONE: �p
1 _F I [,_ 0 0
❑ Consultant Fees Paid by Applicant(Initial)
BUILDING PERMIT INFO
e[,n ELE PLU MICH
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LICENSED CONTRACTOR'S DECLARATION
9 (cocing.
I hereby vffirm that I am licensed under provisions of Chvpmr omme
with Section]000).f Divisir Ir3ofthe Business and Professions Code, and my license is
in funs force and effect.
License
License Class - Lic.k
Dmo 'rontracmr
QTy. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
[I El KITCHEN REMODEL
❑A ❑PLUM BING RE-PIPE
'MULTI-UNIT []STRUCTURAL
- MODIFICATION
REPAIR
IMPROVEMENT
El INTERIOR NDEMO
DEATH REMO •IIREPAIRON
❑ OTHHR
- •
r PERMIT ISSUANCE
APPLIANCES -RESIDF,NTIAh"
N d
FO>y>
z O m ❑
OZr4
ARCHITE 'S DECLARATION
1 ee�rst MPIuy6 Shall h s public record.
�/� /(/'!
PANELS
UP TO 200 AMPS
HGF"
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d
iWS O y U
wC aR+F
5�0
ythat
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d y o C
iC ts,
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Licensed feastmml - .F
OWNER-BUILDER DECLARATION
1 hereby affirm that em exempt Tram the G.ATIONr License Law for the
following reason (Serum; 7031.5, Business and Professions Cede: Any city or county
i mash any statement
which its issuance,
o permit re cones the alter. Improve, demolish, file
poor its lssuonce, also requires the applicant for such pernhmfllovelgnod etmemrm
he is licensed phumart to the provisions ofthe Commcmr's License Low(Chapter9
(cempacia, with Station 7") of Division 3ofthe Business and Prnresoone Codpor
Mat he is mumqu Fetterman and the basis for the alleged exemption. Any violation of
Section]031.5 by uny applicant fors permit subjectsthe applicant to a civil Penalty or
not more then rive handed son[$5o0),
Mei(See 7 4LBuximass
,the pestruc,onnyet intended withwi,cl for
❑ Lo the work,
do nhework, and the structure is not intended omHered for sale (Sec, ]044, Business
and Pmuessions Come The Contractor's License Luw does not apply to an owner or
property who builds or improves Hereon, and who aces such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale.If. however, the huildingor improvement is sold wiMlnone year of controller. the
caner-builder will have the burden of proving that he did not build or improve for pun
oseoale).
pfa
I] 1, as owner of the property, am exclusively contesting with licensed contradicts to
construct the project (Sea. 7044, Business and Professiens Code:) The Contractor§ Li-
rise Law does not apply`to an owner of property who builds or improves tracer, and
who wuntersfor such projects with a comracads) licensed pursuant w the Contractor's
License Law.
❑ 1 am exempt under Sec. . B A, P C (."his reason
201-ION)AMPS _
OVER IOOf1AMP5
SIGNS ELECTRICAL -
SPECIALCIRCUIDMISC.
TEMP. METER OR POLE INS'E
COMMERCIAL:
[:1 NEW BLDG/ADDITION El DEMOLITION
❑FOODSERVIC
El Eata
IMPROVEMENT
IMPROVEMENT '
❑OTHER
-
POWER DEVICES
SWIMMING POOL ELECfRI
OUTLETS - SWITCHES -P 9'U v
-
W RESIDENTIAL ELECTR 01
-
SQ. EI'. FLOOR AREA
v . � �S I
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n
APR' 24 1JJV
i AA7{i
r I n
CI Y ul-'U.I,Y Cil I II�U
SISQ. FI'.
TO L:
g..
QTy' if GING RMIT PEE
PER SSUANC.
ALTER- DRAIN &VEN -W A)
Owner - - Date
rf�1x VALUATION
VVV •r{/��
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofpetjury one of the following declarations:
(] I have and will maintain a Certificate of Coment to self-insure for Worker's Compete-
,an.., es provided for by Section 3]00 of the Labor Code, for the performance of the
work for which this permit is issued.
' ❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 ofthe Labor Code,forthe performance ofthc work for which this permit issued
My Worker's Cam��t tjpp Ins.ma e d Policy nom�er lg
f Cartier: S-r/iliwa � yu l�cerrie Policy Na.:� SO/D3��j
/ CERTIFICATE OF EXEMPTION FROM WORKERS'
. COMPENSATION INSURANCE
(This section need not be completed lfthe permit is for one hundred dollars($ 100)
or leas) I IGREASETRAP
I certify that in the Performance of the work for which t his permit is issued, shall
not employ any person in any manner so as to heme subject to the Workers Compen-
w
s of California. Date
sation Laws
�O
T~jJ NOTICE TO APPLICANT If, are making this CortiGcme or Exemptlen,y.. should
'a become object to the Worker's Compensation provisions of the [,shot Code, you must
W forthwith comply withsuch prnvisicnaor this permit shall be deemad evoked.
Q
(❑� CONSTRUCTION LENDING AGENCY
wP(2 I herebyaffirm that there is o construction lending agency for the performance L,
the work for which this permit is issued (Sec. 3097, Cr, C.)
O ULender's Name
W Lender's Address
l retify that l have read this application and state Is he above information is
F 7:A comet. I agree m comply with all city and county molnunces and state laws reining to
U ❑ building construction, and hereby authorize representatives ofthls city m enter upon the
above-mentioned property for inspection purposes.
' (We) agree to save, indemnify and keep harmless the City of Cupertion against
- liabilities,judgments,costs and expenses which may in any way acerae against said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY Willi ALL,NON-POINT
SOURCE REGULATIONS. '
—•�
y .-�1L(.Q, p
BACK FLOW PROTECT. DEVICE
DRAINS-FLOOR, ROOF, AREA, COND.
STORIES
_
OCC. GROUP
-a
TYPE CONSTRUCTION
APN
FIXTURES -PER TRAP ..
GAS -EA. SYSTEM-1 INC. 4 OUTLETS
GAS- EA. SYSTEM OVER 4(EA) -
GREASFAINDUSTRL WASTE INTERCEPTOR
�'' BUILDING DIVISIdN ITiliS
PLANCHECK FEE
SEWER-SANITARY-STORM EA. 200 FT
ENERGY FEE s
WA'I BE HEATER W/VEN1/11LELTRpplicau-
GRADING FEB
WATER 3Y$TEMlfRBATINC
SOILS FEE .
WATER SERVICE
PAID
Dam R!eceipt# -
NEW RESIDENTIAL PLMB, SQ. pU
-
r, TOTAL:
'UY AE
EE f
QTY, MECHANICAL PERMIT FEE
E /�
PERMIT ISSUANCE.
EE
FEE
lRN
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO lIkWO CFM)•
AL FEG
AIR HANDLING UNIT (OVER IO,WO CFM)
TION TAX
-
-
SigmatumofApplicaMContr Date`
HAZARDOUS MATERIALS DISCLOSURE
' Will theapplicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(.)1
E] Yes -, [Na
Will the applicant or nts auture building occupant use equipment or dMana sea
emit District? s air contaminants as defined by the Bay Arch Air Qoaliry Management
when
D'smictl
❑Ven 7N
Ihlth manthehazard Se materials requirements 6.95 thethat Cali-,
fomia Hexes & Scurry Cele, Sections 25505, ism, and 25534.1 understand that if the
of the requirements which must he met prior t issuance of a Cen'fcem f tX upancy.
of terequirements currently havest be met that t'my res of a C'lltytnTfythepanneY
EXHAUST HOOD(WIDUCU
ITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
-
HEATING UNIT (OVER I tg1,OLs) BIU)
PAID
Dare Rtrial If
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
q'01'AL
BOILER - COMP (OVER 100,000 BTU)
-
AIR CONDITIONER
ISSUANCE ATE
s
ISSUED BY: �a nes
NEW RESIDENTIAL MECI9. SQ. EP.
�
Owner or authorized agent - Data
- „TOTAL:
OFFICE