29016PW.
U
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING - ELECTRICAL,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL.
PERMIT NO, 29016
BUILDING PROJEL71 IDENTIFICATION
BUILDING ADDRESS:-
SANITARYNO.
APPLICATION SUBMITTAL DATE
CW 0—s
OWNER'S NAME; - PHONE: CONTRAC :SNAME: UC NO:
NIC
❑
CONTROL#
�l A l�
fG pqOf
r RCHITECr/ENGINEER LIC NO:
ADDRESS:
0' CA
CONTACT: PHONE:
B UILDING PERMIT INFO
"
❑ Consultant Fees Paid by Applleant (Initial)
Ithl)p ELECT' PLUMB MUCH
c$7f ❑ ❑
I.ICIiNSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT EEE
JOB DESCRIPTION
PERMIT ISSUANCE
sh 0)
wiSecdan?00arnimwian J erne erwmesx and Prarew:ions code, and my Reensc iw
in full force effect.
'ansa IJe.p
ate 'a meant
RESIDENTIAL
❑SFDWL O KITCHEN REMODEL.
❑AUDITION C3 PLUMBING RE -PIPE
❑ MULTFUNIT ❑ STRUCTURAL
MODIFICATION
APPLIANCES - RESIDENTIAL
CHITELT'S DECIARATION
lunde.tvndn ms'Lophe ueW us public rcmrds
PANELS -
Up 10 AMPS
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMflIjELIR R f] MOLITION
LicemedP ssiool OWNER -BUILDER DECLARATION
1 hereby affirm that 1 um exempt frommthe Contractors License Law for e
a
201-100(LAMPS
OVER Logo AMPS
SIGNS ELECTRICAL
fallowing reason. (Section 7031.5, Business end Professions Code: Any city or county
which requites a permit to construct, elect, improve, demolish, or repair any structure
[]OTHER Q/
prior to its issuance, also mounter the applicant far such permit to file a signed statement
SPECIAL CIRCUR/MISC.
that be is licensed pursuant o the pr o. itimirrofBac Conuamors License Law(Chapter 9
TI?MP. METER OR POI,1; INST.
COMMERCIAL:
(commencing with Section7030)ODivision Sof the Bumnessand Pro In ... oo.Cnde)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section]OJ LS by any upplicam fora pemtil.uhjumthe applicennon civil penalty of
no more than rive hundred dollars ($50m.
❑ Les owner of the pmpeny, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended oroffered f rrmle (Sec. RW ' Business
❑ NEW BLDG/ADDITION • ❑ DEMOLITION
F:NANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Cwle:'Ibe Crmactors License Law docs not apply to an owner, of
OUTLETS -SWITCHES -FIXTURES
property who builds or improves thereon, and who does such work himself m through
his own employees, provided that such improvements arc not intended or of1cmd for
NEW RESIDENTIAL ELECIR SQ Irl'.
sale. IL however, the building orimprovement is sold within one year ofcantpletion,the
AREA
SQ. PrEt DNy
s/SQ. PT.
r -b
ownerilder will have the burden of proving that he did not build of Improve for par-
lawn
pn of sale.),
n
'7�-[-�{\/? / I y
r] 1. as owner of the property, am exclusively contracting with licensed contractors'.
emmumuct the project (Sec. ]IW , Business and Professions Code:) The Contractor's Li-
1'
N�
TY PLUMBING PERMIT FEE
cee law does not apply to an owner of pmperty who builds or improves thereon.and
who contracts for such projects with a contractors) Reenact] pursuanpursuant the Contractors
v QQ
vJ
PERMIT ISSUANCE
License Law. i
IamexemptunderSec. ,B&PCh,,In,ma.wn
[.��-.).,i
L(J(
ALTER- DRAIN & VEN'T- WATER (EA)
Owner Date
VALUATION'
Q Q
- WORKER'S COMPENSATION DECLARATION r
I hereby affirm under penalty of perjury one of the following declarations:
BACK FLOW PROTECT, DEVICE.
DRAINS- FLOOR, ROOK AREA, COND. -
i❑ I have and will maintain a Certificate ofConsentto self -insure for Workers Compsto
cation, as provided for by Section 37W of the Labor Cade, for the performance of are
STORIES
TYPE CONS'T'RUCTION
FIXTURES - PER TRAP
work for which this permit is issued.
❑ I have and will minimum Worker's Cmaienseion Insurance, as required by Satio.
37M of the Labor Code , lin the performance of t he work far which this pennil is issued
M arkCnm tion lnsumnce eerier and l'nlicy n^umIber arc: rL
GAS - EA. SYSTEM- I INC.4 (OUTLETS
OCC. GROUP
APN
GAS - EA. SYSTEM OVER4 (HA)
mer. Policy No.:
IeRTIFICATE OP EXEMPTION FROM WONKENS'
' COMPENSATION INSURANCE
(This section need not he completed Ifdtc Permit is for one hundred dollars (s 100)
or Less.)
ich jetto theiremenWisismeorrIell
work for subject
Toy any theinthe any manner
not employ any person in any manner so as m Mnnnu subject m the Wmkcrs' Compcn-
GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNLN'I /HLECTR
sauna Laws of California. Dec
Applicant-
GRADING FEE
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Lahr Cale, you most
WATERSYSTEM/TREVING
SOILS FEE
mnhwith comply wissuch provisions or this permit shall be evemN revoked.
WATER SERVICE
-
CONSTRUCTION LENDING AGENCY
PAIL)
N17W RESIDENTIAL PLMB. SQ. ET.
I hereby off rat that there isaconstmctinn lending agency fonhe performance of
Date Reccipt#
the work for which this pennil is issued (Sec. YN7. Civ: CJ
Lenders Name
- TOTAL:
lenders Address
TOTAL:
I certify that l have read this ..pliceimotion, that the above information is
❑UILUING FEE —aO
QTY, MECHANICALPERMIT FEE
meetI greeto comply with .11 city and county ordinances and state laws rclulingm
building commandant, and hereby author im representatives of this city 10 enter upon the
SEISMIC FEE 0
above-nme ioned property for inspection proposes.
(We) egae m save, indemnify and keep harmless the City of Cupertino against
PERMIT ISSUANCE
ELF.C11IC FEE
liabilities. judgments, costs and expenses which may i n any way acerae against said City
consequence of the gmming of this permit.
pLTEN ON AUL) TO MECH.in
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI, NON -POINT
SOURCE REGULA'TONS.
AIR HANDLING UNIT ('I'O Io BBII CFM)
MECILANICAL FEL
AIR HANDLING UNIT(OVER to." CPM)
'# 1-35
CONSTRUCTIONTAX
Amator fApplicen/Comactor Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD (W/DUCT).
HOUSING MITIGATION FEE
HEATING UNIT On 100,000 BTU)
I the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health unit Safety
-
Code, Section 2M32(a) f
HEATING UNIT (OVER 100j)(MI BTU)
E] yes No
lity Mires which
Will the air contar or future building ache B use . Air
Dist int? us air cnnmminems as defined by the Bay Area Air Quality Manegemem
District?
PAID
Date R.ipt a
V EN TLAI'[ON FAN (SINGLE RLSIU)
BOILER -COMP (7HP OR 10X1,000 BTU)
TOTAL:
BOILER - COME (OVER 100,000 BTU)
❑Yes Fl No
AIRCONDITIONER
I have read the tormakus macros retimprants under Chapter 6.95 of the Culi-
find. Health & Sulery Code, Sections 255115, 255)3 and 25534, I mtderentnd lim if rho
building does not cumendy have a tenant that II is my rcsrymsihility m notify tire occupant
ISSUANCE DATE
NEW RESIDENTIAL MUCH. SQ. PE
mf the requiremems which most be not prima. i ... once of. Certificam of Occupancy.
ISSUED BY:
Owner or.whimided.,em Date
TOTAL:
OFFICE