29750 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 2 9 7 5 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMB NGMECHANICALL J r 'Vl
BUILDING PROJECT IDEM'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2.23 `iShe-Lo Uep GJF .i 3 -2U- 9�
OW E '$N`ME: PRONE C RACfO '�Nt ApME: / LIC NO:
NIC COMROLM
\RCHITI!CI'/ENGINI!F:R: LIC NO: �)DR SQS.� 5, Q�Z� ��t ❑
CONTACT: PHONE: r�/,O// BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG❑ ELECT PLUMB MECH
❑. ❑
LICPNSCD COMRACfOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alEms thnt I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{O{�ICZ with Section 7000) Division Sof he luminae,and Prnfeseinns CNe,undmy license is
FCC in full llsrce and effect. ' PERM11'ISSUANCE! RESIDENTIAL'
�UV License Class Lic.M ❑SFDWI. El KITCHEN REMODEL
k�<S Date Contrnnor APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
E-pm ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z C!rJ� I understand my plans shall be used as public mcords MODIFICATION
CZ UPT02u)AMPS
F+E91'^® LicusscJ Pm[eseianal - ❑INTERIOR' ❑CHIMNRY REPAIR
Appp.•.r'1 OWNER-BUILDER DECLARATION 201-IOIXIAMPS IMPROVEMENT
0 W Q 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER IIXXIAMPS ❑BATH REMODEL*,FyAIR C3 DEMOLITION
C 6 V following teams(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL HER
CF which requires a permit to construct,alter,improve,demnlish,or repair any structure
yy
Prior o its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
,v that he is licensed pursuant n the provisions of the Contractor's License Law(Chapter 9
�� (commencing with Section]000)of Division 3 of the Nosiness and Professions Code)or TEMP,METER OR P(II.R INST. COMMERCIAL:
d cy Nat he is exempt therefmm and Be basis for the alleged exemption.Any violation of
Section 7031.5b an applicant for tsub'ects the applicant to a civil yo ❑NEW BLDG/ADDITION El DEMOLITION
y hundred
perni ) pp Penalty f POWER DEVICES ❑ NANT ❑FOOD SERVICE
ZZy not moreewne five huodperty,or my
PROVIiMENT
C QC
1.asthe work,the pmpcnalme is
or offered
for their sole contpeusinen, SWIMMINGPOOL F:1.1!LTRIC Iral
will do the work and lheewcture is not intended err offered l'ur alta(Sec.]BJ4,Business OTHER
a3$ and Professions Cade:The Cmirse s',License Low does not apply to not owner of OUTLI!9;S—SWITCHES—FIXTURES
property who builds or improves thereon, it who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale,If,however,the building or improvement is sold within one year of eompletiomum SQ IT.FLOOR AREA $/SQ.Ff.
owner-huilder will have the burden of proving that he did nm build or bnprnse for par-
puu of mkJ.
❑1,m owner of the property,am exclusively contracting with licensed anomalous to TOTAL:
omtmat the project(Sec.7044.Bmineaa and Professions CNet The Committees Li-
cense Law does not apply to an owner of pucParty who builds or incomes hancon.and QTY, PLUMBING PERMIT FEE � H
who contrnchs for such Projects with a cnnlrnalons)licensed pursuant urtbc Convector's
License law. PERMII'ISSUANCE (1
[IIamcsmnptundcrSa. ,B&PCfsnlhi,mmm ty
Owner Date ALTER—DRAIN&VENT—WATER(CA) - r VALUATIO
WORKER'S COMPENSATION DECLARATION Lir
BACK PIAW PROI'I!CT.DEVICE �` U
have and
under penalty at of Coneone of(lieFollowingingdecbmninos' r�J/N .
❑Ihom and will faibyntain een..37M of he
sock.furefor Worker's.ofan- DRAINS—FLOOR,ROUP,ARBA,CONED. STORIES TYPE CONSTRUCTION
sabot,as which
for ni Section 3]00 of the Labor CNe,for Ne peRnnnance of Ne
work forwhich ill permit is issue . FlXTURIS—PER TRAP
have and will oxmaintain
c,f mheperfWorker's Compensation work
for which
h required t i Section
3(Xl nfthe LehurCale,for the ped'onnantt of the work tin wM1ichthis permit is issued, GAS—UA.SYSTEM-I INC gOUTLET 15 OCC GROUP A1'N
My Wor 'sC-npensai InsloOtt uran¢e corziera,J Policy tyti�lf�pr emp 45 GAS—.
Cartier: Polioy No.: lel _l PA.SYSTEM-OVER i(EA)
CERTIFICA'T'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
(The section need nut he completed ifihe pr nit is formal hundred dollar,I$100) BUILDING DIVISION FEES
or less.) GREASETRAP
PIANCHF.CK Irl!E
Toy any Nmin the any Performance of the work for which Nis percentsers'Cossum. pan- SEWER—SANITARY—STORM EA.200 FT.
shall
not employ any person in any manner so as to become subject the Workers'Compen- ENERGY FEE
Z sedan laws of California.Data
�O
Applicant WATER HEATER WNENT/ELECTR
PP GRADING PEE
y NOTICE TOij APPLICAN'C If.e,after making this Certificate of Exemption,you should WATER SYSTEMITREAI'ING
ai became a comp m the Worker's Coons or dhis perm it steal nl the Labmeed r Cade,you mull SOILS FEC
P-1
forthwith comply with such provisions motets permit shellhJeemed revoked, s WATER SI!NVICE .
0. A
V O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLACE. SQ.FT. PAID
Ihorwhihthitha0hereissued( eeti0n len ding agency fonhe performance of Dam ReceiptN
0 Newark for which this permit Is issued(Sen 3(199,Civ.CJ
Q U Lender's Name TOTAL:
Lender's A t I10TAL:
I certifynify Nm I have read this applicatin oend sone that move ove information is BUILDING FEE
ta) correct.l agree to comply with all city and county ordinances and state laws relating to construction,
MECHANICAL PERMIT FEE
building constetion,and hereby amhorim representatives of this city to enter upon the SEISMIC FEE!
above-menlinned properly for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hmmlas the City of CuEcnino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acme against said City ALTER OR AUDIO MECII.
I.consequence of the grun
ting of flits permit. PLUMBING FEC
APPLICANT ON STAN ND WILL COMPLY WI LL NON-POINT AIR HANDLING UNITO01(I,ODI CFM)
SOURkEC TI NS. MECHANICAL FEE
,� -- AIR HANDLING UNIT(OVER I0,11(b ) CONSTRUC'1'IONTAX
ignamrt ofApplicanUCn Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haavdous material HEATING UNIT(TO 100,000 BTU)- -
as defined by the Cupertino Municipal Cade,Chapter a.12,and the Hcallh aced Safety
Code,Section 25532(a)P HEATING UNIT(OVER RXL000 BTU)
❑Yes Fl No VENTUAMON FAN(SINGLE RES ID) PAID
Data Receipt#
Will the applicant or future building secupuot axe equipment or devices which BOILER—COMP IJHP OR 100,000 BTU)
'coil humrdous nil cm ociamema as defined by the Bay Area Air Quality Management
District?'
❑Yes ❑No BOILER—COMP(OVER 100,000 BTU) TO AI
1 have mad the hazardous materids AIR CONDITIONER
myuimmemu under Chapter fl95 of Ne Call- ISSUANCE DATE
forma Health&Safety Costa,ll,ha Sections 255115,25533 and 25534.I1.notify h That if the NEW RESIDENTIAL MISCII. SQ.FT.
of me re,imbuilding encs which have be met ,Nntlt ixuace ofa'Cartylumnl Occupancy.nt
of Nu neyuimnen¢which must N met prior In issuance of n Cenificatc id Occupancy.
Owner m authormd agent Date TOTAL: ISSUED BY:
OFFICE.