29497 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 29497
BUILDING PROJECT MUNI'I h'ICATION
BUILDING ADDRESS: A - SANITARY NO, APPLICATION SUBMITTAL DATI
O ' NAV RACfO SNA LIC NO: to LV
60 NlC CONTROL#
i AR 1 FCTIENGINEER: .IC NO: 11 REFS ❑
Lo
I Co CT. PH NE: BUILDING PERMIT INFO
e EDConsultant Fees Paid by Applicant(Init al) BLDG ELECT . PLUMB MUCH
3VA0 ,
❑ ❑ ❑
L SED CONTRA OR'S DE LARIDN QTY ELECTRIC PERMIT FEE
1 hereby arB at 1 am fieenae a der provisions.71 ba r 9 aammenang JOB DESCRIPTION
al„ Z wiNSecurs.700)ofDrvisinn ofttle Guiness dPmfessiom n ,and my license is RFSID NTIAL
00 is full force red effect 7 PERMIT ISSUANCE �—
uI C SFDWL C KITCHEN REMODEL
u U Licens Cb s hie,p
ructt APPLIANCES-RESIDHNU IAL CADDITION CPLUMBINGRE-PIPH
F.Ow CHITECTS ComDF.CLATIONPANNIS CMDLTI-UNIT [I STRUCTURAL
Z O n,Z„ 1 understand my plans shall be used m public records MODIFICATION
O Z- UPTO 200 AMPS '
q - _ ❑INTERIOR C CHIMNEY REPAIR
� {R Licensed Prnfessionnl 201-1000AMPS IMPROVEMENT
raj
OWNER-BUILDER exempt It DP.the RXI Como.eb OVER I00flAMPS C BATH REMODGUREPAIR C DEMOLITION
I hereby affirm Nm am exempt from the Cnnlrvcvir's License 1-vw bathe
3 a F following reason.(Section]031.5,Business and Professions title:Any city or county SIGNS ELECTRICAL El OTHER
L which requires a permit to conswa,alter,improve,demolish,or repair any stratum
prior to its issuance,also osluims the applicant for such permiuo file a signed statement SPECIAL CIRCUFUMISC.
ythat he is licensed pnrsmanot thenmvisions orthe Conn¢mr's license Low(Chapter 9 ~
GC (cammm�cing whh Secant 7IXlB7 of sion 3mfthe Businc,snnd Professions Cade)or TEMP.ME1RR OR POLE INST. COMMERCIAL:
LC
pC that he is exempt therefrom and the basis Ibr the alleged exemption.Any violation of C NEW BLDGIADDITION [I DEMOLITION
4.x t� Section]N1.5 by any applicant for. xim,subjects the applicant..civil penalty of POWER DEVICES ❑
ul�rn TENANT ❑FOOD SERVICE
�6rot more tharise ve hundred dollars(S5(00.
O [.as owner ofthe property,or my employees with wages as their sale czar ersatinr•, SWIMMING POOL ELECTRIC IMPROVEMENT
q will do the work,end next c,ois not lno, edoraffered basal,(Sex.7194,Bulinus COTHER
m and Prolusions Cole:The Contractor's License Law dncs not apply it,an owner of OU`rLEIS_SWITCIIES-plXJ%S
property who builds or improves thereon,and who does such work himself or through
his awn employees,Provided that such imp rucrinums ore not intended m offered for NEW RESIDENTIAL EI.IiCfR FT.
sale.If.however,the building or improvement is sold within one year ofcomplwinn.th< - FT.ILOOR AREA ESQ,FT.
owner-huilderwill have thebnNenofprovingthathedidnothuildmimonst, rpur- T 6291996
pose'da.l..).
C 1,as owner of Ne property,am exclusively contracting with licensed contractors toTOT L: /�
construct the project(Sec.7049,Business and Professions Code:)The Cnmmcm .Li- CITY
ase law does not apply to an owner of property who builds or improves been,and QTY PLUMBING PERMIT 2 I... VY UUrCnfllyV
who contracts for such projects with a connections)licensed national to the Contractors
License Law. PERMIT ISSUANCE '
C l am exempt under Sec. ,B&P C for his reason
•Owner Dam
ALTER-DRAIN&VENT-WATER IF a) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of the following declarations:
❑ I havcnnl will mnimuin a Cenlficnte of Consent to.self_insure for Worker's Compere- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES TYPE CON$'HtUCI'ION
station.vs provided for by Soclion 3700 of the Labor Credo,for the performance ofthe
r which this permit is issued. FIXTURES-PER TRAP
wo I have and will maintain Worker's Compensation Insurance.as topmost by Section
3]00 of labor Coda imine naQce0 the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40IIILErs OCC GROUP APN
My W s C m s.tin sore a vrrl red Policy nm h r
Carrier my Nm./iYr GAS-IiA.SYSTEM-OVFI34(EA)
CERTIF ' EMPTION FROM WORKERS'
C PENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
('Dtissccuonnee no ftecomneved ifthepemtit is foronehundrWdollors(5100) BUILDING DIVISION FEES
at less.) GREAS El RAP
PIANCHF.CK FEfi
l certify than erG,rmance of te hwork for which this Permit is lssueJ,Ishall
not eoy anyp .renin n4.manner: a u a to Wlioo to the Workvx'Conn SEWER-SANITARY-STORM EA.200 PP.
pen- ENf?RGY FEE
Z mplcation Laws of limn .Date
ZO Applicant WATGR HEATP.R WNENT/ELECTR GRADING FEE
h NOTICE TOAPPLICA ,aper making this Cedi t e of Exemption,you should WATER SYSTEMOREATINC,
alissome subject to the Wo is Compensation prmtsions mf the Labor Cade,you must SOILS FEE
forthwith comply with such provisions or this permit shut he deemed revoked. WATER SERVICE
Q .
Z) z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
UQ Ihercby affirm that thereisvconstmetion lending agency fordie neRnrmanae of Date Receipt#
{2r F the work for which Nis permit is issued(Sec.3097.Civ.C.)
0 U Leader's None TOTAL
Lender's Address TOTAL:
Fy I cenify that 1 have read Nis aMfc.1 a and store dim the stain.infnnnmioa is BUILDING FEE
h correct.I agree to comply with all city and county ordinances and state laws relating to City. MECHANICAL PERMIT FEE
U Z mildingcnnsuuctior,and herebyauthoriee rcpresentmi,esofthis,ity inciter upon the SEISMIC FEE IV
above-mentioned property for inspection Purfstses. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEf
liabilities,judgmentm.,,is and exp...,,wochnryirany way acerae aguiexl skid City' ALTER OR ADD'I'O MUCH, PLUMBING EEL'
in consequence of the gusting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION' X
Signature of Appllcant/Contmnnr Umc HXHAUS'1UOOD(WIDUCT) HOUSING MINIION PBfi
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sure nr hundlehazalloumvmnal HEATING UNIT(TO 100,000 BTU)
as defined by the Cupenino Municipal Code,Chapter 9.12.and the Health vad Safety
Cade,Section 25532(x)? HEATING UNIT(OVER 100.01(10 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
eocipt N
mit
Will Napplicant tbuilding occupant use equipment or devises which Date
BOILER (3HP OR 100000 BTU
harnNacontaminantsair contaminants
a es define)by the Bey Arc - ,
Area Air Quality Management )
District? TOTAL:
❑Yes F-1 No BOILER-COMP(OVER 100.000 BTU)
reed Ne hazlWous materials r AIR CONDfI'IONER
I have
cyuirements under Chapter 695 of the Cali- ISSUANCE DATE
forme Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECIL SQ.Fp.
building dues not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authimits d agent Doc TOTAL: ISSUED BY:
OFFICE