29533/ APPLICANTTO CITY OF CUPF.FILL I INFORMATION WITHIN REO LINES•USE BALL POINT PEN ONLY
_ BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERhIIT PLUMBING-MECHANICAL
29533
BUILDING PR0JRCI'IDENTIFICA'rioN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'Z'E
/ ,q 9 7 e �O 6 L✓ss A--✓F� Lot'I'�.. -6
OWN R'S NAM': PHONE: CONTRACTORS NAME: LIC NO:-
I H -F 'eG G NIc CONTROL A
iRCHITE /ENGINEER: LIC NO: ADDRESS: ❑
JCe
7_4
CONTACT: - PHONE: - BUILDING PERMIT INFO
Sec ('/L 7 3 7 -O PI / ❑ Consultant Ftts Paid by Applicant(Initial) BLDG A B ME
IR
r,CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE /�'�
Iinchy arum that 1 am licensed under provisions of Chapter 9(commencing i DESCRI ION
wz with gection](I(Xp of Divisiun3ofinellusiness and Pmfessinns Code,end mylicense ie pGRMI'I'ISSUANCF.
1400 ly in full tome unJ effect. �DWL ❑KITCHENR MODEL.
a U,�+ Licenie Class Lic.«
6 U APPLIANCES-RESIDENTIAL ADDITION 11 PLUMBING RE-PIPE
�i64 Ua¢ TSConDECLARATION
ARCHITECTS UF:CLARATION ❑MULTI-UNIT El STRUCTURAL
PANELS
-Z O'^Z I understand he useas public records d my plans shall d bliCATION
OZ— UPTo 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F� ti Licensed Professional 201-i NX)AMPS IMPROVEMFZtNT
J OWNER-BUILDER DECLARATION OVER(o)AMPS 11 RATE REMOBEIr EPAIR El DEMOLITION
yypS Q 1 hereby all m on thin I aexempt f[mn the Contractor License Law for tho
W CLU following reason.(Section 71131.5,Business and Pmfieesion.d Cale:Any city m county SIGNS ELECTRICAL ❑OTHER
fA 3 0. which requires a permit to construct,alter,improve:demolish,or repair any strvcwre
prior to its lssumce,also requires the applicant for such pcnniuo file a signed statement SPECIAL CIRCOIT/MISC.
fray JUN 1qqS--
that he is licensed Pursuant ro the lowisionsof me Cmumemea Lieense Law(Chapter 9
C4 E5 (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.MLGER OR POLE INST. COMMERCIAL
Wa c C that he is exempt therefrom and the basis for the alleged exemplion.Any violmion of LIWIeLDG/ADDITJON.1��DEMOLITION
^m Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑Ir00D SERVICE
not more than Eve hundred dollars(b5(NB. IMPROVEMENT
sC [D1,ns owner of the properly,or myentpinyees with wages us theirsnle cempensatiun, SWIMMING POOL ELECTRIC
F� wdldothe ismk.anJthesunatmeiemt intendeimoffered forsale(Sea 70, Business []OTHER
and Professions Code:The Connector's License Law does not apply to an owner it -.NITCHES-FIX'NRES
6 3^ property who builds or improves Thereon,and who does such work himself or though
his own employers,provided mm such improvements ore nm intended or offered for �) -icTE SQ Flt
sale.If,however the building or imprmcmcnt is sold within one}roof completion,the SQ.FT FLOOR AREA SISQ,FT.
owner-builder will have the burden of proving that he did not huI1J of improve for par �/�,/�
pose of sa )lef _ � `f J)sw
1,as owner of the properly,am exclusively contracting with licensed contractors to
construct he project(Sec.0094.Business and Professions Code:l The Contractors Li-
nseLawdoesnotapplytoanownerof properly who builds or improves thereon,and QTY PIUMBI GPIERMIT FEE
whocontmds for such projects with a contrectims)licensed pursuant m the Contractor's
License law. PERMIT ISSUANCE
I am exempt under Sec. ,11&P C for this reason
Owne[ Date AUl'ER-DRAIN&VHNT-WATER(EA) VALUATION ,
WO
1 herebyRKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2'`( B,.rC`s
film under penalty of perjury one of the following declarations: •l
\�❑ I louvered will moimaina CarificamnfConsenr[oxelf-insure for Woder's Co.,. DRAINS-FLOOR,ROOT',AREA.COND.
mtinn.as povided far by Section 3700 of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will n mot.an Worker's Comp nu,ndo n Bauman,as required by Section
3700oflhe[,No Cale,for the performance of the work fir which this permit is mounni. GAS-EA.SYSTEM-I INC.40U'1'LETS OCC.GROUP APN
My Worker's Compensation Insurance canier and Policy number are:
Canine Policy No: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASInNDUSTRL WAST(?INTERCEPTOR
BUILDING MVISION FliliS
(Thissection need notbe completed if Thepermit is for one hundred dollars($1(XB OR PSE TRAP
or loss.) PLANCHECK PEE
(cenify that in the perfomsancenl the work fnrwhiah his permit is issued,lshSEWER-SANITARY-STORM FA.200 FT.
not employ any person in any manner w us Tn became sohjnt Tn the Workers'Cnntpen- ENERGY FEE
Oz cation Lawsof Culifgmis.Date WATER HEATERWIVENTIELECTR
z Q Applicant GRADING FEE
.N. NOTICE TO APPLICANT:If,attar making this Cenifirme of Exemption,you should WATER SYSTFMG7REATING
abecome subject to Ne Worker's Compensation Provisions of the Lahor Code,you must SOILS FEE
ly foMwlth comply with such provi,mr,or this Not shell he deemed revoked. WAFER SERVICE,
l Q
CONSTRUCHON LENDING AGENCY NEW It1i51DENTIAIJ'LMIi, SQ.F1', ('AID
L) 0 I forwhich rm thot
picarl i i.{sued(Sectinnlen ding agency f:nhe perfnrmuncc of DoT He t
p•T
'he work for which this permit is issued(Sec.3097,Civ.C.l
F+ Lender's Name A TTAL:
LUkI I<ndeYAddress TOTAL:
I
'� cenify It.,1 have reel this application and stStu that the vM1ove information it DU Dh FEC
T.F. tZII correct.l agree to comply with all city and county ordinances and suite laws relming In QTY. MECHANICAL PERMIT FEE O
U Z building consuoutito.and hereby..thou,ormewuninves if this city to enter upon the 9HISMIC ..
nMrve-mentioned property for inspmtion proposes. PERM I'F ISSUANCE ELECTRIC PEE
(We)agree to save,indemnify and keep harmless the City of Cupenin,against
llabilides,judgment,costs and expenses which mayinany wayucemeagaiost said City ALTER OR ADDTO MECH.
in consequence of me granting of this perent. - PLUMBING FEE
nsQ
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL PE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION T' X
Signature of Applicunt/Counnefor - Date EXHAUST HOOD(WIDUCf) HOUSING MITIGAT )N FEE a
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building swcupam store lir bundle hazallous nmtenitt HEa'1'ING UNIT(TO 100.000 PTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255321x)^ HEATING UNIT(OVER 100,000 BTU)
❑Yee ❑No PAID
VENTILATION PAN(SINGLE 111351D) Una eceipt k
Will the applicant or future building occupant use equipment or devices which
si dt'hasallous it comaminams vs defined by the Bay Area Air Quality Management BOILER-COME(3HP OR 100.000 BTU)
TOTAL:
District?
❑Yes E]No BOILER-COMP(OVER 100,00s)BTU)
AIR CONDITIONER
1 have had the h iale,Sections s ma255 5.255 3 a..or,Chapter nni of ua Odi- ISSUANCE DATE
fomiu Health&Safety Code,have.
255115,25533 and 25534,1 undersmnd that if The NEW RESIDENUALMECH, SQ.vr.
building requirements
which
my have o Rnem4 that it ism}reaof aCilirymnod Occeosiday. T
if the requirement which must be inn prior to ofaCenilicam of Occupancy.
Own,m,mithomad agent Dam TOTAL: ISSUED BY:
OFFICE