29918 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL, PFRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL 29918
BUILDING PROJECT IUINTIFICATION
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DATE
t0 S _ zr Lea PL v- 0
'R'S NAME. ••PHONE: CONTRACTOR'S NAME: IC NO:
41AU;,RITEC'E'ENGINHEA�.
is GL� ct I / Q rt.✓µ � N/C ONTROLM
LICNO: A fRjRESS:.r or. - ke O UN�JeI V C U
CONTACT'. PHONE: - - BUILDING PGRMIT INFO
3`r5 -gY.va consultant Fees Paid byApplicant(Initial) fl� BLDG ELECT PLUM11 MECH
LICENSED CON'TRAC'fON:S DECLARATION QTY ELECTRIC PIERMPP PEE
1 hcmhy affirm that 1 am liccnud ander pnwislets of Chapter 9(commencing JOB DESCRIPTION
D O
Qat with Section 70Wpd Division 3of the Businessnnd Pmfeasions Code,and my liccme is
PERMIT ISSUANCE RESIDENTIAL:
in full force end effec pp
�UF LicenseC s Lica rfs 05� FOWL. ❑KITCHEN REMODEL
FZYI Umc 4 Contrast •� i APPLIANCES-RESIDENTIAL UADDITION 0PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS
FDH [ MULTI-UNIT ❑STRUCTURAL
y p r2�. I understand my plans shall b,used as public records MODIFICATION
p k--a UPTO 2(O AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I-a4Licensed Professional 201-10110AMRS IMPROVEMENT
q y,' Oat I am eU rapt fi DECLARATION OVER 1000AMPS ❑BATH REMODEL/REPAIR 0 DEMOLITION
Fq 1 hereby affirm o that 1 em exempt from the Contractors Civil
Liceme Law for the
X3hV Much followinquires n.apSection]constrain,
alter
impniand Ynfenions Co de:Any city or crmtrY SIGNS ELECTRICAL - ❑GTHER
which ns..m o permit to wnswet,nlmr,impmvn,danurlish,or repair troy structure
prior to its issuance,also rest res the applicantfnrsuchpetmillofnlca,lgnedstamment SPRCIALCIRCUTT/MISC. ^
} that he is licensed pursuant to the provisions ofthe Contractors license Law(Chapter 9 - - R 10
GC (commencing with Section 7000)of Division 3 of the Business and Professions Code),, TEMP.METER OR POLE INST.
a h e¢ Nm he is eaempt thcrefmm and the basis for the missed exemption.Any violation of NEW BLD TION ❑DFNOLI']ION
X^N Section 7031.5 by any applicant file a permit subjects the applicant to a civil Penalty of POWER DEVICES ,r�g�p
E-yy not more than five hundred dollars($500). ❑TENAMT� 7 y+Iap��SIERVICF.
G ❑ Lux ownerof Ne Property,or my employees with wages as their sole compensation, SWIMMING POOL ELECI'RIG IMPROVEMP e�WSI�/uY
will do the work,and the etrncmee is oat intended m offered fnrsule(Sec.71W4,Business ❑OTHfgI
and Professions Crile She Contractor's License law does not apply un an owner of OUTLETS-SWITCHES-FIXTURES V rtH I IVU
property who builds or improves thereon,uad who docs such work himself or through
his own employee,,prnvidN that such itnpmvename,are nm intended or offered fur NEW RESIDENTIAL ELECfR SQ FT.
sale.IL however,the building orimprovemem is sold within meycarofromphuinn.the SQ.FT.FLOOR AREA §/SQ.P1'.
owner-builder will have the burden of proving that he did not build or improve for par- tow
pile of owne O
C]1.in owner of the property,am exclusively contracting with licensed confiscates i-
cunstmn the project(Sea.71144,Bushes,tad Przdcssinnx Coda;)The CoContractorsli-
censeLawdoesnotapplytoanowner of Propiny,who builds or improves thereon,and QTY. PLUMBING PERMIT 17EE ww..kk �
who contacuforsuch projects with accountants)licensed pursuant m the Communes �y/f1Y7S
License Law. PERMIT ISSUANCE !!!
❑ I am exempt under Sec. ,B&P C for Nis reason
ALTER-DRAIN A,VENT-WATER IRA) VALUATION
caner Uwe
WOR ERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ^' 1
5 I hereby affirm under penalty of perjury one of the fallowing declarations:
(have and will nmimuine Certificate ofConsem to selGinsurc for Worker's Croupier- DRAT S-FLOOR.HI3(3F,AREA, ND.
satiaa,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYI'F:CONSTRUCTION
work for which this permit is issued. FIXTUR•S-PER TRM
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthc labor Code,hn theµrtormamce of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLL-f OCC.GROUP APN
My Workers Compensation le,orawe,ituam mad P.licy number ore:
Comer. Policy No.: GAS-P.A.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need nm be complemdifthe permit is(crone hundred dollars(g100) GREASE TRAP 'Olt-to
nr less.) PLANCHF.CK FER
(certify thminthe performance as
work for which this theparmalmitis'Con,hall SEWER-SANITARY-STORM F.A.20(1 FT.
tact employ any person in any manner so us to become subject m the Workeri Cntnpem ENfiRGY FEE '-2"�
,7.' codon Laws of Culifamia.Dare (X/
zApplicant WATER HEATER W/VEN'I'IIiLEC'I'R GRADING FEE
t•-r fn NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATIiR SYSTEM)TREATING
hecmne subject to the Workers Cmmpensatlnn provisions of the Labor Calc,you most SOILS FEE
aQ kmhwiN comply with such provisions nr this permit shall be dttmN mvokeJ. WATIiR SERVICE ,
� z CONSTRUCTION LENDING AGENCY NEW RESIDI?NTIALPLMII. SQ FT. PAID
L) 0 Lhcrehy affirm thauhere iseconstmction lending agency fonhe pertommnce of D e eceiptM
� H the work for which Nis pernm Is Isvucf[Sec.31197,Civ.C.)
G 1'•r Lenders Name TOTAL:
W Lenders Address
pr 1 verify,that I have read this appllcmion and slam that the above Informmes.is - - HIIILDI FP.
i--. if) camre l agree mcomply with all city and county ordinances and suite laws relating to QTY. MECHANICAL PERMIT FEE
V G building anustmnion,and hereby nothorize representatives ofthiscity hsenmrupon the SEIS -TY�
above-mentioned property for inspection purposes.
(We)agree,tosave,inlcmnifyand keep harness the Ciryof Cupernatiagminm A PERMIT ISSUANCE ELECTRIC FE
Iimilities,judgmmn......,.ad expenses whichnmy in any wayuccrue a,mmt,rid CityAL'l1iR OR ADD TO MECH, PLUMBINGh E
in consequence of the granting of this permit. t
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT TO IQWOCFM) ^
SOURCE EGULATOS. MECIIANICA,FEE L+
2-r, G� e..QA.C, 5M iG AIR HANDLING UNIT(OVER 10,000CFM) CONSTRU ONTAX
Signtre ifA,humuCanaactae Dam EXHAUST HOOD(W/DUCT) HOUSINGM IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theupplieata or future building occupant store or handle harurdous material HEATING UNIT(11)100,000 BTU)
in defiled by the Cupertino Municipal Cask.Chapter 9.12,and the Hcahh and Safety
Cole,Section.' 2553260 f HEATING UNIT(OVER I 00.00s)00.00s)BTI)
C]Yes (PNo VENTILATION FAN(SINGLE RESID) PAID Data Receipt)
Will the applicantorfuture building occupant nae equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
of emit haurdous air contaminants as defined by the Bay Area Air Quality Management
Uivriefl TOTAL:
_ [J Yes pJ No BOILER-COMP(OVER 1(10,00(1 BTU)
T L have read the hzv
adoes materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
r tinnia Heald,&Safety Crude,Scedc.25505,25533 ad 25534.1 undentnnd that it he NEW RESIDENTIAL.MEC{(. SQ.FI'.
building fries ion momently have a mruint,tem it is my resrymsibility m nmify the occupant �{YyT//
ofthe requirements which must be met prior to isatnnce of a Cenifcate of Ocmuponey.
Ownermirtthsizedagent Date 0 _ ISSUED BY:
OFFICE