29538 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 2 9 5 3 8
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL LJ
BUILDING PROJECT IDENTIFICATION
ILDINGADDRISS: SANITARY NO, APPLICATION SUBMITTAL DATE
__J0021 -7
N' 'NAME: P 10NE:` �Z ONTRACfOR'S A ,: LIC NO:
I 14 11 C�lNIC
.4RCfi1TELTlENGINF,I3R: LIC NO:: RF.SS' (>J�Q/ CONTROL a
IILts S. I ST.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LUhte
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby nmrm tat h 1 am licensed under previsions of Chapter 9(e.nunencin
COO g LOB DESCRIPTION
1with$acrceaneffec Diviai.nJ.fthc Business and Pmfcxsions Code,and myliccnscis PERMIT ISSUANCE RESIDENTIAL
F• foil force and effect. ❑SFDWL ❑KITCHEN RE MODEL
Q U V in
COLic.p
vFi66 Uvte� -7 —Contract., APPLIANCES-RESIDENTIAL
/ CADDITIDN CPIAMe1NG REPIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z O t.Z I understand my plans shall be used as public records
to MODIFICATION
O Z- UP TO 200 AMPS
❑
Licensed Professional INTERIOR ❑CHIMNEY REPAIR
Q ' 201-10)(AMPS IMPROVEMENT
pd 1d 2,J
OWNER-BUILDERexemptDECe Contractors
ON OVER BWAMPS TH REMODELREPAIR [I DEMOLITION
S:a W a 1 hereby uflirm that 1 am exempt From the Commmor's License Law for the
a�6 C) following mason.(Section 70315.Business and Professions Code:Any city or county SIGNS ELECTRICAL OOTHE
WO y which requires a permit to construct,alms improve,demolish,a,repair any structure
^�rn� prior to its....ance,also ran.in,the applicant homeh pc.it o file asignedswmme., SPECIAL CIRCUITAUSC.
tam he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
W�GO� (commencing with Section700(a.f Division 3 oftae Bminessand Professions Crde)or TEMP METER ORP LE(NST Ll'
dp,eC that he is exempt thcmfr.m:rad the Fads for the alleged exemption.Any violtaion of
X
Section]011.5 by any applicant fora permit subjens he upplicam macivil nvhy of LL ❑NEW BLDG/ADDITION El DEMOLITION
t4o1 tpcPOWER DEVICES OTENANT
ESCant mons than live hundred dollars($5W). ❑FOOD SERVICIi
O Las owner mine property,or my employec.v with wages as their sole cnntpenwtion, SWIMMINGPOOL I RIC IMPROVEMENT
W1- will dothe m
work,and are sratum is not intended oroffered JtNa
for sale(See Business COTHER
W $ and No fiessions Code:The Contractor's License Law does not apply to an owner ofOUTLETS-SWITCHF RES
property who builds or improves them,).,and who does such work Itirnself or th....M1
his own employees,provided that such improvements ata not intended or offered fro NEW RESIDE IA LECfR S
sale.If,however,the building orimprovcment is sold withinonc yearofrundetion,the .,SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- a•s
pe.
❑L as owner of the property,am exclusively contracting with Ilconwd Conrzucmrs to TOTAL:
construct the project(Sec.]INS.Business and Professions CWeq'me Commemes U. P n
c se Law does not apply to air owner ofpmpertywho builds orimproves flommon,and QTY. PLUMBING PERMIT FEE fi '1 1996
who contracts for such projects with a contmemr(.$)licensed Pursuant to the Continuum's
License law. PERMIT ISSUANCE V) !
O 1 am exempt under Seo. .B A P C for this reason LIT �al/I'LYI I IIVU
ALTER-DRAIN&VENT-WATER(EA)
Owner Dae VAfAAI'ION
Wm under SCOMPENSATION Dfteollow0N BACK FLOW PROTECT.DEVICE
(hereby affirm under penalty of perjury one of the following declarations:
I W
(have and will mainwina Ccrtilicateof Consent to self-insomfor Worker's Compeer- DRAINS-FLOOR,ROOF,AREA,CONE.
smion.as provided!for by Section 3700 of the labor Cole,for the performance of the STORIES TYPE CONSTRUCTION
work for whichthis permit is issued FIXTURES-PERTRAP
❑I have and will maintain W'orker's Compensation Insurance,as required by Section
37M of the labor Code.for eRnrm
he pence ofthe work for which this permit is issue(]. GAS-FA.SYSTEM-1 INC 40UTLE'rS
My Worker's Compensation Examine carrier and Policy number arc: OCC,GROUP APN
/ Carrier: Policy No.: GAS-EA,SYSTEM OVER J(G)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASEhNDUSTRL WASTE INTERCEPTOR
(Thm,eedim orad not b,completed lDhe peri far one hundred dollons X1fen BUILDING DMS NFEES
or less.) GREASE TRAP
I certify thm In the perfommncc nfthe work for which this PLANCHECK LEE
pee Woo issued,Conifer-
SEWER-SANITARY-STORM FA.Zoo ET.
mLowIny inanYmanner t u emblem no Worked Compeer- ENERGY FEE
,Z no
tion taws n! lif rnia Dam C m WATER HEATER W/VENT/ELECTR
Z Applicant (,�� ! ✓ GRADING FEH
NOTICE T ICA T:It.at nalkitaxthis Cenifican,of Exemption,you should CS WATER SYSTEM/I'REATIHG heron.,subject ,, he Workers Compensation provisions of are Labor Code.you must SOILS FEE
W forthwith comply with such pmvisinns onhis pe.it shall he deemed rownkoak WATER SERVICE
P Ca
rDZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAIB. SQ.Er. PAID
UQ I hereby affirm that is v mnswction lending agency for the performance of Dam Receipt#
LL t-' the work for which this permit is issued(Sec.3097,Cie C.)
O U lenders Name
Lenders TOTAL:Address TOTAL:
y
a. I certify that 1 have read this application and state chat tae above information is BUILUIN �
t/] correct I agree.,"imply with all city card worry ordhounces and stem laws relating to QTY, MECHANICAL PERMIT FEE
U Z building construction.and hembyuth
aorim representatives ofthiscity m .,
eeruper the SEISMI t U
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRI EE r'
Iiabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE O
APPLIC 'NDERSTANDS AND WILT OMPLY WITH. LL NPO T AIR HANDLING UNIT IO.000CFM)
SOUNCI REGULATIONS.• MECHANICALF E
AIR HANDLINGUNITfOVER n(WCFM)
CONSTRUCTIO TAX
Sig urren pplieanUC.nOador Dae EXHAUST HOOD GVMUCT)
HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITI TION FEE
Will rhe applicant of but um building accepted store or handle hazardous material HEATING UNIT(TO 100.010 BTU)
as def neJ by the Cnpminn Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553200 HEATING UNIT(OVER IUBBINI BTU)
❑Yes C]No
VENTILATION PAN(SINGLE RESID) PAID
Will the applies.,or future building occupant use Impartation-devices which Data art or,
entir barardnus air cnntarninana to demand by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU)
Dinner'
❑Yes ElNo BOILER-COMP(OVER 100,0008TU) TOTAL:
Ihavereadthe hazallous mmenuls reyuircmenu under Chapter 6.95 of the Cali- AIR CONDITIONER
forma Health A Safety Cole,Sections 25505,25533 sual 2553J.1 uMertard that if the ISSUANCE DATE
huildingdocs not cumnnyhavcuteram.that it is try responsibility monody thccecupant NEW RESIDENTIAL MECIL SQ.ET.
of the requimmener which must be met prior to issuance of a Cedifcam of Occupancy.
Owner err anion-an agent Date T
_ ISSUED 8
OFFICE