29944 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, r� /f
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 29944 Qq.
9/I
BUILDING PROJECT IDENTIFICATION V V T
BUILDING ADDRESS: - -SANITARY NO, APPLICATION SUBMITTAL DATE
121915Alas „
OW
.R'SN NMf?: P ' / NTRACTOR'S NAME: LIC NO:
PrZNIC CONTROI.p
A it LI pl ,S&I ADDRESS:
CONTACT.
PuoN1i: • BUILDING PERMIT INFO
❑ Consultant Ftt5 Paid by Applicant(Initial) xphpG FX CT PLUMB MEVI.
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC Pf?RMIT FET: ❑
I hereby nRmm prat 1 um licrnsed under pmvisionx of Chapmr 9(commencing JOB DESCRIPTION
00
0with Seorcea 001 Of DDivision 3of the Busineusnud Professions Cnde,aPERMIT ISSUANCE L:
ndnry license is RESIDENTIAL
yDO i
License Class Lic.p - ❑SFDWL El KITCHEN REMODEL
y�WW Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z p.'/l Z I understand my plans shall the used as public records 1'ANIiLS
:11 MODIFICATION
OZ O UPT02MAMPS C1 INTERIOR ❑CHIMNE REPAIR
Licensed Professional 201-IOW AMPS IMPROVEMENT
OWNER BUILDER DECLARATION OVER 201-1000
gMPS
Q 1 hereby offirrm that 1 am exempt from the Contractor's License Law for the 0AMPS ❑BATH RF,MODELIREPAIR ❑DEMOLITION
O 0.iU following mawn.(Section 7031.5,Business and Profession,Code:Any city or countySIGNS ELECTRICAL (]OTHER
.LL O F which requires'a permit to construct,after,improve,demolish,or repair any sun cmre
�Fp�yJ primmas I....ncgalm requires the opplicens fomeh pemtit to file.signed statement SPECIAL Cl RCUrLMISC.
that he is licensed p...anvothe provisions of the Contractor's License I..w(Chapter 9
(commencing with Section 70110)of Division 3 ofthe Husin ei and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
ti y o y that he is exempt themfrom and the basis I'nr the alleged encmptian.Any violation ofSect - ❑ W BLDG/ADDITION 1-1 DEMOLITION
kXl„t 4y, no]iorethanSby any handled dollfor a ars
subjects applicant tovcivil penalty of POWER DEVICES �NANT ❑FOODSERVICE
nal more than five hondretl Jnllms ISS W).
,z^„Q ❑1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC I OVI1MEN'I'
p ro will do the work,and the swetum lx not intended orofferel for sale(See 7044,Business OTHER
W m and Professions Code:The Contractors License Use does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who Lincs such work himself or Ihmugh
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC'IR SQ IT.
sale,ILhowever,the haildingor nalutivenern issuld within ane yetrofmmplction,the SQ.for FLOOR AREA 5/SQ.FT.
owner-builder will have the burden of proving that he did not build or impmve far pur-
pose of sale.).
❑1,as owner M the propmy,am exclusively contracting with licensed contractors to TOTAL: -
compact the project(Sec.90,14,Business and Podrosions Code.,,—Commcmr's Li-
censeLa timit,lyroowrerofprnperty who builds or improves thereon,end QTY. PLUMBING PERMIT FEE
.boom ac Oean
fors jec th so. 'Ims) ''eitedpursuonuothe Commnors -
License is . PERMIT ISSUANCE
❑Ian, serm is 5 ,B&P C for this reason
Owner Date ALTIM-DRAIN&VENT-WATER UOA) VALUATION
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
ereby affirm under Penalty of perjury one of the fallowing declarations:
❑ I have and wil l mainean a Cenificme of Consent it)sel Gimure for Workers Compen- DRAINS-FLOOR,ROOF,ARF. ND. STORIES 'TYPE CONSTRUCTION
nation,as provided far by Section 3/00of the Labor Code,for the performance of the
Work far which this permit is issued. FIXTURES-PHR TRAP
❑ 1 haveand will inion in Workers Compensation Insurance,os required by Section
Thin of the Labor Code,for the Performance of the work for which this permit is issued. GAS-EA,SYSTEM-I INC.40 OCC GROUP APN
My Workers Compensation Insurance carder and Policy number are:
Com ice Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE-OF fiEMPTIONFROM WORKERS' -
COMPENSATION INSURANCE GREASE/INDUSTRI,WASTE INTERCEPTER
or less) BUILDING DIVISION THIN
section need not becompleted ifthe Permit is future hundred dollars(S100) GREASETRAP
I madly that in the perfommanceofthe work for which this permit is issued,I Jmll PLANCHECK EEE '
not employ any person in any manner so as to become subject in the Workers'Compen- SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
Z inion laws of C.lif arm..Date
Z O Applicant WATER HEATER WNEMT/ELECTR GRADING FEF.
NOTICE TO APPLICANT:11,after making this Certificate of Eimmptior,you should WATER SYSTEMUREATING
abanrrm subject to the Worker's Cmn,ameminn provisions of the Labor Code,you must SOILS FEE
fonhwithcamply withsuchprovisinns ordon,srmit shall hedcemedrevoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIUEN'1'IAL PLMIt, SQ.FT. PAID
U O k for
which thi that Nrre isoconstmnian lending agency for the performance of Date Receiptp ,
OF the work dirt which this permit is issued
(Sec.3097,Civ.C.)
U Lenders Name TOTAL:
>' 117 Lender's Address TOTAL:
I certify that 1 have read Nis application and site that the above information is BUILDING PEE
r Val cored.I.gree to comply with all city and coamy ordinances and stair laws relating to QTY. MECHANICAL PERMIT FEE
G Z building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection pm,ows' PERMIT ISSUANCE
(We)adds,to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way come against said City ALTER OR ADD TO MECH. PLUMBING FEE
to ca ems,ta nee of the goading of this sands.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CPM)
SOURCE REGULATIONS. MECHANICAL PEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicaniContraaoO r Mae EXHAUST HOOD DODUCHOUSINGMITIGATIONFF.F.'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamor future building acupam stort.(handle humrdom maenad HEATING UNIT(TO IW,O(1(1 BTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health odd Safety
Cale,Seen..2553200? HEATING UNIT(OVER 100.000 BTU)
L3 Yes F1 No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt
will the applicant or Intra building occupant use ear devices which
emit limitations air contaminants as defined by the Hay Areaa Air
Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District? TOTAL
❑Yes 0 N BOILER-COMP(OVER IIg),ggI BTU)
I have read the hamrdtms materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornix Health&Safety Code,Sections 25505,25533 and 25534.1, d...land Ihat if the NF.W RCSIDEN'1'IAL MF.CH. SQ.FT.
building docs not currently have a tenant,that it is my responsibility to notify One iteration
of the reconstitutes which must be met prior to Is,werce of a CcnilTcute mf Tkcupancy.
Owner or aulborimd agent Dam TOTAL.: ISSUED BY:
OFFICE