29133 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2.9 �I O
BUILDING PROJECIADENTIPICATION J 1 J
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
o - s"6 sa ��GG` t l
OW'NER'S NAME", PIIONE: ONTRACTOR;SME: LIC NO
A :.y
M N/ l y N/C - CONTROL#
IRCHITECT/ENGINEER: LIC NO. AD I DRESS
l J ❑
CONTACE PHONE: BUILDING PERMIT INFO
fl _ A!�d1 �[��{•I O Consultant Fees Paid by Applicant(Initial) RL ELECT PLUMB MECH
ICEhat I CONTRACnOrproDECLARATION QTY ELECTRIC PERMIT FEE
1 hereby umrm Ito 1 em ucenaea under prnvimourc of Chapter 9(commencing JOB DESCRIPTION
�DZ with Section 7")of Division 3 afore Busimessand Professions Cade,and my license is IDENTIALF
O PERMIT ISSUANCE
W F in full force end effect.
UU License Class Lic.H - - 'FOWL. .. ❑KI'TGHEN REMODEL�4i Date Contractor APPLIANCES—RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
Z�py ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
I understand my plansshull he used as hllcmcmds PANELS
�jC pu A 4 /E MODIFICATION
OZ—Q UPTO AIAMPS C3 INTERIOR •y ® 6HIMNEY REPAIR
�.y..F, Licensed Professional 201.1000 AMPS IMPROV3p�t�'T ((JJ
OWN am exemDERpt
mDECLARATION� OVER 1000 AMPS ❑HATH I1I3M14HI J 1' IR El DEMOLITION
1 herchy affirm that I am exempt from the Contractor's License Low far the B
iLd a.
F V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL O �"
f-' which rewires a permit in construct.alter,improve,demolish,or repair tray structureprionnits issuonce,also regores the upplicam for such permiuolilensigned stanmem SPECIALCIRCUTUMISC. Uh
} that he is licensed paramount o the provisionsofohe Contractor License Law
(Chapter 9
Section 4 C0 (commencing with Sion 7")of Division 3 of the Business and Professions Code)or TI7M R ME rFR OR POLE INST. COMMERCIAL: /n/
d W o C
that he is exempt therefrom and the beai,hu the alleged exemption.Any violation of El NEW BLDG/ADDITION UP.MOLITION
4X1 H Sxoion 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
ZZZZ t m rte flu m rive handled dollars($500). - ❑TENANT ❑FOOD SERVICE
f � ❑I......exiahe propeny,m aiynrmcccs with wagesnsmei,mle compenwtion, SWIMMING POOL VLECTRIC IMPROVEMENT
will dmhe worU said the nraaum is not intended oroffined for sale 44.(Sce.70Business ❑OTHER
W 3 and Professions Code:The Contracmes License Law does not apply to on owner of OUTLETS—SWITCHES—FIXTURES
propeny who but Ids or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NI?W RESIDEMIAL CLECIR SQ CE.
sale.If,however,the building or improvement is sold within one year of completion,the O SQ.PT.FLOOR AREA $/SQ,IT.
owner-builder will have the burden of proving that he dad not build or improve for put-
El 1,as sale). � �
1,ass owner of the property,ora exclusively contracting with:)The
cnmrnor'%10 construct Lo the es not (See o an owner Business and property
who coo d,at i The Connector's Ll-
whocomwdoesnnuapplyloas%ilh aofpmpcny whosedp.rimto thethoraco.and Q7y, PLUMBING PI3RM1"P FEE
who cammcros for such projects with a contmcmrts)licensed punuanun the Commcmrs
License Law. PERMIT ISSUANCE
❑I con exempt uMn Sec. ,B&P C fonhia anran
Owner
ALTER—DRAIN&VENT—WATV (EA) VALUATION
Date Is
WO
FINER C(IMPENSA'I')ON DECLARATION BACK FLOW PRO9'I?CT.%
I hereby affirm under Finally of perjury one of the following declarations:
❑Ihave and%ill maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS—Il"OOR,ROOF. D. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 97M or the L.ahar Code,tie Ito....forma...ofd—
work for which this permit is issued. FIXTURES—PERI RAP
1 have oral will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Code,for perommum ufthe work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS
OCC GROUP ANN
My Worker's Compensation Insurance carrier and Policy number Brei
Carrier: Policy No: GAS—EA.SYSTEMOVER 4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASOINDUSIRLWASTIi BU D ISIf1N FIRE(This section need non Mcompleted if the pennio N ficraveha akesidolHn151(p) GNI?ASE TRAP or Ices.) PLANCHECK '
Iemify tba in mho perfonnaane nflhc work for which this ponnit is issuul,lshnll SCWER—SANIT —S MEA,20)IT.
not employ any person in any manner seas to become mbijeeun the Workers'Camper- ENERGY FF
Z mcionlawsof Culifomia Date
Z 0 Applicant - WATER HI?ATER WNEM' R GRADING F 2•/�
y
NOTICE TO APPLICANT.If,after making this Cenifieme of Exemption,you should WATER SYSTE4VIREATING Ill
a ^ become subject ro the Workers Compeamfon provisions of the Labor Gde,you most -SOILS ME
W G forthwith comply with mint provisions or this IsamiLvhAl be deamed revoked. WATBR Sf?RVICP. .y
Q
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L) , I hereby affirm that there iv a Imamo nonl'ndang agency for theperforn ncc of Date ceipop
na the work for which this permit is issued(Sec.3097,Co,C.)
0 U Lenders Name TOTAL:
W Lender's Address TOTAL:
fy I certify that 1 have read this application and some than the above nomination is BUILDING FEE
IA eamet.I agree to comply xim all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
LIZ huildingcnnswetion,and herebyamhorixe representatives rethiscity mcberupon the SEISMIC 197E Z
abovomemionedrumsny far imp:ctim purposes. PliRMITISSUANCE �1 T
(We)agree to save,indemnify and keep harmless me City of Cupcnine,against ELECTRIC FEE (r V
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEF. 2
incorsequenme of the gmming of chis permit, s ,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.000 CPM) AIF.CHANICAL FEC
SOURCE ULknONS.
CC / AIR HANDLING UNI'r(OVIiR 10,000 CFM) CONSTRUCTION I'AX
Signa
m e,ofApifil! OComrac� / Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cecupon store or handle hazardous material HEATING UNIT(10 100,M)BTU)
as defined by the Catania.Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'? HEATING UNIT(OVER 100.010 BTU)
❑Yes ❑No PAID
VENTILATION PAN(SINGLE RESID) Date ReceiptN
W re II the applicant or furobuilding occulter use equipment or devices which
an lunzardous air committed,as defined by the Buy Am A it Quality Managamm�l BOILER—COMP Li HP OR 181,000 BTU)
TO'T'AL:
District? BOILER—COMP(OVER 100,(X10 BTU)
Lo
❑Nnad Ne hmntdo..inaocdale AIR CONDITIONER
rryuiremems under Chapin 6.95 of the Cdi- ISSUANCE DATE
SafayCode,Sections05,8533 and 25571.I understandtmatheNEW RESIDENTIAL.MECH. SQ.ET.m curleit"havemeant,Nmrismyrcsproff itymnotify the occupantenlxwhu'rourtmet prion.issuer-'ofCedifsheofonp rayrunmd agent Date TOTAL: ISSUED BY:
OFFICE