29559 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I . - BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT- PLUMBING-MECHANICAL. 29559,5 5 9
REBOUND PROJECT IDENTIFICATION L 9J V V
ILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
�c3oc £vE+r eek IVd, - ,r aa'�G
OWNER'S NAME: P : N A R'SNAME:
HONENIC CONTROL#
ARCHITEC NGINEER: IAC NO: SS ❑
BS�,S fo�5't �9 r " •
CONTACT: - PHONE: - 9'S BUILDING PERMIT INFO
i ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE _
- 1 hemild,affirm thin 1 am licensed u d' p ns.r Chapter 9(commehei is JOB DESCRIPTION
with Searle.71)(Spiff positive 3.f the Business andP rsvior,Coca dray license is
Op in full( and effect. PERMIT ISSUANCE RESIDENTIAL:
U��J License Class - D SFDW L D KITCHEN REMODEL,
tiZ Dam Conform, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
G ARCHITE T'S DECLARATION
Fof t • 'PANELS ❑MULTI-UNIT ❑STRUCTURAL
OOy'uZ idem is 1 shall he sedos puhlic records , MODIFICATION
OZ`+ uPT02W AMPS El INTERIOR El CHIMNEY REPAIR
Fs.�1q. men s mal 201-IOOOAMPS 'IMPROVEMENT
�I�i,....11 OWNER-BUILDER DECLARATION Card ION OVER 1000 AMPS "D BATH REMODEUREPAIR GDEMOLITION
( a t�6 I herehy affirm o that 1 nm exmnpt Tram the Cnntrns Chi License Law for them, _
(7P��cc 0.V Following reason.(Section]onsu r, lie, and improve,
demolish,
h,m Any city ns aunty SIGNS ELECTRICAL D OTHP.R
which requires a permit r1.e consumer,nlme improve,h permit t or repair any gnucmre _ -
prion t,'issuance,also requires the applicant such permit fl signed t t mem SPECIALCIRCUIT/MISC.
p, tbuthe islicensed Immea a It.pmvisimith C t t ',License L (Chapter 9
�' GD
haturnmencre,w ill,golden 711WI of Division 3 of the Business and Prtfeioms Code)or TEMP.METER OR POLE INST. - COMMERCIAL:
d y m y that he is exempt marefmm and We basis for the alleged exemption.Any violation of W BLDG/AUDITION El DEMOLITION-
.ry
Section 7031.5 by any applicant for a pcmitnallea,the applicant o a civil penalty^( tPOWERDEVICES
ZZ not more than five hundred dollars(5500). #ANT D FOOD SERVICE
F G D1,as owner of the property,or my employees wiN wutgw as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMB �• -••I
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business -77, []OTHER
6 and Professions Code:The Comc
^tmre License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURESDo
`j AA�
Property who builds or improves there..,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Cr
aide If, the huilding or improvement:sold witHr.m,ceh.f completion,the SQ.FT.FLgOR AREA,D $/SQ.IF.
er-builderrwill havethe burden of that he did notheildorimrrovefor , ^ v BP
proving I Vur-
pose.fsaled. - .•
1,as owner of the property,am exclusively contracting with licensed contractors 10 TOTAL: APR
` ���
construct they loot(Sec.]044,Business and Professions Code)The ContrucctoAPlsLi-
e Law does not apply to an.wner of property who builds or improves thereon,and QTY. PLUMBING PERMIT PEE
who contracts for such projects with u contractors)licensed pursuant m the Contractors ��1
y
License Law. PERMIT ISSUANCE 1 I yr UU1
,C1.1II-
0ImsexemptunderSec. ,B&PCfim1Iusre.smn
ALTER-DRAIN&VENT-WATER(EA) - VgLUAT10N
Owner Data ..�
WORKER'S COMPENSATION DFCLARATION BACKFLOW PROTECT DEVICE
r have
and will
penalty.(ofConconofthefollowing r doolmostWorkers Creole.-
union,
and will for by n aSc Certificate of the
rCor,fie for Worker'sce of the DRAINS-PLOOR,BOOR AREA,COND. STORIES TYPE CONSTRUCTION
walk
as provided far mi Section J]W of the Labor Cedq for the performance of the
work fov which will
is orke a FIXTURES-PER TRAP
-
0 I have end will maintain Worker's CompensationInsurance,in requited by Section
37W of the Label Coda,Trade perf.rrtmnceof the work for which
this permit is issued. GAS-LA:SYSTEM-I INC.4OUTLETS UCC.GROUP - APN
My Wnr @lion lam�araeparae d,ley n•
Caniu: 6 a it SAl�lM Wi�)I t�.d GAS-HA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WOI&yyS�l��
COMPENSATION INSURANCE VV�y GREASEINDUSTRL WASTE INTERCEPTOR
(This section need not hecompleted if the permit is furore hundred dollars is 100) - - BUILDING DIVISION'PP.E9
nr less.) GREASE TRAP PLANCHECK FEE
I certify that in the performance offie work for which this pump is Issued,l shall SEWER-SANITARY STORM P.A.200 F1'.
not employ any person in any manner so as to become subject to the Workers'Compen- - ENERGY FEE
smina L.wa of Cnllf.miv.Da¢
O O Applicant WATER HEATER WNENT/ELECTR GRADING FEE
F7 NOTICE TO APPLICANT:IL after making this Cutifam of Exemption,you should
h ; become mb'ecno ilia Wank l's Com pr WATER SYSTEM/IRHATING -
p,orthin .visions of the Labor Code must SOILS FF.P.
� Q forthwith comply with such provisinnsmthis pemtit shill be deemed revoked. WATER SERVICE. i .
] z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID '
V 0 I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
Hthe work for which this pemtit is issued(See,309],Civ.C) -
0 V Lender's Name TOTAL:
L1a Lenders Address - TOTAL:
F0. ,. 1 certify thin 1 hove mad this nppliontion trod stem that the shove inform......Is BUILDING FEE n �•
r.+ y mnect.l agree to comply with all city and county refinances and state laws relating to QTY. MECHANICAL PERMIT FEE
building construction,and hereby authorize represmactives(if this city to enter upon the SEISMIC PEE Z
above-mentioned property,
roperty for inspection purposes, PERMIT ISSUANCE
(We)agree to save,indemnity and keep harmless the City of Caperton against ELECTRIC FEE '-
lishilities,judgments,costs and expenses which may in any way accrue against said City ALTEROR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WIT ALL N-P INT PIR HANDLING UNIT(TO IO,tNYJ CFM)SOURCE REGULATI S. MECHANICALFEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIGNTAX
p1IanUContrec m Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOS RE
Will the appllc.m or future building occupavtetnreorhandlehuivrd0us material HEATING UNIT(TO IfN1,fNq BTU) "
as defined by the Cupertino_Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑YIN .GNo VENTILATION FAN(SINGLE RESID) PAID
- Date -Receipt#
Will
rd the applicant or(mum holding furby the nt use equipment or dMana which BOILER-COMP(SHP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality ManagementTOTAL:
District? '
Fl Yes No BOILER-COMP(OVER 100.000 BTU)
Ihave mail.the kvyN.stheamilxrequiru^ents under Chapter 695of the Cali- AIR CONDI'I'IONER ISSUANCE DATE
fomia Health&Safe,,Code,Sections 25505,25533 and 25534.1 ondersmnd that if the NEW RESIDENTIAL MECH. SQ.BE
building does not currently have tewm,(list it is my responsibility to ootify the occupant
of the requirements which moos he met prior m issuance of a Cenificete of Occupancy.
Owner or authonmd agent . Dine r TOTAL:
ISSUED BV:
OFFICE