29633 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY !
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-NIECHANICAL [`
BUILDING PROJECFIDENTIFICATION o
33
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
LtA 6_q4
OW '5AM PHONE: CONTRACroR'S LIC NO:
Li 1.1. NIC ^CONTROL&
UICHITECT/ENGINES . LIC NO: ADDRESS; ❑ (�'/ I�\
CONTACT. PHONE. - - - - BU ILDIINNO PERMIT INFO)
r 1 _ I I ' ❑ Consultant Fees Paid by Applicant Onitial) RLDG ELF. PLUMB MUCH
CEN )CO SDECLARATIDN QTY ELECTRIC PERMIT F
I Hereby amraat mat fain
r en�m nude p n r chapter v(emmnaem<ing ;JOB DESCRIPTION
Opm Slack i 700,nof Dmamn Som Business and Prot..a m,endo,madm license ix RESIDENTIAL,
wt y PERMIT ISSUANCE D F
n full force and effect.
pf - ❑SI'DWI. ❑KITCHEN REMODEL
G U U License Class Lic.p
rr�i64 oma Commcwr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING R&PIPE
LOrn ARCHITECTS DECLARATION PANELS - ❑MULTI-UNIT []STRUCTURAL
z 0 m z 1 understand my plans shall be used as public records MODIFICATION
0241-0 UP'1'0 200 AMPS
fir43 {Y Licensed P..issional - ❑INfCRIOR ❑CHIMNIiY REPAIR
201-1000 AM PS IMPROVEMENT
�0XthatIa c.cluDERDLCLARAnDN OVER 1030AMPS ❑BATH REAIODELIREPAIR [I DEMOLITION
P� OOCG I hereby vffinn that I am exempt from the Comrunnr's License Law for Ne
3iC) following reason.(Section]031.5.Business wed Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER.
LLwhich requires a pemm to construct,alter improve,demolish,or repair any xwmure
�0 prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC.
thence is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
POO (commencing with Section7W(1o1Division 3 lithe Bnsineax and Professinmx Code)or 'I'I?MRMETERORPOLEINST. COMMERCIAL:
6 ry�m e' that he is exempt therefmm and the basis for me alleged exemption.Any violation of NTOTAL
NEW BLDG/AD 701.1(10
i� Y.
Section LS say any applicant loco pemtit subjects me npplicwtto a civil penalty of ('OWER DEVICES7BNAM' ❑FOO ERVICE
=Q h rot more than five hundred dollars($501H IMP EMENT
❑I,as owner of the progeny,or my employees with wages as their sale compensation, IMMING POOL ELECTRIC
I- will do the work,and the mashie is not intended of offered for role(Sec.]IN4,Rosiness 0' ER
Y�l' and Prohssinns Code:The Contractors License Law does not apply o an owner of TLET SWITCHES-FIXTURCS
4i 3.. property who hulnAs ur improves thereon,and who Jnex such work him.velf or through
his own employee.,provided that such improvements are not intended nr offered for NE E IAL ELECIR
allf
aide.If.however.the building or improvement is sold within one yew ofcnmplome,me S OpR AREA $/SQ.FT.
owner-builder will have the ha den of proving that he did not build or improve for puri- In /1 1 I'w
ale.).
owner of the poperry,am exclusively contracting with licensed cnnaucoas to sme,theproject(Sec.1144,Business and Professions Code:)The Comnsto's LIcenseLawlaxxnotappl mann,nerofpmperywhnbWldsorimprovcxthorum,and QTY. PLUMBING PERMIT �QY� 71996'
whocommnsforsnchp jects will'a euntmerons)Ilansed pursuant to the Contractors
❑License Law PERMIT ISSUANCE �C�r 1!" VkJr L1 11%U
Ifie con eve n er5 c. ,B&PCfor this mason
ALTER-DRAIN&VENT-WATE:R(EA) VALUATION - '
er Doe
RS )MPENS\TION DECLARATION BACK FLOW PROTECT.DEVICE I /��t1I�
's Ihereb ahma under pe alty`nTpeylary one of the liJlnwimg dechrtudon.. coo
❑ Ihuve and willnmimaina Cenil icma ofCnnsennn xelGinsurc far Worker's Conipen- DRAINS-FLOOR,ROOF,AREA,COND' STORIES TYPL'CONSTRUCTION
sation,as provided for by Section 370C,of the Labor Code,for the performance of the
work Tor which this pcmdt is issued. 'FIM ORES-PER TRAP
❑1 have and will orwanda Worker's Compensation Insurance,as requited by Section
37M of me Labor Code,for performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker.Cnmpensmion Insumn<c carierand Policy numtxaare:'
Carrier Policy Na; GAS-FLA.SV59'IiMOVER 4IGA)
CERTIFICATE Oh EXEMPTION FROM WORKERS'' GRP�ASE/INDUSTNL WASTE INTERCEPTOR
(This
INSURANCE
(This section need rot he completed if be permit is Prone hundred dollars IS 100) BUILDING DIVISION IECS
or IessJ GREASETRAP PLANCHF.CK FEE
I anify ohm in he performance ofthe weak far wInch this permit isismC (shall SEWER-SANITARY-STORM EA.2W FT.
not employ any pars...in any mm anner so as become subject m the Worker, nmpero ENERGY FEE
Z sation Laws of California.Date
7�O Applicant WAI'CR HEATER W/VLNT/ELECTIt GRADING FEE
G u NOTICE TO APPLICANT..ILaRer making this Certificate of Exemption.you should WATER SYSTChVIBEATING
F become subject w the Workers Compensation provisions of the Inbar Code you ants, SOUS FEB
WfoNawith comply with such provisions or this scranitshall be deemed revoked. WATER SERVICE
lia Q -
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Q Ihereby affirm that is n construction lending agency for the perfnrmmnce of Date Receipt#
40 TOTAL:
F the work for which this permit is is,ucti(Sce.309],Civ.C.)
0 U Lender's Name -
W Lenders Address TOTAL:
y I certify that 1 have read this application and same ma,the above information is BUILDING FEE
(n comet.l agree to comply with all city and county ordinances and estate laws relating to QTY. MECIIANICAL PERMIT FF
building construction,and hereby mmhorhe representatives ofthis city to enter upon the SEISMIC hEE
above-mentioned property for inspection par pose., pEµMITISSUANCIi
(We)ugrocroSave.indemnify and kap hurmlcxs me City of Cupertino egoias, ELECTRIC FEE
Iiabiblies,judgmems,costs and exp ens ea which may many wayacn'me againsLaid City ALIEN OR ADU'lY)MECH' PLUMBING FEE
in consequence of the granting of this peown.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT. AIR HANDLING UNIT-(TO 10.000 CFM( MIiCHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRl1CT10N'fAX
Signature of ApplicauXtouaaor Date EXHAUST HOOD(W/DUCT) 1{OUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle herardnus material HEATING UNIT(To Halt"BTU)
ss defined by the Cupenum Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section 25532(a)p HEATING UNIT(OVER 100,00d BTU)
Fl Yes No
VENTILATION FAN(SINGLE RESID) PAID
Will,he applicant or future building occupant use equipment or devices which Date Receipt#
emit huzancous air contaminants as defined by the Hey Arca Air Quality Management BOILER-COMP(3HP OR I00.000BTU)
Districts T L:
❑Yes Fl No BOILER-COMP(,OVER IM."B'MH
I have rtmt the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
foISSUANCE DA
mia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if,he NEW RESIDENTIAL MUCH. SQ.IT.
building does not coren0y have a mmant,that o is my responsibility tons,tify me occapnm
of me aequircmems which mus,be met prionoissuance nfn Certificate of Occupancy
Owner or authorized agent r Dam TOTAL: ISSUED BY:
OFFICE