29806 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29806
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIArvlcnl. L VX O/N
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BUILDING PROJECTIDENTIFICATION
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL.DATE
2D� C4eML 1►�a :tS'��
OWNER'S NAME: PfIONE: NIRA NAME: LIC NO:
NIC /� CONTROL.
•4 E.DECDENGIN ER: LIC NO_ UDNESS: ❑ R/)/1 yl
CONTAL7: I'IIONE: s BUILDING PERMIT INFO
M 1 vr, a,.1
� �f b ❑ Consultant Fees Paid by Applicant(Initis. BLDG IjFCT MIiCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
qaZ with Section 70(alf.f Division3ofthe Busines.iand Professions Cale.andmy license is 'RESIDENTIAL:
O O - PLRMIT ISSUANCE,
to full force and.[fiat.
�UZff]' Weeds.Class Lic.N ❑SFDWI. El KITCHEN REMODEL
InQ Dare Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RC PIPE
[F.,7y ARCHITECCS DECLARATION PANIiLS ❑MULTI-UNIT El STRUCTURAL
ZOy'K I understand my plans shall In,used as Indbiwrceotds MODIFICATION
OZ—p UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
Fs WIria Licensed professional 201-1000AMPS IMPROVEMENT
O8 OWNER-BUILDER DE CLARATION OV"HR I"AMPS ❑BATH REMODEL/REPAIR (]DEMOLITION '
O p;X555 U I hereby affirm that I am exempt from the Camrns Co is Any c Law for the
iyS O y U f.hiih as tenon.(Section 7nmon Business and Professions Cade:Any city simomy SIGNS F.LF.CI'RICAL ❑OTHER
w 3
41- wM1ich requires a permit o amslma,idler,improve,demolish,or repair any kvucture
0 prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUITIMISC. /r
} that he is licensed pursuant to the provisions of Ne Conhamors License Law(Chapter 9
G� (commencing with Section 7 Mu of Division 3 ofthe Businessand Professions Code)a, TEMP.ME*[ER OR PULE INST. COMMERCIAL:
Lyme that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ElDEMOLITION
W I oe Section 7031.5 by any applicant fora permit subjects the applicant to v civil permlry of POWER DEVICES / ANT ❑FOOD SERVICE
.�. } t more than five hundred dollars($500). IMPROVEMENT
M [1I,as owner of the property,or my employees wit wages as their sokmpen
cnsutinn, SWIMMING�{'OOL ELECTRIC -
�� will do the work,and the shucore is not intended orolfered for sale(Sm.7044,Business - ❑OTHER
and Profeni.ns Code:The Collusion's Licenseap
Law does not apply t owner
an of OUT — CUM—Fl URFS
ro
6 3^ pperty who builds or improves thereon,and who does such work himself or through
his own employees,provided that inch improvements are not intended or ofi'ered for NBW RF,SIDR ELECTR SQ00,
aide If. the building orimpmvemem isnddwirhim oncyearofcomplction,to SQ.IT.FLOOR AREA S/S4a .
owns builder will have the burden.(.roving that he did not build or improve for par- l ��
pose ofxnla).
Fl 1.as owner of the property,am exclusively contracting with licensed contractors to .,TOTAL:
onmua the project(Sec.70W,Business and Professions Calc:)The......_ e..i-
aseLawdoesnmapplytoanownerofpropenywhobuildsorimprove,theroon.and QTY PLUMB ER T PEE
who contracts for such projects with a uontmetons)licensed pursuant to the Contaetoe
License law. PflRMf1slSSUANCH
❑Iamexemptunder .Sec. ,B&PCfim Nisrcnon
ALTER— 1AIN&VENT—WATER INA) VALUATION
Owner Date /� �/I�
WORKER'S COMPENSATION DECLARATION BACK PLO ICE s 1 f4 Ti ter
I hereby affiror under penalty of perjury one of the following ditctsti0ns �'�
•❑ l have and will notintain a CertlOemc orCotnmam set F lnsum for Worknes Cnnspen- DRAINS—FLOOR.RO( s OND. STORIES 'TYPE CONSTRUCTION
union,as provided lot by Section 3701)of the Labor Code,for the......mance of the
work for which this permit is issued. FIXTURES—PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37(X1 of the Labor Code,fm the perfunnancc of rhe work(or which Nis permit is issued. GAS—EA.SYSTEM.I INC,4 OUTLLTS OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Carrier, Policy No.: GAS—It.SYSTEM-OVER 4(EAI
CERTIFICATE OF EXEMPTION FROM WORKERS' `V`
COMPENSATION INSURANCE GRHASE/INDUSTRL WASTE IN
(Ihisseetian need nm ba e complete)ifhe permit is Lomhundred dollwe(5100) U .DIN DIVISION EELS
or lira.) GNF:ASE TRAP PLANCI LLE O I'
(certify thin Ne manner
ol'tewnrkfm which this permit is iss'Cancer- SUMER—SANITARY—STORM EA.200 FT.
at tiss—
not employ any person in any manner so as to become subject to W.rken'Cnmpen- HNERGAt
zAppl cant Lawsof California.Dam WATER HE,IER WNENTMLECTR GRADING PEE,
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMaREATING
a , become subject to to Worker's Compensation provisions of the Labor Code,you must SOILS FEE
� ,..I forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB, SQ.Pf. PAID
U l hereby affirm that there is a construction lending agency for performance of Dao R cci tM
{L the work fnr which this permit is issued(Sec 3097,Co,C.)
Lenders Nome TOTAL.:
U Lenders Address 'TOTAL:
f a 1 certify tm 1 have read tis applir tion and ramie tm Ne aGwbinforntation is BUILDING FEE �..e
`Cr+ Vl corect.l egrcemenmply wit all city and coumy oNinances and ramie laws relatin6o QTY MECHANICALPERMTT FEE
U z 'building nmswaion,and hereby autorixv repreunmtives of this city o enter upon the SEISMIC PER
above-mentioned property for inspection purposes. PERMIT ISSUANCE
IWO agree to save,indemnify and keep harmless the Clry.f Cnpertinn against ELECTRIC ME 1 J6
liabilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in consequence of Ne granting of this permit PLUMBING FEE
APPLICANTy! LRSTANDS W L COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO IgINq CFM)
SOURCE t GU .TIONS. - MECHANICALFEE
/ AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TA%
rgnewreof ApplicuLAZArucmr Doe EXHAUST HOOD(WI)UC'U I LOUSING MITIGATION FEB
HAZAke !ATE RIALS DISCLOSURE
Will
ytepCuportor future buildings.Chamsmreor handle hmath and Safety HEATING UNIT(TO IW,000 BTU)
as defSeJ by the Cupertino Municipal Ctde,Chapter 9.12,and the Health and Safety
Code,Sarin 25512(.77 HI:ATINO 11X1'[(OVER 111(1,000 DTII).
El Yes ON. VENTILATION FAN(SINGLE RCSID) PAID
Date Receipt#
Will rd rhe air contami,ana or nants as
building by n,rotthe
an Area
Air sin or Quality
Minagement BOILER—COMP OHP OR IW,000 BTU)
emit hazardous air rnntaminems ns def red by the Pay Area Air Quality Maneg.tnem
District? (]N0 BOILER.—COMP(OVER 100,1X1(1 BTU) AI.
Yee
I have rend the harardons materials¢quimmens under Chapter 6.95 of the Cell- AIR CONDITIONER JUL
/x. I SJ�JAp 1 Ii
If t
f nein Health&Safety Cale,Santos 25505,25533 and 25534.1 understand that if to NEW RESIDENTIAL MECH. SQ.IT. I U L 0 ^' j J V
building does n u currently havc n octant rb0 it toy responeihllity m notify Ne...part
of to requirements which most he met prior to ismance.f.a Certificate.!Occupancy.
Owner or authorized agent Date TOTAL:
OFFICE