29719APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUILI:;NO. ELECTRICAL PERMIT' NO.
HUILDINO DIVISION APPLICATION/PERMIT PLUME-IS-MECHANIC.A
29719
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kRCHITECT/ENG EER: - - LIC NO: 41
ADDRESSv _ - _-� _
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CONTACE PHONE.
BUILDING PERMIT INFO
❑ Consultant FCC9 Paid by Applicant (Initial)
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LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (c.....mutwing
with Section 11X0)ofDivision 3 afthe Business and Professions Cale, and my license is
i p [�
n full fame and effect. vY'35+��C(
Cluesy---�hic'k
te�J-2t_ Con
ARCH[ "TEC I'S DECIARAf10N
I undecaand my dract,hall be trinlas onlie recoNs
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑ PLUMBING RE-PIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMFNT
Ll BATH REMODEUREPAIR DDEMOI.H'ION
� OTHI?R
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPI 0200 AMPS
F'4pl
UOWNER-RUILDER
j ty1 << J
I i UF
40 N
Licensed Professional
DECLARATION
1 at]!.ereby aflithat I am exempt him, 'he Convector's License Law lin, the
following mason. (Section 7031.5, Business and professions Code: Any city or county
which requires o permit m consuum, alter, improve, Demolish, or repair any swewrt
ptiorto its issuance, also requires the applicant for such penniun Bile a signed statement
201-1000AMPS
OVER HWAMPS
SIGNS ELECTRICAL
SPECIAL Cl RCUITIMISC.
jythat
oC
la•
�ZYnot
;=6
he is l icensed pursuant to the provisions of the Contractors License law(Chapter 9
(commencing wim Section 7000)If Division 3.l me Bmincssaod Posex,rons Calc)nr
that be is exempt therefrom and the basis for the alleged exemption. Any violation of
Sections 7031.5 by any opplicamfar Or permit subject, the applicant o a civil penalty of
more Nan five hundred dollars ($304
O Les owner afthe property. or my employees with wages as their sole compensation.
intended for xolaec.l(Iaa.Baom,s
will Juthe work,and thesvucmrc isaq (S
and Professions Code: The Contractor's License Law does not apply to an owner ofOU
property who builds or improves rhemon, and who does .such work himself .r through
his own employees, provided thaf such improvements are not intended o offered for
sale. If. however, the building or improvement is sold within one year ofcomplitiorahe
TEMP. METER OR POLE INSF,
COMMERCIAL:
El NEW BLDG/ADDITION ❑ DEMOIA17ION
❑TENANT' ❑FOOD SERVICE
IMPROVE NT
❑OTHER ^^`
,
POWER DEVICES
SWIMMING POOL ELECTRIC
I. TS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR S
SQ. PTI FLUOR AREA
S/SQ.I•T
.wren -builder will have the burden of proving that be did nm build or improve lar pur-
pawof sale.).
❑ 1, as owner of the propcny, am exclusively contracting with licensed contractors to
AL.
construct the pmjem (Sec. WW, Ituslness and Professions Ctati) Me Contractors U
claim Law down not apply m an owner of pmpeny who build% or improves thereon.and
FGE
QTY. PLUMBING PERM IT ACE
who contracts for such palpety wim a comracmd s) licensed pursuant ns the Comroctors
PERMIT ISSUANCE CT
Lieenw Luw.
1 am exempt under Sec. . B & P C Our this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTF.CL DEVICE
VALUATION
1 hereby .10 -Ole penalty of perjury one of the following declarations:
FJ I have and will maintain a Certificate of Cometh m all -insure for Worker's Compcn-
ration, as provided for by Sutton 3700 d the Lobo Code, for the perhmnrnee of the
work for which this permit is issued.
DRAINS- FLOOR, WHOP AREA, COND.
STORIES
TYPE CONSTR 11CTIOF
FIXTURES -PER TRAP
Ll 1 have and will maintain Worker's Compensation Insurance, m required by Section
3101 of the labor Code, for the perfmman, al the work for which this permit is issued.
OCC. GROUP
APN
GAS - EA. SYSTEM- I INC. J OUTLETS
My rocs Compensation Insurance carrier and Policy number are:
C r. Policy Na:
GAS - EA. SYSTF.MOVERa(lik)
GREASE/INDIISTRI, WASTE INTERCEPTOR
CERTIFICAM OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This sectiunnced not be conmplctcA ifthe,crna i, Out hundred dall... (SIM)
or less)
GREASETRAP
PLANCHECK ME
SEWER -SANITARY -STORM CA. 200 PP.
ENERGY PEE
OZ
22
F-'
7ZCONSTRUCTION
UO
W r
U
I sonify that in the performance of the work for which this permit is issued, l shall
nor employ any pers.. y manna, 'r�lmecymme subject to the Workers' Campers-
lasofC form., A `YY
satins wm
Applicant y-
WATER HEATER WNENTIELECfR
GRADING FEE
NOTICIf TO APPLICANT. If, after making this Cenificam of Exemption, you should
becomesubject, the workers Compensation erma,hns of the "nor Code,.- oma
forthwith comply with such pmvisinns or this pemmiO shall be deemed revnkal.�
LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
me work for which this permit is issued (Sec. 3091, Civ. C.)
Lender', Name
WATER SYSTEM/TREAIING
SOILS FEE
WATER SERVICE
PAID
Dwe Receipts
NEW RESIDENTIAL PhMB. SQ. FT.
TOTAL:
TOTAL:
O
Lenders Address
BUILD FEE
SEISMIC PEE
F V0.i
U Z,
1 certify that 1 have read this apps anion mord state that Nc aluwc Information is
cored l agree to comply with all city and county ordinances and store laws relming to
building conswetion. and hereby numorim mpiewnwtives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE.
ELECTRIC ME;
uMrvcnmminncJ pmlwny Its, Inapetlion forlows.
(Wel agree to save, indemnify and keep harmless the City of Cupertino against
ALT ER OR ADD to Est ECI I.
PLUMBING Plili
liabilities.judgments, costs and expenses which may in any way accrue against said City
in permit.
AIN I]AN DUNG UNIT (A) 1111X1(1 CFM)
MSCI{ANICAI. PCE
PLICANT Nthe RSTAN Sthis
APPLICANT UNDF.RSTANUS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
AIR HANDLING UNI'T(OVER I0.000CRM)
CONSTRUCTION TAX
Olt `Date
. ignition,of A,,heinVCom.acmr
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(T0100.00 BTU)
Will the �ppli.......l'umrc hnilding rxcupam xhm nr b:uWlc hmardous material
as def ned by the Cupenino Municipal Code, Chapter 9.12, and be Health and Safety
Code, Section 25532(a7 t
HEATING UNIT (OVER I W.tIW BTU)
VENTILATION FAN (SINGLE RESIDE
❑Vc, [:J No
Will the applicant nr future briding acaR.m use equipment or devices which
emit hmardous air contaminants as defined by the Bay Area Air Quality Management
PAID
Dole RaciptM
BOILER - COMP LIMP OR 100.000 BTU)
TOTAL
BOILER -COMP (OVER 100,000 BTU)
Dmsma?
F7 Vic, FNo
AIR CONDITIONER
(have rood the hunuNous nm¢rials iequimmentx wmJcr ChnpmrfiJS nl the Culi-
I CE DA '
NEW RESIDENTIAL MECH. SQ. FT.
from. Health & Safety Cale. Sections 25505, 25533 it 255.34. I understand not if the
building dues not currently have a R...1. that's is my responsibility is, notify th. osenrynt
r\
of Ne r 9u� temems wnich mast banner Prior m osmose of a Cenifrne of Occupancy.
ISSU BY:
TOTAL: _
Owner or auodagent Dam
maed
OFFICE