29426 _APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
" CI'T'YOE CUPERTINO I 1 BUILDING.E:LF.CTRICAL - PIIRMITNO. w
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. 1
1. BUILDING PROJF.C'I IDENTIFICATION
HUILDINGADDRESS: - ' SANITARY NO. APPLICATIONSUBMI3TALDATE
T < <� cr cu -n Na --u�q,�
N'R'S NAME: PHONE: CONTRACTOR'S NAME:. �.j LIC NO:
Ir11 i NIC /C�OwwNf��ROLp
ARCHI117CIIHNGINITER: ar LIC NO: ADDRESS: ❑
CONTACP.- .„ PHONE: BUILDING PFiRMiT'1NFU
nh
❑
-Consultant Fees.Paid by Applicant(Initial) - BLDG „ ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB
h hereby error that 1 am licensed finder foo,mans at Cmpinr,9(caromendns JOB DESCRIPTION
000 with Section7000)of Division 3 ofthe Business and Professions Cade,and my license it
eDOp - RESIDENTIAL'
in full fares end effect. 8 I PERMIT ISSUANCE
y'IDC ❑SFDWI. KITCHEN REMODEL
-dUZ License Class Lie.p APPLIANCES-RESIDENTIAL DRION El PLUMBING RE-PIPE
y<L Date--Cammemr -
ARCHITLC7CSDECLARATION PANELS CMULTI-UNIT' CSTRUCIURAL
,•�pr�� [understand my plans shag he used rad public accord, � MODIFICATION
oz—0 . 111"10210 El El CHIMNEY REPAIR
I=.,h„E-ID Licensed professional - - 201.10WAMPS IMPROVEMENT
�Sd OWNER-BUILDER DECLARATION, OVER 111100AMP5 - ❑HATH REMODEL/REPAIR CDEMOLITION
6Y' a 1 hereby affirm,hal 1 am exempt from the Contractor's License Law for the
L O d U following reason.(Section 7031.5,Business and mofe,uom Cale:Any city or county SIGNS ELECTRICAI, COTHER
1D'3 4 which requires a permit to consumer idler,improve,Jemnli>h,err repnir any xwcdurc a (/0L_
prnowitsis...nc,.N.requiinstheapplicnnt farnmch penniuo file anignedstmemem SPECIAL CIRCUIOMISC. '
10
OgyG tyy> that he is I cemed pursuant to l he provisions of the Comrnnar's l.iccnse Law,(Chaper9
1++500 (commencing with Section 700)of Division 3 of the Business and Professions Code)nf TEMP.METER OR POLE IN ST.
Mm he is exempt rhemfrom and the basis for the alleged exempting Any violation of C NEW BLDG/ADDITION C DEMOLITION
n Section 7031.5 by any applicant for a permit&objects the applicant m u civil penally of 'POWER DEVICIS ❑
L, } not mart man Eve hundred dollars($500). TIiNANT. CPOOD SERVICE" j
d C Luxawner of the property,or any emplayeas with wages as their sale compensation, SWIMMING.POOL ELECTRIC IMPROVEMENT
O will do the work,and the swdure is not intended arnffered formle(See 7614,Business COTHHR
and Parex'slons,Cali:The Contractors License Law does not apply m an owner of OUTLETS-SWITCHIS-FIXTURES -
�' property who huilds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended oroffered far, NEW RESIDENTIAL ELECIR SQ IT.
sule.ILhowever,the huildingnrimpmvememissoldwithinone year nl cnmplvU...the r SQ.FT.FLOOR AREA ES .FT.
ner-hudder will have the human of proving that he did not build or Lmpinse for par. Aim
pn<a of sale.). I I
❑I,as owner of the property ant exclusively contmeting with licensed coatmi to TOTAL: �1
construct the project(Sec.7044.Business and Professions Code:)The Contractor's U.
cense Low does not apply to an owner of pntperty,who builds of lmpmves lhemon.Imd QTY PLUMBING PERMIT FEE
who contracts for such projects with a comramar(x)licensed punoam to the Conlmctors
+ License Law. ."1 + PERMIT ISSUANCE
❑1 am exempt under Sec. ,Il&P C for this reason
Owner ' Dam - ALTER-DRAIN,&VI?NT-WATERRIA) JVAKJATION 0 g
WORKER'S COMPENSATION DECLARATION BACK FTOW PROTECT.DEVICE ^•
Thereby affirnt under penalty of perjury one of the following declarations:'
❑I have and will maintain a Certificate afConseneo sef-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONI, STORIES - TYPE CONS'T'RUCTION
&&Ilan,as pa,,ded for by Scelion 37W of the Labor Cable,for the performance of tile
work for whichdi,permit is issued. FIXTURES-PER TRAP
❑.I have and will maintain Workers Compensation Insurance,as required by Section
TIDO of the LabarCade,for the parmar urreofthe work for which this permit is issued, :GAS-EA.SYSTEM.1.INC.4 OUTLETS OCC.CROUP APN
My Workers Compensation Insurance carrier and Policy number oar -
Carrier: % Policy No.: GAS-EA.SYSTEM-OVER 4(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPANDUSTRL WASTE INTERCEPTOR BUILDING[)(VW ION FEES
('Ibis section neednot he completedifthe peradd is intone hundred dollars( HM) GREA58 TRAP
or less.) - PLANCHECK FH
Iroulfy that In the performance at fie work for which thislwnnil is stated.Isholl S13WHk-SANITARY-SgORM 13A.2U1)FI'.
not employ any person in any manner so as to beeome untried to the Worker'Compen- ENERGY FEE ` O
C) z xntionl.awsof Califnrniu.Data WATER IIEATLR WNENTIIihP.CTR V '�
Applicant - GRADING E -
rjl NOTICE.TO APPLICANT:IC ager making this Certificme of Exemption,you should WATER SYS'IEM/IREATING
a � become subject to the Wor'ker's Cmapeaslion pn,,mans of the Labor Code,yam most SOILS FEE t
W forthwith Comply with such Provisions or this(icon,shall be dermal invoked. WATER SERVICE
Q
CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL PLMII. SQ.IT. PAID
d >'
U Q - 1 hereby offimuhatthem is a conemction lending agency fonhe perfarnluna of Date Receipt#
(-' the work for which this permit is issued(Sec.3097,Co,C.) -
O Lender's Name TOTAL:
Lender"AJJrexs - "' TOTAL:
I certify that 1 have mad this application and sure that the above information is BUILDING FE a,ti
U) Ln cvmO.l egrec m colony'with all city and reality ordinances and state laws remingto QTY, MECHANICAL,PERMIT FEE
Z hu ildingconsuuction,and hereby auNoure repraenutises ofthiscity insider upon the SEISMICPEE
abmw,- 11alinod property for inspection purpose". +
(Wej agree�o ram
ve,indemnify mid keepml
haress the City of Cul;cri na ngalnst PERMIq'ISSUANCH EL C M ,
- Iiabifiries,judgments,costs and eipenux which may in any way accrue against mid City ALTER OR ADD TO MECH. PLO 1
n wrron,u nm of the mm ing"of mix Pin nlI.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO IBM)CFM) '
SOURCE REGULATIONS, MECH ICAL FE A III
AIR HANDLING UNIT(OVER 10.00 CFM) CONSTRU TION TAX
Signorina,of Applicunl/Comrnctnr { Dote EXHAUST HOOD(W/DUCT) HOUSING Ifl
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fulure building occnryaln stare or handle haeameus material HEATING UNIT(TO 100,0(11)BTU) -
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the ile.IN and Safety
Code,Section 25532(x)? IIIATING UNIT(OVER I W.WO BTU)
❑Yes - ❑No PAID -
VENTILATION FAN(SINGLE RESID)
Will Oma liam,or future buildin Date Receipt Y
pp eoceupanutse egnipmenf err Aevicu whish BOILER-C OM Is P OR I W,M)BT U)
emit standards air communion as defined by the Bay Area Air Quality Management TOTAL:Distinct? '
0y. CNo BOILER-COMP(OVER I W,M)B'FU) „
I have read the hazanlous materials requimnical under Chapter fi95 of ro Glli- AIR CONDITIONER s - ISSUANCE DATE
forma Heald&Sifedy Cede,Sections 8505.8533 and 8534.1 understand the if the NEW RESIDENTIAL MECH I SQ.PT
of m my doax nm c whichally baso the met prior[hilo is my rgofa Celidy m nrnlfy ccat,of cupancy.
buNetntuldraments gdoesadcuravichrouebenant, niissuance ofuCsrtlytoralythrocney.
Owner or aumoniuJ agars Uam r TO'1'A L: ISSUHU IIY:
OFFICE
' 'APPLICANT TO FiLLIN INFORMATION WITHIN RED LINES:USE BALL"POINT PEN ONLY ''� ' ' 1"{n ° ' - " "' "i'
CITY-OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 2 9 4 2 E
":r`-,--- BUII.DINGPROJECr IDENTIFICATIONLt„ -;
BIRLDINGADDRESS - SANITARY NO. APPLICATION SUBMITTAL DA
T c df Af cv -i •".60—ItAco .
R'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
f+� MkC.HAIELPC L45 15 L N/C ///C���sONTROLp .
.\ CHRECT(FNGINEER: LIC NO: ADDRESS: ❑ _ ( / 7 ,-
vgf� K )
CONTACT, PHONE: _ - BUILDING PERMIT INFO ^
❑ Consultant Fees Paid by Applit:ant(Initial) - BLOG .ELECT PLUMB .MECH•, ;
❑ ❑ 4
LICENSED CONTRACTOR'S DECLARATION QTy xx,.ra v .ELECTRIC PERMIT PEE 1. -
I hereby.from that 1 am licensed under provisions of Chapter 9(comma g r r E,..3 ,.^•,_R r .MIT- .,iw.0 ere c'. 4 JOB DESCRIPTION
a'Z wit Secdon7000)of Divlaion3ofte Busmeaaad Profeaioa Codemdmy license is
W� in full fora andcffat. PERMITISSUANCE RF M NTIAT• .
FUZ License Class Lic.p ❑SFDWL ❑KITCHEN REMODEL
h6W Dau Contractor APPLIANCES-RESIDENTIAL DITTON C1 PLUMBING RE.PrPE
FF,,M0 ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
?O i/1� I understand my plans shall be used as public records PANEUPTO 200 AMPS _ MODIFICATION
_JF., ❑INTERIOR s ❑CHIMNEY REPAIR
g Littnscd professional W1.1000AMPS IMPROVEMENT
OWNER-BUILDER DE CLARATTON
1 hereby emrm am exempt 1 aexempt from to Contrector'e License Lew for to OVER I"AMPS ❑BATH REMODEIJRP.PAIR [I DEMOLITION
3 0.Ur following reamn.(Section 7031.5,Business and Profession Code:Any city or county SIGNS ELECTRICAL ❑OTHER _
0.0a which requdes a permit to construct,alta,improve,demolish,or repair any awcmrc u
y.] prior to am issuance,also requires the applicant for such pemuuo rite a signed statement SPECIAL CIRCUIT/MISC. Io,
>. that he is licensed pursuant the provisions of the Conwnoh License Law(Chapter 9
00 (commencing with Section 7")of Division 3 ofte Business add Professions Coded or TEMP,METIER OR POLE FIST -
Y p,M oC Out he is exempt therefrom and thbasis for the alleged exemption.Any violation of F1 NEW BLDG/ADDIWN ❑DEMOLITION
P� u.
Section by any applicmtfo%peanut subjects NT,applicant m enalty a civil pof POWER DEVICES ❑TENANT ❑FOOD SERVICE
sI
at more than five hundred dollars($500).
Q 0I,aownaaf tepropeny.ormy employees wit wages as teiraole compeusmion, SWIMMING POOL ELECTRIC IMPROVEMENT
' q willdothework,andteawchmei.notimendedoroffercdforsale(Sec,t044,13mmesa 'I]OT'HER
W a l and Profeenioa Cade:The Convantors License Law don not apply to an owner of OUTLETS-SWITCHES-FDCDIRFS
3 property who builds or improves turner,and who does such-weak himself or trough
his own employees,provided that such improvements are tat intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
We.If.however,to building or imprevemem is sold within one year of completion,the SUPT.FLOOR .FL
wear-builder will have to burden of proving that he did not build or improve for pur- s1 iw"w
pouofsale) % (..W
❑I.a owner of to property,am exclusively contracting with licensed contractors to TOTAL
coahuct to project(Sec.71M4,Built.and Professions Cade)The Contractors L - - '
cense Lew does not apply to an owner of property who builds or improves tenon end ,QTY ,li' PLUME[NG PERMIT FE8 syr '
who convects for such projects with o convactm(s)licensed pursuant to to Contructora - °+ - n. *-,. ws ,i• IP 11- '
License law. PERMIT ISSUANCE
C]Iamexemptunder Sm. ,B&PCforthisrtaun
ALTER-DRAIN&VENT-WATER HIM a,
.._` Owner Dau ''V ATION'' yrs-
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby alarm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent itself-insure fm WorkerCompeer- DRAMS's CompDRAINS-FLOOR.ROOF,AREA,COND, STORIES TYPE CONSIRUCI'10
'on,a provided for by Sectiod 37M of the Latour Code,far to perfamunce of to
work for which this permit is fasted. FIXTURES-PERTRAP t
❑I have and will maintain Workers Compensation Insurance,an required by Section
3700 of me labor Cole,for the performance of the work for which this Permit is named. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INpUSTR1 WASTE INTERCEPTOR - -s-.
(This section need not bcmmpletediftone hundred ($IW)e permit is far - _ ;/(;q{,,, '.BUILDING IONPEEq
or leaf GREASETRAP
PLANCF3ECK FE
Toy any train to Perforanymmmtto as t work for subject
ich jetio theWorkesuadunter-I shall SEWER-SANITARY-STORM HA,200 PI.
not employ any person in any manner so a to became subject tote Workers Counter- ENERGY FEE .
Z anon Inwa o(Celifomia.Dere
o O
Applicant ' WATER HEALER WNENT/PIFCTR GRADING -
[[[�rrri NOTICE TO APPLICANT.If,.der making tis Ceniflc.0 of Exemption,you should
WATER SYSTEM/IREATING
become subject y the Worker's is Compensation provisions of the labra Code,you mon SOILS PEE 1-
foMwith comply with such pmviaions or his permit shell be domed revoked. WATER SERVICE
� z CONSTRUCIONLENDING AGENCY NEW RESIDENTIALPLMB, SQ.FL PAID
(�0 (hereby all=that there is a construction leading agency for the performance of Dau Raeiptp
IL pP Ore work for which this permit is issued(Sec,309),Civ,C.)
O U Lender's Name TOTAL:
Leaders Addrnu TOTAL:
W 1 ttm(y that I have and to application and sou that to above information u _ , _ - _ BUH.DING FE �+
V2 cia.t I agree to comply with all city and county ordinances and Stam laws relating t Q•py MECHANICAL PERIv11T R` FEE,' ,
U , building contraction.and handi,mtonse rtpreerannesof this city m enterupon the ^- ^ a'- +-` SEISMICFEE
above-mentioned pmpemy for inspection purposes.
(WT,)agree to save,indemnify and keep harrnlos the City of Cupenim against PERMIT ISSUANCE EL El j
liabilities,judgmenm,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO METH.
in consequence of the granting of this permit PLU
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IOpW CFM)
SOURCE REGULATIONS, MECH ICAL FE
AIR HANDLING UNIT(OVER 10,000 CFM) CON6TR ON TAX
Signature of Applicant/Convacmr part P.%HAUST HOOD(W/DUCT) HOUSING 10
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or ftmre building occupant store or handle harsedous material HEATING UNIT CM 100,000 BTU)
as defined by the Caper ino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? HEATING UNIT(OVER 100,"BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RESID) ��
Date Receipt Is
T Will to applicant or future building occupant use equipment or devices which
) mit haardoucommandants air condants as defined by the Bay Area BOILER-
MP(O
AU Quality Management COW OR 100,000 BTU)
istrict? TOTAL: '
E]Yes ❑No BOILER-COMP(OVER I W.000 BTU)
I have mrd the b.aardous materials requUm
eemCal
s under Chapter 6.95 of the i- AIR CONDITIONER ISSUANCE DATE
orma Health&Safety Code.Sections 25505,25533 and 25534.I understand tat if the NEW RESIDENTIAL METH. SQFf
tat itismysaponsibilityunotifytooccupant . .f the requirement which must be met Prior to issuance of a CeniOof ancy.cate OccupL,\wner in autonsed ,at Date TOTAL: ISSUED BY:
OFFICE
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