29463APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PFRMIT NU.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL n � A � �i
Itrm, f11N1. VYllioll rr1r�NTINI!`aT111N L 4 J
OFFICE
102-0% -'reFFG poo.
iWNER'S NAME: //--n PHONE:
S WIZ .
CONTRACTOR'S NAAM�&'- IAC NO:
N\G% pN\a\hN
NIC
❑
'
O' )l.x
—
RRCCHI_T.ECI'/F.NGINEIiR: LIC NO:
ADDRESS:
//y►yy��
G011f«�iiV ��1/1A% V
CONTACT: PHONE:
BUILDING PERMIT INFO
.� &w0s�- T 1 �N�•
✓�r1 a.1Y.T�lc'ev.Wj .5' (
❑ Consultant Fees Paid by Applicant (Initial)
W ELECT' PLUMB MECH
❑
LICENSED CONTRACTORS DECLARATION
I hereby sfGrm that I am licensed under provisions of Chapter 9 (commencing
with Sconan]000)rf Dlvlstom3oribe Basimssand Pmfessinns Cndc,mdmy license ix
in full force and effect.
License Class Lick
Date Comrador
QTy, ELECTRIC PERMIT FEE
Fwon
OO
W h'
JUI"'
{..Z 4
y un
Pl7a
JOB DESCRIPTION
RESIDENTIAL
❑ SFDWL - [I KITCHEN REMODEL
[]ADDITION PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES - RFSIDENTIAL
'� ARCHITECTS DECLARATION
I understand my plans shall be used as public acords
PANELS
::JJQQ
I rit=
iG O G U
3 F
UPT02MAMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑HAT" RC•MODEUREPAIR El DENIOLITION
❑ OTHER
Licensed l'rnfex.imed
OWNER -BUILDER DECLARATION
I hereby affrtn that I am exempl from the Contractor's License Law to the
following reason. ISnctinn ]031.5, Business and I'rofcasinm Code: Any city or county
201-IMBAMPS
OVER 1000AMPS
SIGNS ELECTRICAL
tL a.
C-�ofnn
gf
which ar,in a a permit to ennnmet. alcor, improve, demolish, nr ¢pair any strveturt
priors. its is....rc.rdui rcyuircs theupplicanl forsuch permit In 0lea.cigned xminnert
that he is licensedpmsuam mthe provisions of the Contractors License Law(Chapter9
SPECIAL CI ITIMISC.
THMP. ME RORP LE INST.
COMMERCIAL:
❑ N W BLDGIADDITON 11 DEMOLITION
p0(commencing
d tY
with Section]000) of Division 3 of the Business and Professions Corm or
that he is exenspt Therefrom and the basis for the alleged exemption. Any violation of
0
Section 7031.5 by any applicant far a permit subjects the applicant to a civil Penalty of
not more than five hundred dollars (SSW).
01, os owner ofthe property or my employees with wages as their sole compensation.
willdolhewor1, and the structure is not intended reoffered far sale (See 7044, Basiness
POWER
ENANT ❑ FOOD SERVICE
r Ift80VFME1sT
❑OTHER
SWIMMINGP l.E URIC
L3
and Professions Code: The Compactors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
OVfLETS -SWITCH - RES
his own mmployees, provided that such improvements are not interceder offered for
sale. Rhoweveethe building or improvement is sold within oneyca rd'completion, the
NEW RESIDENTIAL CLE SQ FT.
SQ. FT. FLOOR AREA
SISQ. FT.
owner -builder will have the burden of proving that he did ern build m Improve far par
puce of rolene
I, as owner of the properly, oro exclusively mg with licensed omss i.
aa��
•R�
VVVJ
T
Prom.i
conswcl Ne projttl (Se<. ]DW, Business and Professions Qule:) The Cnnvncmrs Li-
C ume
censeLawdoesnotapplytoanownerofpropenywhobuilJsorimprmvesthereon,and
QTY. PLUMBINGPF.RMIT FEE
who a mpacts for such priori with a crntroams) licensed pursuant to the Convectors
PERMITISSUANCE
License Lo
❑ Tum n p umile, Sec. �B& P C�far flinnown
ALTER-GRAIN&VENT-WATERI�
Owntt Sm,- p�ivaz
WR'. DMP: SATIONDECI.ARATION—T
VALUATION
�
c= 1/`K_lUUK/
BACK FLOW PROTECT. DEVIC PIZ
•O
I hereby affirm under penalty of perjury one of the following declarations:
" IJsJH
DRAINS -FLOOR. ROORA_ .CO
l have and will maintain a Cenlfic.m ofConsentto self-insue, for Workers Compete
cation, as provided frr by Section 3]W nl the labor GWe, fur the performance of the
work far which Ria permit is issued
TORIES
d I r Ur cu. L
TYPECONSTRUCTION
11 INN
FIXTURES - PER TRAP
respired by Section
❑ 1 have and will oak, fon he per or Co ce of the w workwhich
thelCionpmigfur the the work for Penni) is isaueJ,
OAS-EA.SYSTEM-I INC.40U_TL
OCC. GROUP
APN
are:
My Worker's Compensminn Insurance currier and Policy number are:
MyW canna murder
Cartier. Policy No:
GAS - EA. SY$TEM-OVIiR4(EA) ��\ \\
a
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
GREASPJINDUS'fRL WASTE IN'TERCEPTOIt \ �a
BUILDING 0I VI � FEL'S
( section need not be completed ifthe permit is for one hundred dollars SIW)
or IessJNix
GREASETRAP �
PLANCHF.CK FEE
0
Z 0
. try
a ^
w G
d
z
L)�
{& (~
0 V
�' DJ
�
I comytha inda,milonnnnceofthe work for which this permit is issued, i shall
not employ any Person in any manna so as to Izcotne mbjecuo to Workers Corepen-
an.. Iaws.f California. Date
Applicant
SEWER - SANITARY - STORM EA. 200FT. �\
.\
ENERGY FEI, V
WATER HEATER WIVENTIELECTR
GRADINOFEE
NOTICE. TO APPLICANT: If, after making this Certificate of Exemption, you should
hme.object m the Wurkeh C.mpensmion provisions of the labor Code, you must
eco
I'onitwith comply with such provisions or this pemtit shall he deemed revoked.
CONS TRUCTIONLENDING AGENCY
Thereby affirm that there ice crnswdirn lending agency fm the penananrmrf
the work for whichthis pemtit is issued(See3090. Civ. C.)
Latta, Name,
WATER SYSTEM?REATING
WATER SERVICE
SOILS FEB
PAID
¢ Receiptp
NEW RESIDEMI'IAI. PLMB. SQ. FT.
TOTAL:
Lendera Address
TOTAL:
BUILDING FP.P, �
1 certify that 1 have read this ipplicatiom and stem tem the above information is
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
it
tq
V z
correct. l agree to comply with all city and county ordinances and start laws relamag t.
huiWing mnaweiun, mid hereby meorfs.c representatives arthis city., enmrupn the
PERMIT ISSUANCE
ELECTRIC FEE
above-memianed porperly, for inspection purposes.
(We) agree to.sme, indemnify and keep harmless the City of Cupertino against
AL9'ERORADDTOMECH.
FEE
liabilities,judgments. costs and expenses which may inany way uccmeagairetsuid City
in consequence of the granting of this TortPLUMPING
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10," CFM)
CONSTRUCTIONTAX
Sigeame.&ApplicaMCatimeter Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WIDUCO
HOUSING MITIGATION FE'
HEATING UNIT UT) 10.0110 BTU)
Will the applicant or future building occupant atom or handle hanadous mmend
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(.)?
HEATING UNIT (OVER I W.000 BTU)
C] Yes F-1 No
Will thea applicant or future building I use equipment or devices which
PP gbytheBBOILER-COMP(3HPOR
emit harsNous vie conmmiwms as def nod by the Rey Arca Air Quality Management
PAID
Rtt t p
Dam at
VENTILATION FAN (SINGLE RESID)
IW,0WBTU)
BOILER- COMP(OVER 100.OW BTU)
District?
❑Yes ❑N.
I
AIR CONDITIONER
I have read the Mumlo w materials tesuirem oro under Chapter 6g5 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
fomin Youth & Safety Cole. Sections 25505, 25533 and 25534. 1 understand that if the
building does not currently have a tenant, that it is my responsibility to notify the rc[vpaml
of dm requirements which must 4 tad pian n issuance of a Certificate of Ocura mcy.
OFFICE