29833 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL.
BUI.DING PROJECT imEhrTIFICATiON 29833
BUILDING ADDRESS: 11 SANITARY NO, APPLICATION SU ITTAL DATF.
0)'4Q
O ER'S NA IE: k HONE: CONPR CfOR'S NAME: LIC NO:
- NAC R I.
e I ARCHI'IE T/EN INFER: LIC NO: ADDRESS: ❑
CONTACT. PHONE:4 BIJILDINC PERMIT INFO
L /O ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
r 33- 1:1 El
❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
rumat
I hereby am I am licensed under Provisions of chapter 9(commencing lOR DESCRIPTION
GIY'Z 1th ScOm.7000)or Dtvfsf 3 fth<Business an 10 Jm licenvc is
�0O w su Y PERMIT ISSUANCE RESIDENTIAL:
in full frmeundeffec�- ❑SFDWL ❑KITCHEN REMODEL
F�.V Ticen. C as Lic.M
bG
Data Cummnor PPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
f,,,pan CH1FECPS DEC PANELS ❑MULITUNIT ❑STRUCTURAL
20,..17- IunJersmnd my plunsshvl l be used as public ree"w MODIFICATION
OZ-q UP'102WAMP5 INTERIOR ❑CHIMNIiY REPAIR
Fbd ty Licensed Professional 201-1000AMPS IMPROVEMENT
�bd S-�l6^� - Oat lam eUmon from
Ce Contractor's
� OVER IWO AMPS
y a W 1 hereby affirm rmv 1 am exempt from the Comrncuv's License Law fm the C3 BATH REMODEVREPAIR �DEMOLITION
x a O.V fallowing mason.(Section 7031.5,Businessland Professions Cud,Any city or countySICNS ELECTRICAL ❑OTHER
F LLO which requires it permit to comwa,sate,.improve,demolish,or repair any saucturc u
prion.its ismarea..1sarequires thevpplicas brsuchpermit to filevsignediaitument SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant to the provisions of the Contractor's License Low(Chapter 9
GC (commencing with Section]WO.f Division 3af the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
L y m� that he is exempt therefrom and the bulla for the alleged escmptirm Any violation of
W Section any applicant for permit subjects the applicant to u civil Penalty ❑NENANT ADDITION ❑DEMOLITION
tv-y Y Y re Pe ) pp penelt f POWER DEVICES ❑TENANT ❑FWUSCRVICE
t mom man frvo hundred dollars($500).
1,as owncrof the ro norm employees with wages as their sole cote neation, SWIMMING POOL ELECTRIC IMPROVEMENT
GG" O ❑ 11 Pro Yut in Y g Pe
ill domework,andthehe Contra rots License
I.wdoffened Cmole(Sec.]fU4, wnerof ❑OTHER
Land Professions Code:The Contractors License law door not apply es if .caner of OUTLETS-SWITCHES-FIXTURF_S
- property who hyees.or improves t such I and who Improvements
a each work himself or through
his own employees,Provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ it17.
ole.l[hawer will have
burden
of prmentithat hewithin one wild or l'campletfonthe SQ.PI'.FLOOR AREA S/SQ.IT.
owner-builder uilder will have the burden of proving that he did not buil)or improve for pur-
0 1,a ole.).
1,as t the V.f the Seeproperty.a Biomass
contemns with licensed rammer,i- TOTAL: n"
nntswm the prnjen ISec.]IN4,Dnsinees ansa Professions CudcU The Cnmmcmrs Li- k'
cense Law does nate 1 to an owner n who hands or int
vPY profanity gmacs Contortond QTY. PLUMBING PERMIT FEE
who nimruna for such project with a comracmrts)licensed punuam tome Commnnra ���
License I.aw. PERMIT ISSUANCE 2 O
❑ I am exempt under Sec. ,[I&P C.for this reason
Owner Data ALTER-DRAIN ak VENT-WATER HDO I'll rJ� UATIO
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE .
I bratty affirm under penalty of perjury one of the following declarations: 0-n5--I nu
40F l have and will maintain a Certificate of Comminto self-insure her Workers Courtlier- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIONsation,as provided for by Section 3]1X1 of the Labor C de.for the performance 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
37I0of the Indi Co e.forth pe)' area .e nfthe work for which this pnmit is issued. GAS-RA.SYSTEM-I INCAOITLETS OCC.GROUP APN
My
Is t t stela 'a ¢rand Policy
Certie. Poliry N.,: AS-EA.SYSTEM OVER 4 TA)
CERT KATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING
(This made.need not bevompleted fthe p,ndDIVISION FEESt is Coruna hurried dollars GREASE TRAP
or less.) PLANCHECK FEE
Icebfy that inthe anyamenerance of an,workfor which this tenthisissued.
mapeshall SEWER-SANITARY-STORM EA.200 FL
not employ any person in any manner so ns to become subject,.the Wnrkm'Compen- ENERGY FEB
,Z sation laws of Cel ifomia.Data
�O Applicant WATER HEATER WNENT/ELBCfR GRADING FEE
h NOTICE TO APPLICANT.If,after making this Cortificde of Exemption,you should WATER SYSTEM/TREATING
abecome subject to the Worker's Compensation provisions of the Ichor Code,you must SOILS FEE
Lit forthwith comply with such previsions.,this permit shall he deemed revoked. WATER SERVICE
6t
CONSTRUCTION LENDING AGENCY NEW RP_SIDENf1A1.PLMB. SQ.FT. PAID
L) lhee which rntha.I,i isamndmaion len ding agency furthe perf.nnance of Dam Receimtp
the work for whist this pctmit is issued(Sm.lug],Civ.C1
Q Lenders Name TOTAL:
L) Lenders Address TOTAL:
F0. 1 certify that I have mad this application and state that the above information is BUILDING FEE
F-t N correct.I agree to comply with all city and county ordinances and suite laws saluting to QTY. MECHANICAL PERMIT PGE
V 7- building contraction,and hereby authodi,represemntives ofthis city recover upon the SEISMIC FEE
above.mentioned property for inspection pmposen.
(we)agree to save,indemnify and keep harmless the City of Cimarron against PERMIT ISSUANCE ELECTRIC FEE
Iiabilities,judgmems,costs and expenses which may in any way amme against mid City ALTER OR ADD TO MFCH.
in consequence of the grunting of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCIONTAX
Sigoanre of ApplicanuCurnmemr Date I?XHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haerbous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cafe,Stenon 25532(.)? HEATING UNU'(OVER JU),(=B'i'U)
❑Yes ON.
VENTILATION FAN(SINGLE RPSID) PAID
Will the applicant orfmux building receptor use equipment or devices which Data Receipt p'
h hamabous air comamimuals as defined by the Bey Atte Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
D
TOTAL:isvin7
Yes ❑Nn 1X)BBOILBR-COMP(OVER 10(,0TU)
❑
(hovPy
us andervli p AIR CONDITIONER ISSUANCE DATE
requirements under Cha mr695oftheCuli-
fomia it thactions 25511525577 an 255341 undcrstanJ that ifthe NEW RESIDENTIAL.MF.CIL SQ.FT.building ohet ;� cola Qni cafe. nc. y\(PlL/-)-
Owne,orludi.u,farfrtgcm �f am TOTAL: ISSUED BY:
OFFICE