29669 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATIONXERMIT PLUMBING'MECHANICAL
BUILDING PROJECT IDENTIFICATION 29669
ILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I V) I WIUM c26S OR 52-400
ERS N ME: PHONE: )NI'RACTOR:S NAME: LIC NO:
1 N/C CONTROL#
ARCHITECTtE GINEER: LICNO: ADDRESS:r3wIV ❑
CONfACE: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Pali
LICPNSED CONTRACTOR'S DECLARATION mQTY ELECTRIC PERMIT FEE ❑ ❑
1 herchy union that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aw0ZO with Section 700(hm'Division Sof the Businessand Professions Cole,andon,baciamis RESIDENTIAL:
O PERku r ISSUANCE
F in full force rant ellen.
f:�)u ❑SFDWL El KITCHEN REMODEL
aa.UzU License Class Contractor
NQS Dam Cnnttecmr APPLIANCES—RESIDENTIAL [3 ADDITION [I PLUMBING RE-PIPE.
y INNF!1.S ARCH[FECTS DECLARATION - ❑MI11.T[.UNrr- [:1 STRUCTURAL.
ZO�
F �j IundcrntunA my plans shall he umA e .,ad,public s � MODIFICATION
gOZ O UP'10200AMPS ❑INTERIOR [I CHIMNEY REPAIR
F4 ul Licensed Professional 201-1000AMPS IMPROVEMENT
,� OWNI!R.BUILDER DECLARATION OVIiR IINX)AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
y 1 hereby affirm Nm 1 am exempt from the Contractor's License Law for the
x 3 L UU. fnlluwing reason.(Section]031.5,Business rand Professions Cale:Any city m coumY SIGNS Ii1.liCiRICAL ❑OTHER
Y7 y LLO k which requires u permit to construct,alter,improve,demolish,or repair any structure
pit to its ismmice,.I requires Negppliaantforsuch Permit to file asignedsmtem,nt SPECIAL Cl RCUIT/MISC.
Ir;by!�} that he is licensed pursdanno the provisions of the Contractor's License Law(Chapter 916
y'a� (commencing with Section 700 of Division 3 of the Business and Professions Code)or 'PEMµMFT1iR OR POLE INS . '
S pp�, shut he is exempt therefmm and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDTrION ❑DEMOLITION
pS^INtSection]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES TENANT ❑FOODSERVICE
YF-Z} not more than five hundred dollars 155110). IMPROVEMENT
0 ❑I,ssowner of the property.nr mycmployeus wimwages as their solccompensatinn, SWIMMING POOL ELE
s�
will Ja the work,and theammurc is not intended orufferW Tarsale(Sea.9BM,9asineaOlt [)OTHER
ul and Professions Curie:The Contractors License law does not apply to an owner of OU'11RrS—S W ITCHES—FI
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA VSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par.
pose of gala].
E) 1,as owner of the progeny,am exclusively contracting with licensed contractors to TOTAL:
construct the project Ser.7094,Business and Professions Cade:)The Cmdoft ors Li. P roll A O
cans,Law duce not apply m an owner of progeny who bui Ids or improves thrown,and QTY. PLUMBING PERMIT FEF. H
whocontruetsfmsuehprnjeman to the Cmannam's
License law. PEIRMIT ISSUANCE
exempt under Sec. &P C far this rc:mn° FEB151996
!y CII
er Da ALA AR-DRAIN&VENT-WATER(EA) -
VALUATION
WORKER'SCOMPENSATIO A N BACK FLOWPROTECI'.DEVICE CITY Uhtksut"CrI I BVV '
I hereby affirm under penalty of Perjury one of the fall ing declarati im:
❑ I have and will maintain aCenificumof Consenuo self-insurefor Worker's Compete DRAINS—FLOOR.ROOF.AREA.COND.
action,as provided for h Semina 3000 of the labor Code,for the STORIES TYPE CONSTRUCTION
pnrvi y perfonnencc of the
work forwhich ill permit is issued. FIXTURES—PER TRAP
1of and willmaimonhe pan's Cance of th!w Insurance,kforwhihrequired by Section
My of the Labor Calefonthsurance anttof the work number am,this permit is issued. GAS—CA.SYS'IEM-I INC.4OUTLETS OCC.GROUP APN
Ca Workels Compensation Insurance carrier and Polity numberare:
Carrier. Policy No.: GAS—G.SYSILM-OVER 4(EA)
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASEVINDUSTRL WASTE INTERCEPTOR
This section used not be completed i0he permit is Torose handrail dollars(Slant BUILDING DIVISION FEES
or less.) GRFASETRAP PIANCHECK FEE
I certify that in the performance of the work for which this permit is issued.I shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as m Mcome subject to the Workers'Camper- ENERGY FEE
Z soon Laws of Cut prime.Dam
Z O Applicant WATER HEATER WNENT/ELECfR GRADING FEE
tr V2 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTF"rREATING
Ckbecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE .1 V17
{iI forthwith comply with such provisions or this permit shall be deemed revoked, WATTµSERVICIi
Q
CONSTRUCTION[.ENDING AGENCY NEW 'DENIAL PLMH, SQ. PAID
" V O Iherebyich hisilia
for iii isaad(Sra.30 leading agency for the perfanngnce of D «ciptN
w the work for which his permit is issued(Sec]099,Civ.C.)
O U Lenders TOTAL:
Lenders AJJrAddo esx' - - T
AW. I certify that I have read this application and state that the above information is BUILDING PEE
V1 cnrect.I agree m comply with all city and county ordinances and state Igws relining m QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorite representatives of this city to enter upon the SI,ISM IC PF.E
abovc.mrmahmed property for inspection purposes. I'I!RA1ff ISSUANCE.
(We)sgme m save,indemnify unit keep hsnnian the City of Cupertino ngmost ELECTRIC FEE
iiabilities,judgments,cosuand expenses which may in anywayaccme againauscrdCity ALTERORADDTOMECH.
in consequence of the kasm is of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO TO"CFMLTTE
SOURCE REGULATIONS. MECHANICI-
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUIONTAX
Minimum of ApplicanUCommcmr Dae HXI TAUNT HOOD(W/DUCD HOUSING ITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willdo.,licant or famobuildingoccupant store m-lemdlehazrdausmid, al HEATING UNIT CTO IW.glO BTU)
as defined by the Cupcnino Municipal Cole.Chapter 9.12,and the Health and Safe,,
Code.Section 25532(#)7 HEA'T'ING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Data Receipt#
Will the applicant i future building by the
use equipment or Mang emelt
Dignozerdaus air contaminants ns defined by the Bey Arw Air Quality Management BOILER—COMP(3fIPOR IIIO,(XIOBTU)
Diarin9 TA
F1 Yes [J No OOILIiR—COMP(OVER 1100,000 BTU)
1 has.mad the Notorious materials requirements under Chapter 6.95 of the Cull. ADR CONDIT IONER ISSUA E DATE
famia Death&Safety Cole Sections 255115,25533 and 25534.1 umlemand that if the NEW RESIDENTIAL MECH. SQ.FT.
building dues not current,has.a loom,that It is my responsibility to mildly the occupant
of the mg moments whwh must he met prior to Namora tef a Cenificme of Occupancy.
Owner or gahmimd allow Dam I I TOTAL: ISSUED BY:
OFFICE