29630 (2) APPLICANT,TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO'' BUILDING.ELRCTRICAI. PERMIT NO. 2/� ��O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L`9-
BUILDING PROJECT'IDENTIFICATION
BUILDINGAD DRES$r,', SANITARY NO. APPLICATION SUBMITTAL DATI
o ((7 J ,Bve
OWNER'S NAME:. PHONE; ret CONTRACT'OR'S NAME: LIC NO:
N/C CONTROL#
CHITECT/ENGINEER: LIC O:wrADDRESS: .❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION El El ❑
QTY. ELECTRIC PERMIT FEP.
1 hereby affirm chat I am liaised under provisionsest ofChapterEndo, 9(commenting ]OB DESCRIPTION
0000 with Section T000)ofDivisionJofthe Business and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL
yW in full force and effect CSFDWL ❑KITCHEN REMODEL
6UV License Class APPLIANCES-RESIDENTIAL ❑ADDITION CPLUMBING RE-PIPE
4 Date—Contractor
[F..Dm ARCHITECTS DECLARATION PANELS CMULThUNIT ❑STRUCTURAL
oz p tJ z I understand my plans shall be used as public records MODIFICATION
{-�r/��y1fp9 UPT02W AMPS [I INTERIOR ❑CHIMNEY REPAIR'
t�ya.,yy Licensed Professional 201-It00AMPS IMPROVEMENT
4 9p.•J]
OWNER-BUILDER DECLARATION 1�0I^y 6 I hereby affvm m that 1 eexempt from theeCharacters License Law far the OVER I"AMPS [-I BATH REMODEI/REPAIR (]DEMOLITION
4 L) followingagars.(Section 7031.5.Business and Professions Code:An cit or count []OTHER
a 4 F reason.
SIGNS ELECTRICAL
tJ which requires a permit to construct,alter,improve,demolish,or repair any structure
ern prior to its issuance.also requires the applicant(orsuch Permit to file a signed statement SPECIAL CIRCUIT/MISC.
That he is licensed purecanrto the provisions of the Contractor's License Law(Chapter 9
W CC (commencing with Section 7")of Division 3 of the Business and Professions Cede)or TEMP,METER OR POLE INST. COMMERCIAL
4 e that he is exempt Nerefom and the basis for the alleged exemption,Any violation of
Section 7031.5 by any applicant a permit subjects the applicant to a civil penalty of POWER DEVICES El NEW BLDG/ADDITION CDEMOLITION
(y i not more man five hundred dollars($500L CTF.NANT� CFOODSERVICE
a❑ C1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
_ wdldome work,and the structure is not intenlad oroffered for sale(Sec.TW,Business - El OTHER
4✓$ and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements are not intended or offered for NEW RESIDE ELECTR SQ Pr.
sale.If,however the building or improvement is sold within one year ofcompletion.the ,\ SQ.FE FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for pur- r
f saleJ. -
1,as owner of tM property,am exclusively contracting with licensed contmemn to TOTAL: ��
ct Ne project(Sao 7000,Business and Professions CNet)The Contractor's Li-
co se Law does not apply to an owner of property who builds or improves thereon,and QTy, PLUMBIN T FEE Q O
who contrasts for such projects with a contmctimid fanged pursuant to the Contmeang H 1996
License Law. PERMIT IS A "
El am exempt under Sec. ,B&PC for Nis reason tz— I•/IPr
?net Date ALTER-DRAIN& -WAT'ER(EA) -' `�VALUATIONf
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECC DE
I hereby offnm under penalty of Perjury on<of the following declarations:
C l have and will maintain a Certificate of Consenuo self-insure for Worker's Chat DRAINS-FLUOR.ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
mom,m provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is ismed. FIXTURES-PER TRAP
C 1 have and will maintain Wmkces Compensation Insurance,as required by Section r'
37M of Ne Labor Carlo,(a,Ne performance of the work far whichthis permit is issued. GAS-EA.SYSTEM.I INC 4 OUTLETS r OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Carie,. Policy Nn.: GAS-EA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This sion rad not be completed if the Permit is for one hundred elollors(Ston) BUILDING DIVISION FE65
w less.) sesGREASE TRAP PLANCHECK FEE
1 employ
any matin the my nater performance close work formew subject
to the permit is issued,l shall
not em to an SEWER-SANITARY-STORM EA.200 PI'.
p y y person in any mamaer so u to become subject m the Workers Compen- ENERGY FEE
0 z session Laws of California.Date WATER HEATER WNENT/ELECTR
z Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
5 become subject to the Worker's Compensation provisions of the Labor Cede,you most SOILS FEE
a�
forthwith comply with such Provisions or this munition be descant comfort. WATER SERVICE
;Dz CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.ET. PAID
L) O l hereby affirm that there is a construction lending agency for me performance of Data Receipt#
O H she work for which this permit is issued(Sec.3197,Co.CJ
Lattices Name TOTAL:
WLenders Address TOTAL:
0. 1 certify that 1 have read this application and stag that the above information is BUILDING FEE
(/) corset.I ngam to comply wish all city and county ordinances and stag laws relating to QTY. MECHANICAL PERMIT FEE
L) z building construction,and hereby authorize representatives of this city theater upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE
liebilities,judgments,coas and expenses which may in any way axme against said City ALTER ORADDTO MECH.
in cmnequence estate granting of this armit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WDN ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCfIONTAX
Signature of ApplicargAmornaor -Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum building occupant store or handle hazardeas materiel HEATING UNIT(M 100,000 BTU)
as,defined by the Cupenim Municipal Cada Chapter 9.12,and the Health and Safety
Code,Section M532(a)9 HEATING((NIT(OVER 100,00)BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building mcup w use equipment or devices which Data Receipt N
emit functions or mataminums as defined by the Bay Aga Air Quality Management BOILER-COMP(IPP OR I00000 BTU)
TOTAL:
District?
i ❑Vas FIN. BOILER-COMP(OVER 100.000 BU)T
1 have real the haurdea s materials AIR CONDITIONER
r5,Z553 an 2553a,1 understand
of Cali- ISSUANCE DAT
forme Healed B:Safety Code,e.hong 25505,is my and 25534.I undentaal that if the NEW RESIDENTIAL MECH. SQ.ff.
buildingdoesnn,mwhichmmial,haves bactpthato ismyce,ofaC irainotifymatum pant
of me requirements which most be Inn prior to issuame of a Certificate mf Oaupancy. '
Owner or authonmil Date TOTAL: ISSUED BY:
OFFICE