29724 (2) APPLICANTTO.FILL IN INFORMATION WITHIN RED LINES:USE BALI:POINT PEN ONLY
CITY OF CUPERTINO - - - BUILDING'-ELECTRICAL PERMIT NO.
BUILDING DIVISION.. .APPLICATION/PERMITi PLUMBING MECHANICAL 297
2 4
BUILDING PROJECT IDENTIFICATION
I BUIL/DINNGADDRESS:
SANITARYNO. APPLICATION SUBMITTAL DATE
OWNER'S NA BE: _ CgNTRACTOR'S NAME:' 1IC NO:
0. ^L)S V {` /1- NAC CONTROL R
HDRESS
Cf/ENGINEEk:, y LIC NO: + r�O�O �1+ (�me-r� .v S{Ay„ � ^❑ +
CONTACT. PHONE: - I� C BUILDING PERMIT INFO
+ '*. ❑ Consultitnt Ice"Paid by Applicant(Initial) - BLDG ELECT PLUMB C
LICENSED CONTRACTOR SDECLARATION hap - QTY. ELECTRIC PERMIT FEE -
El
1 hereby ).f that 1 em licensed under prodk11 of Chapter 9(commercial, JOB DESCRIPTION t
�„,r withI n]ODO)mDtvtston3 of[M1e Busi dPr Testi Cad a d ylicense is
in full force and RMn 2.� PERMIT ISSUANCE TIAL
�UzU Licenses Xii Lic.p - FDWL [I KITCHEN REMODEL
hQG Date Con nor - APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O�'? 1 understand my plans shall be used as public records MODIFICATION
OZ"� UP T0200 AMPS
[til LsenuJ Protess;onul . ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-IOOOAMPS a1MPROVEMENT
1 hereby affirm that I um exempt from the Contractor's License Law for the OVER 1 WO AMPS [I BATH REMODEUREPAIR ElDEMOLITION'=
NbO y U following rcac.n.(Section]0315,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
`O FN¢ which regaires a fummi to constmen alto,improve,demolish,or repair aoyv truc[ure
I,
rn.i priortoits issuance,almoaquires the applicant(ersuchpermit m ileo signed statement SPECIAL CIRCUIT/MISC.: 17<OOV
<� hat he is licensed pursuant to ithe provisions of the Contractor x License Law(Chapter 9
00 (commemm�g with Secti.n]Wr)of Division3mf the Bsiness unJ Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL..
a[y o e+ that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDRION• El DEMOLITION
]031.5 by any applicant fora permit subjects the applicant to a civil penally of POWER DEVICES
[more than five hundred dollars($500); ❑TGNANT ❑FOOD SERVICE
OE]1,as owner of Ne property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the sticture is not intendedmoffered forsele(See.90gq,Business ❑OTHER
tt a and Professions Code:no Cmmracmrs License Law does a.,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 an,not intended or offered for NEW,RESIDENTIAL ELECTR SQ Pr.
sale.If.however the building.rimpmeamentis sold within ane year,.f completion,the SQ.FT.FLOOR AREA l; $/SQ.PI'.
owner-builder will have the burden of proving that he did not build or improve for pur- b' Fi, g ltd '
Free of sale.). -
❑ Las owner of the pnPerry.am exclusively contracting with licensed commc[on to ,TOTAL:
exantrme[the project(Sec.'l04A,Business end Pmfeseions Codop The Conmac.rr'sBRAD
cense Law does not apply titan owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE MAR 19v796
who wmrocts for such injects with a commcm (s)licen ed pursuant to the ContraemrLs / V License axeLatPERMITISSUANCE ,� VII 1 Ur W;-CMIINV
[7]'1 em exempt under Sec..inverts with
pCfor Nis reeso
Owner" // Date ALTER-DRAIN&VENT-WATER IRA) .VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE +
I hereby affirm under Penalty(if perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
salon,as provided for by Section 3]00 of the Labor Code,for the performance of the work for which this permit is issued. .. FIXTURES-PER TRAP'
)t,�,T���� and will maintain Workers Compensation Insurance,as req.ire'd by Section
3]OO otlhe LahorCode,fonhe Performance of the work for which this permit is issued, GAS-EA.SYSTEM-IINCAOUTLETS OCC.GROUP APN
My Worker's Coope 'r [mimeo carrieramd Pollcy�yy;bpr ore. I 1_!Z 2-2—Coria: 7.Qm( PolicyNo.. GAS-EA.SYSTEM-0OVER
CERTIFICATE OF EXEMPTION FROM WORKERS' "
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Tbi"o'ban dead..[becompletcd ifthe permit is f.,m!.h dreddollam($100) BUILDING Of ISIONFEBS
or less.) . � GREASETRAP " ' � + PLANCHECK PEE
I certify that in the performance of the which this permit is issued,I shall SEWER-SANITARYSTORM LA.200 FT.
not employ any parson in any manners become wbjat t.the Wrrkeri Comped -
- ENERGY FEE
O Z cation Laws of California.Dare iVATER HEATER W/VENT/ELECTR
O Applicant GRADING FEE -
h NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a �^ Become imbiber n the Workers Compensation Provisions of the Labor Code,you most - SOILS FEE "
W.Q forthwith comply with such powhi.nscrthispem
nditalml be deeedrevoked' WATER SERVICE +
CONSTRUCTION LENDINGY NEW RESIDENTIAL PCMB. SQ.FT. PAID
I hereby offirm that there is.o.m ett dingagency for the performance.( Date Receipt#
r O (~ 'the work for which this permit is issuedi ne.30 C.)
U Lenders Name / - - TOTAL:
GLI Lenders Address TOTAL:
4y 1 comfy that 1 have ad a -p,l cation and site that the aboveinformation is BUILDING FEE
V) 'correct I agree to comply seth II city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U bolding conetmc[ion.and hereby amhorize represematives of[batty treater upon the SEISMICFEE
above-mentioned property for inspection purposes. .
(We)a nee to save,indemnify p y r Cuppronto PERMIT ISSUANCE
g y and which
-harmless the Cit nv a arts..against D ELECTRIC FEE ,
liabilities,judgmentsegrantand ex this pewhich may many way accrue against said City ALTER OR ADD TO MECH.
in consequence NDERSIjirNof this permit PLUMBING FEE
"APPLICANT UNDERSI\NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000(TM)S URGE REGULATIDN. - � MECHANICAL FEE . 20
AIR HANDLING UNIT(OVER IO,000 CFM) CONSTRUCTION TAX
Signature ofA IlcaucComractor I Fine EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU) -
as defined by the Cmentin.Municipal Code,Chapter 9.12.end the Health and Safety '
Cale,Section 25532(a)? '. HEATING UNIT(OVER 100,000 BTU)
Yes X� VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date i Receipt W r t
emir hazardous air comandant;as defined by the Bay Area Air Quality Management BOILER-COME(3HPOR IW,IXIO BTU)
District? - TOTAL:
.❑Yes ILNo - BOILER-COMP(OVER I Oid"ITTU) -
_l AIR CONDITIONER
1 have and Ne hazardous toms 255 5,requirements an under Chapter understand
of the Cali- - ISSUANCE DATE
fonds Health ne Safety d:h Sections 25505,is my end 25534.1 to notify
the
mat if the NEW RESIDENTIAL MECH. SQ.ET. '
build,requ.snot currently ha atenwL ohmic is my responsibility to notify the occupant
f the uiremems whi u be at p'or m its a e of a Cenifieme Oce ncy.
ter rem u0 agent - I Pate - TOTAL: ij2, ISSUED BY:
OFFICE ,