29695 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - 29695 C
BUILDING PROJECT IDENTIFICATION - v 5
BUILDINGADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
DESS
OWNL• N HONE: 'S NAM LIC NO:
_ TR
.NIC CONOL#
RCHITECf/ENGINEE0.: LIC NO: ❑
CO CT. - PHONE: BUILDING PERMIT INFO
^❑ Consul nt Few Paid by Applicant(Initial) BLDG ELE PLU MECH
LICENSED CONTRACTOR'S DGC1, ATION QTY ELECTRIC PERMIT FEE ED
I hereby aff that 1 ata licensed under provisions of Chapter 9(co coling JOB DESCRIPTION
�Z with Section'/0W)of Division 3 of eBminexsand afessions Cmc, cram is
in full Tome and efl'aL' ',(.J(h PERMIT ISSUANCE RESIDENTIAL:
QUU License ` Lic.N , ❑SFDWL ❑KITCHEN REMODEL
-H4W Dore Contract. APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RF.-PIPE
EF-�p msc�j ARCHITECTS DE RATION - ❑MULTLUNIT ❑STRUCTURAL
ZOO 1 understand my plans shall be used as public ri I PANELS
MODIFICATION
UPT0 200 AMPS
[-. I"'1�1�� Lmereed PrafessmmL ❑INTERIOR ❑CHIMNEY REPAIR
W� ;J, OWNER-BUILDER DECLARATION 201-IMAMPS IMPROVEMENT
�6 I hereby affnn that 1 oto exempt from the Contractor's License Law fur the OVER 1000 AMPS '
y{xt, y p ❑BATH REM O IRF.P ❑ fOL1T 0
W36U following reason.(Section]0315,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
LL7 W OEa which requires a permit to cadewet,alter.improve,demolish,car repair any stmcmre
N.] prior to its issuance,also requires the applicant for such permit m Ne a signed etmn^arts SPECIAL CIRCIRT/MISC.
y that he is licensed Poland 1.am provisions of the Convector.,License Law(Chi pmr9
00
(commencing with Section7")af Division3of Oe Businmsand Professions CMc)or - TEMP.METER OR POLE INST COMMERCIAL:
a y M C that he is exempt therefrom and the basis faf the oItetm]emomma.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ttX] Y• Sation]OJIS M1y any applicant fora permit xuhjwts the applicwl mu<ivil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
as..Nan five hundred dollors($500).
0 I]1.towner ofthe property,or my employeca with wagesm their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended moffaed l'ofxale(So.70t4,Business ❑OTHER
63 and Professions Code:The Connectoda License Law does not apply to an owner of OUTLETS-SWITCHES-
propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not inmmled or offered for NEW RESIDENTIAL ELECT,
41 saleJf.however.the building orimprovcmem is sold within arm ycvrofcompletion,the SQ.FT FLOOR AREA $/SQ.PI'.
pobler-uilder will have the burden of proving that he did not build or improve for pun
sy m sale.).
JPF11,us owner of the property am exclusively contracting with licensed contmdon m TOTAL: "� •.
construct the project(Sec.701 Business and Professions Cade:)The Contractors Li-
cemaLaw does notapplymanowmesafproperly who holds.,improve,Initial,and CITY PLUMBING PERMIT FEE rte 4.199
who convects far such projects with n conuaztoda)licensed pursuant m the Contractors �py��H{`
License law. - pP.RMIT ISSUANCE ""
❑I am exempt under Sec. - ,B&P C for this reason ,Ul",: 1VV
AUTER-DRAW&VENT-WATER(EA)
{�Owner DVALUATION
1$ WORKERSCOMPENSATION DECLARATION
I hereby affirm m under under penalty of perjury one of the following declarations: BACK FLOW PROTECT.DEVICE
❑Ihave endwillmainoinaCenifcate of ConsemmselLinmmfiat Workers Cnmpcn- DRAINS-FLOOR,ROOF.AREA.COND.
cation,as provided for by Section 37W of the Labor Cade,for the perfonnsnce of the STORIES TYPE CONSTRUCTION
o for which this permit is issued, FIXTURES-PERTRAP
w 1 loveand will maintain Workers Compensation Insuonce,as required by Section
37000 e labor Cale.for the pefo ofthe walk for which t' perms is issued GAS-EA.SYSTEM-1 INC.4 OUTLETS .
OCC.GROUP APN
My V C nation 'er and Policy u ge t
Cam Policy No. -+-�� GAS-EA.SYSTEM-OVER 4(EA)
ERTI TE OF EXEMPTION FROM WORKERS' --
OMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(This section need not be completed lithe Permit is foront hoodred dollars($10a BUILDING DIVISION FEES
or less.) GREASETRAP - -
I ttnify that inthe performunceofthe work forwhich this pmit is issued,I shall PLANCHECK FEE
er
not employ any person in any manner m as to become subject mme Workers'Compel- SEWER-SANITARY-STORM EA.200 FT
ENERGY FEE
z sation Laws of Cullfomia.Date
7�O Applicant WATER HEATER WNENT/ELECTRGRADING FEE
G y NOTICE TO APPLICANT,IL after making this Cendwride of Exemption,you should WATER SYSTLM?RCATINO
a become subject to the Worker's CompmaoBnbar
on Provisions of the ICade,you must SOILS FEE
[t7 forthwith comply withsach provisions mind,permitslull be deemedrevoked. WgTE0.SERVICE
PL
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL MB, SQ FT, PAID
U I hereby affirm thalthem is aconsvuction lendingagency forthe performance of i Receipt#
Lks p+ the work for which this wood is issued(Sec.3097,Civ.C.)
U
1--� Lenders Name "TOTAL:
V Lender's Address TOTAL:
y 1 certify Nm 1 have feud this application and some that the above information is BUIL
V1 correct.l agree to comply withal[city and county ordinances and state laws mining to QTY, MECHANICAL PERMIT FEE
U z building construction,and hereby maborite representatives alibis city to enter ups the SEISMIC FE
above-mentioned property for inspection mimes. 61 A
(We)agree mauve,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC EE
Retail mens,,mso end expenses which may in any way acute against said City ALTER OR ADDTO MECH.
ince quence fthe granting of this permit. PLUMBING E
AP (CANT NDER. A DS AND WIW,COMPLY WI'Tggq ALL NO AIR HANDLING UNIT(TO IU.000 CFM)
5 URC .GULATI S y/ MECHANICA E
AIR HANDLING UNIT(OVER IQl100 CFM)
c CONSTRUCTIO 'fA%
Signemreo pD canl/Contoaor Dam EXHAUST HOOD IW/DULT) HOUSING MITIGA ION FEE
HAZARDOUS MATERIALS DISCLOSURE
the applicant or future building tncupant store or handle hsafdous material HEATING UNIT(TO UJI10fn BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety '
Cole,Section 25532(a)'! HEATING UNIT(OVER JSU"BTU) -
❑Yea 71 No
VENTILATION FAN(SINGLE RESID) PAID Dee Receipt
Will the applicant or future building occupant tem equipment or device,.which I
emit hazardous orf contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(JHP OR 100.000 BTU)
•DnstdcR, I t BOILER-COMP(OVER 100,000 BTU)
1.
C]Y's [I No ,
I have read the himandous materials mquirements under Chapter fi 95 of the Cali AIR CONDITIONER - ISSUANCE DATE r
forma Health&Safety Cade,Sections 25505,25533 and 25534.1 m erm nd that if the NEW RESIDENTIAL MECH. SQ.PF.
building does at ewready hale a temnl that it is my responeuti lily as notify the occupant
of the requirements which must he met prior to exec mor of a Cen flea c of Occupancy,
a .
Owner or tothoriud agent Uate TOTAL: - ISSUED BY:
OFFICE