29274 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. ^9^� rte
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L�4J L 1/ 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: CONTR 'OR' MEs:�.R Ur.Trf yf CO
z3 b
7 NIC CONTROL#
RCHITE MNGINEER: LIC NO: ADDRESS: ❑
Sa ,v 4,r
CONTACT: PHONE: If BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTP UMN ❑MUCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE E3 El
I hereby affirm that I and licensed under and
Professions
of Chopin 9(commencing JOB DESCRIPTION
X00 with Section 7(Xll)of Division]ofthe Business and Professions Cale,mdm license is
�O y PERMIT ISSUANCE RESIDENTIAL:
at full force an �. Q
cense I s c I Lic.q C`� CShDWL [I KITCHEN REMODEL
kC3� Uate Comruarr
APPLIANCES-RESIDENTIAL ❑ADDITION IMBING RE•PIPE
F.Dym ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O'Z J Z I understand my plans shall he mad ss public records MODIFICATION
Jqq UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4t Licensed Professional201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
yy g V I hereby aflirm that 1 am exempt from she Contractors License Law for the OVER 10110 AMPS [D BATH REMODCIIREPAIR [I DEMOLITION'
ser a 6 V following reusom.(Section 9031.5,Business and Professions Come:Any city or county SIGNS ELECTRICAL []OTHER
4471 IkO which requires n Permit m comouri elm,,improve,demolish,or repair any Alachua
priormnstisuance,olsoregoires theapplicant forsuelTermi or fileasignMstmemem SPECIAL CIRCUIT/MISC.
tW�pN.
that he is licensed pursuant o Ne Provisions ofthe Contractors License Law,(Chapter 9
Cp0 (commencing with Section 7000)of Division 3 ofthe Business amt Professions Code)or TEMP,METER OR POLE INST. COMMERCIAL:
A.p`,M K Nat he is exampt thereRom and no basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y� Y. Section9031.5 by any applauds for a permit subjects the applicant to a civil Penalty of POWER DEVICES El ❑FOODSERVICE
y t moremm rive hundred dollars(S50(l) IMPROVEMENT
O ❑ I.as owner f the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will dothe work,and the swctum is not inmadeJ oroRered for sale(Sec.9094,Business COLLIER
and Professions Cale:The Coatrmmorn License Law does but apply m an owner of OUTLETS-SWITCHES-FIXTURES
propery,who builds or improves themes,and who does such walk himself or through
his own employees,provided that such improvements oro not intended or offered for NEW RESIDENTIAL ELECIR SQ Fr.
sale.IL however,Ne building orimpmvement is sold within one y<atof completion,the SQ.FT.FLOOR AREA SISQ.ET.
owner-builder will have the burden of proving that he did not build or improve for put"
Poseof sale.). - -
C 1,as owner of the properly,um exclusively contracting with licensed contractors m TOTAL:
answer the project(Sec.7099,Business and Prefessioal Cade:)The Commerce,Li- I/�N "-2
1996
cense Law does not apply 1.m owner ofPropery who huilds or improves thenn
en. al QTY. PLUMBING PERMIT FEE JA
who contracts for such projects wit a commemrls)licensed pursuant to she Commc oes rx
License law. - PERMIT ISSUANCE
❑ C UUrtHI INO
I exemaction undersea ,N&PC for this on Ur
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dme
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby union under penalty of perjury one of the following decimations:
i]I have and will maintain a Cerifc=e of Coasenuo self-insure for Workers Compete DRAINS-FLOOR.ROOF.AREA.COND.
non,as provided for by Section 37M of the Labor Code,for Nfor
e permanre of the STORIES TYPECONSTRUCTION
a
work for which this Permit is issued. MIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as restored by Sectinn
37M of the Leber Code,for the performunceof the work for which Nis permit is issued. GAS-CA.SYSTEM-I INC.4 OUTLETS
My Wmkei Cm tion rrierand Policy OCC.GROUP APN
y�hntA Jce ynun
Carrier. S `]'Y ��-and Policy No.: GAS-BA.SYSTEM-OVER I(EA)
CERTIFICATE OF EXEMPTION FROM WDI K!R '
COMPENSATION INSURANCE. GREASPIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION MM
(Thissection need not be completed line permit is form=humlredaollaa(5100) GREASETRAP
m less.) PLANCHECK FEE
Icenify that inthe performany..ance, fthe,
walk for subjectch In Permit ssesued''C.rnpn.Ishaft SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner m rax In become subject m the Workers'Cumpen- - ENERGY FEB
Z secs..Laws of Culifomia.Date
0 Applicant WATER NEATER W/VENT/L•LECI'R GRADING FEE
44 NOTICE TO APPLICANT.If,after making this Ceoificam of Exemption,yes should WATER SYSTEM/DtEATING
abecome subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
forhwith comply with such provisions or pewh shall be deemed revoked. WATER SERVICE _
0
CONSTRUCTION LENDING AGENCY NEW RES IDE NTIAL PLMI3. 1,Q S .Pf. PAIDFY i Thereby aflirm that there isnconnwction lending agency for the perfonnmcc of D If Receipt#
t•+ the work far which this peanut is initial(Sec.'3097.Civ.C.)
0 V lamders Name TOTAL:
UJ Leaders AddressTO
f y 1 cmify Bad I have read this application and state that the above information is BUILDING E
�•' IZ) connect.l agree to comply with all city and county ordinances and state laws relating to QTY" MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives of Nis city to enter upon the
SBISMIE
above-mentioned property for inspection Purposes. PERMIT ISSUANCE(We)agree to save,indemnify.and keep harmless the City of Cupertino against ELECT+ iiii P4
liabilities,judgments,costs aural expenses which may in anyway accrue against said City ALTER OR ADD TO MECII. AHOUSINGMUIG
inconsequence iiia ting is Pewit.
APPLICA ' N .+STA.' ANDW11.COMPLY WITH A LNON POINT AIR HANDLING UNIT(TO IQIp)CFM)
SOUR
'ly AIR HANDLING UNIT(OVER IB,IXIB CFM) AS
Sif.AWKApp Contractor - J set EXHAUST HOOD(W/DUCT) NFEE
HAZARD@@ IATERIAIS DISCLOSURC
Will the opplicantorf7
utur ;: ldingoecupanismrcorMndlchazardousmtcTial HEATING UNLFOD 100,01011111)
as defined by the Cupertino Municipal GMC.Chapter 9.12,and the Haddh and Safety
Cods,Section 25332(a)? HEATING UNIT(OVER 100.000 BTU)
C Yes CNo VENTILATION PAN(SINGLE RESID) PAID
Data Re #
WIII the applicant or future holding orcupunt use equipment or device.,which BOILER-COMP(3HP OR 100,(100 BTU)
mit hazandous air em mminams as defined by the Bay Area Air Quality Management TO
Jisr ct?
❑Yes FIN. BOILER-COMP(OVER 100,000 BTU) -
Ilk A
AIR CONDITIONER
4- 0/fh
°'pus mamriWs quiamcna under Chapter 6.95 of the Cub. ISSUAN DATE
foSection r 5,25533 and 25500.1 understand that if the NEW RESIDENTIAL MECH, SQ.FT.
buve iy rot it ismyresprmsihility mnotif)me mcupam
st sen o t`iry oafsdoll Imo of th n y. -
eel mgcm te TOTAL: - ISSUED BY:
OFFICE