29552 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICALPERMITNO. 29552
BUILDING DIVISION AI'PLICATION/PERMYp PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
Bit CADDRESS'. I - SANITARY NO." APPLICATION SUBMITTAL DATE,
(WNE SNA% PHONECONRACORN LIC NO I •
NIC CONTROL#
ARCH 'CI'/ENGINC•ER: LIC NO: ADDRESS:
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT
/ ❑
1'LIIMB MECH/
LICENSED CON I RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE �
I torcby allhm that 1 am licensed under boskims of Chapter 9 knmmencing JOB DESCRIPTION
"ZZ with Section9t00)ofDiv' on3ofNallusinessandPntCadna'Codaandnrylicumals P11 MIT 5.51 T
to[Oil force andcffie ,l
aUU License Clas O Lic.p V Fn�i El KITCHEN REMODEL
APPLIANCES-RESIDENTIAL ❑PLUMBING RE-PIPE
I-Z<,i Dam Contmcun ❑ADDITION
A IITT;fTS DECLARATION ❑MULTI-UNIT
ZONZ Iundentand p w 1,11 'edits public re..ds PANELS ❑STRUCTURAL
r2_ MODIFICATION
O Z— UPT0200AMP5
F f'ed Liccnscd Nnficssmnaf _ ❑INTERIOR ❑CHIMNIiY REPAIR
OWNER-BUILDER UECLARA'I'ION 201-100JAMT'S IMPROVEMENT
CL G I retail affirm that I at.cnunpl from the Cnmracmr's License Law for the OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
aU following reason.(Section Il3I.5,Business and Professions Cada Any city or county SIGNS ELECTRICAL ❑OTHER
Oy which requires a permit to actuarial.alter,improve,demolish,or repair any simulate
< prior taus nsuance,dsocequims the applicant farwch permiva flenaigned aaemcnl SPECIAL CIRCUITIMISC. —�
that he is licensed pursuant to the provisions ofma Carimcmr's License Law lChapter9
¢1 00 kommencing wish Section](6U)af Division 3nf the Hnainwsund Pm[esinns Crxle)nr TEMP.MUER OR POLE(NST. COMMERCIAL
W t
a d n thaw he is exempt therefrom and the basis for the alleged cxcmpum,Any vialatiou of ❑NEW BLDG/ADDITION ❑DEMOLITION
_ar' Section 7031.5 by any applicant fain forchil subjects the applicant to a civil Penalty of POWER DEVICES
F. � not more than live hundred dollars($500) �' �' ❑TENANT ❑FOOD SERVICE
QQ1,ns owner of Ne pmpcny,ornry employccn wiN wugn'as their sok cnmpenation. SWIMMING POOL ELECTRIC IMPROVEMENT
p.. willdulhewod,and destruction is nut imcndeJoroflind forsale(Sec.]DLI,Business ❑OTHER
L3 ro and Professions Cade The Contractor's License law,does not apply to an owner n( OU'fLBi'S-SWITCI HIS-FIXTURES•
property whit builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If,however.the building or improvement is sold within one year ofcomplelinn,the SQ.IT FLOOR AREA 5/SQ.IT
cr-builder will have the burden of proving that he did nor build or improve for put-
pis al'cele.).
Q 1,as owner of the property,am exclusively contracting with licensed carnractors to TOTAL:
construct the project(Sec.](Wt,BaslaI,,and Professions Code:)The Contractor'.U.
cense Law does not apply to an owner of property who builds or i mproves memo,and QTy.. PLUMBINGP FEE
who contract for such projects with a eommmur(s)licensed purmenuo the Contractor's
License Law. PEk MIT(SSU E
am exempumder Sec ,B&PC for this rream -
AITER-DRAIN&VEW A (E
Owner Date VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �'k 00
I hereby tfirin under penalty of Perjury one of the following declnmtions: / !'-
Ihave and will maintainsCertificate ofComenuoself-inr:ure for Workers Cmnpen- DRAINS-FLOOR,ROOF AREA,,CONE.
sation,as provided for by Section 57W of the Lafor Cole,for the performance of the ST RIES '1'Y1'E CONSTRUCTION
work for which Nin permit is issued. FIXTURES-PER TRAP
Q I have and will maintain Workers Compen.satinn Insurance,us required by Section
3700uf lh Labor Crde,fnrN perfnmmnce ofrM1e work for which Nis permit in issued. GAS-HA.SYSTEM-]INC.4OUTLETS OCC GROUP pPN
My Wo 'srContllerirnr;,nce c;tmi�-r and 1'nlicY n r
Comic ,cE Policy O GAS-EA.SYSTF,M-OVBR 4(EA)
CF.RTIIIC OMPr. E COMPENSATION
ON RAN WORKERS' GREASIIfNDUSTRI.WASTE INTERCEITOR
COMPBNSAed it ho INSURANCE
(This rection nmA mol M romplmW il'Nc permh Is fnrone hunJmJ Jnllars(Slap _ BUILDING DIVISION PEES
nr les') GREASE TRAP I'LANCHECK PEE
I ccnify Nat inthe{crlormuna of the work for which mi.tomtit isissuce.l shall SEW'fiR-SANITARY-STORM EA.2W I'1'.
riot employ any person in any manner so as,,become subject to rhe WorkcrK Comiscm ENERGY FEE
Z .(.lion Laws o
O WATER HEAI'F.R W/VEN-1/11
Applicant
? fn NOTICE TO APPLICANT':If,after making this Ccnifcnm of fxcmptinn,you should GRADING FEE
become soh eel m the ItA kers Com tion WATER SYSTEM/fREA'fING
j Pensa pmvisinns oftbe Lahr Code.you must SOILS FEE
fS.1 forthwith comply with such provisions nr this permit shall he deemed resokal. WATER SERVICE
ap
CONS]RUCTIONi1Cf10N LENDING AGENCY
= Z lhcrcb ff nn thio There i'a cnnswninn leading NEW RESIDENTIAL PCMB. SQ.F[ PAID
U Q Ya g agency for thcPM'onnancc of Doc Rccciplp
� f" the work for which this permit is isaeJ(Sec.1097.Co.CJ
U Lenders Name
O Lender'sAdress TOTAL: TOTAL:
F0. 1 comfy that 1 have read this application and nam that the above information is BUILDING FEE
N correct.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z haddingconsuuction.and hereby authorize representatives ofthis city rucnerupntWe SEISMIC FEE
aMvemcmionee papery,for inspection purposes. FERMI I'ISSUANCE 35'• 5-2 ELECTRIC FEE 9
(WO)agree to save,indemnify and keep harmless the City of Cupertino against
Ilabilities,judgments.eoal'and enterics which may in anyway accrue against aid City ALTER OR ADD TOS1ECIL
firs asequence of the granting of This pcmtit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P IN AIR HANDLING UNH'(TO IB.ap CFM)
URCE ' .AI'IONS.
SOMECHANICAL FEE S ,r
AIR HANDLING UNIT(OVER IB,fN6 CI'h1) MECHANICAL
FEETAXJ
CONST
Sign rc ofApplicmkjCmcavm, o EXHAUST HOOD(W/DUC)
HA- RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous original HEATING UNIT(TO l On"BTU,
to,defined by the Catarina Municipal Code,Chapter 9,12,and the Health and Safety
Cede,Section 25532(x)? HEATING UNIT(OVER 106,0011 BTM
Q Yea 0N
VENTILATION FAN(SI NGM RES ID) PAID
Will the applicant or future building occupant use equipment or devices which - Date Receipt#
thazaMcus air comm�tirmats us defined by Ne Bay Area Air Quality Management - ROLLER-COMP(ll{pGR Ia),(IW BTU)
Fruit
TO)FAL:
Q Yes ON. A2ILER-COMP(OVER 100.000 BTU)
Ihave lead Ne Increments tramdaBrc nundcr Chencr695oflhc Cab- AIR CONDITIONER L� ISSUANCED�
quiromen 1 !y , /� ELAT.F
fismio Hwhh no Sefcry Gde.esti na 25hat i 25533 and 25534,I undarly ba Wal if do NEW RESIDENTIAL MECH. SQ.ET.
building does now currently have a tenant:that it Is my responsibility,.nndly Ifm acuPant
of are requirements which must he out prior m issuance its Cenili<om of Occupancy,
Owner or authorized agent Date TOTAL; y /x /J �Q
ISSUED BY.':70 JeJ1�L•ft, rLj
OFFICE