29230 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. .PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT SID2UPIFICA'FION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDA9
OWNER'S NAME. N I'I10NC: C NTRACTOR:SN E: V X1338 NIC CONTROLq
a.
RCHITECT/ENGINEER: LIC NO: ADDRESS: 3� El'� 0 M6.SclIc «'
CONTACT: PHONE: BUILDING PERMIT INFO
/ ❑ Consultant Fees Paid by Applicant(Initial) Ly pG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby of ina that 1 am m
licensed under provision;of Chapter 9(commencing QTY
DESCRIPTION
FwoZ with Section 70pp)uf Divisimn3 nDhe Businexzand Profession;Code.and my Breast,ia
SB t,full force a ul effect. Q yPERMIT ISSUANCE RESIDENTIAL
CF.U F- License Class 429 Lic..6 Z 3 3 g ❑SFD W L ❑KITCHEN REMODEL
NQL Date�O�--O4—Canlrenor_L-C� APPLIANCES-RFSIOLNTIAL ❑ADDITION ❑PLUMBING REPIPE
p.Dvs ^� RCHITECPS U[CLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p tA Z I understand my plan;shall be used as public records MODIFICATION
O Z 4 Q UPT0 2M AMPS
F 4 F W Liccn; Professional ❑INTERIOR f HIMNEY REPAIR
Q
201-1000AMPS MPROVEMENT
Sifo w< OWNER-BUILDER DECLARATION
E
G C Q I hereby affirm mm 1 exempt from thee Contractor's License Law for the OVER 1000AMPS ED BATH REMODELiREPAIR ❑DEMOLITION
3 LLU following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL DOTTER
y which require,it permit to inflamer.alter,improve,demolish,nr repair any stricame
�:' poor to itsissuance.also requires the applicant for such permit,,file a;ignedxlmement SPECIAL CIRCU IT/MIS
EN
Q that he is licensed p.,,aant'o the pmvisior;of the Cnmrecmr's License Law(Chapter 9
�aOCI (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POL INS . COMMER_RCIAL.
L tY o 'hat he is exempt therefrom and the basis for the alleged exemption.Any violation mf
Section 7031.5 by any applicant for a canot.wNects theapplicam m a civil [_1 NEW BLDG/ADDITION ❑DEMOLITION
t serve than live hummeddollars($500). 3 penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Esq ❑Las owner(if tire property,or my employees with wages as their sole coa,cn,aiom, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended or offered Bar sale(Sec. Business 0 OTHER
0.3 m and Pomes;ier,Code:The Con'raclors License latw does not apply to an owner of OUTLETS-SWITCHLS-FIXTURE.
property who builds or Improve;thereon,and who Ane;such work himself onhrough
his own employees,provided'bar such improveamnt,urc not intended nr offered for NEW RESIDENTIAL ELECTR S
sale.If,however he building or impnmeinent is sold within one year ofcomp@tion,the T /;SQ.FFT.MOOR AREA $ISQ.FT.
mer-M1ua ildwill have tire barren nl'proving tire,hedid not build or improve for per- V 4"' LI,1 pT
pose of
❑ 1,as owner of me p,,,,By, at emb,i,ely contracting with licensed cmntmcmrs In
mwroje //j� y
nse"he pct(Sec.70,14.Business and Proles.;ions Code:)The Contractor's Li- j4 / (]
course Law news not apply n)anowner ofampeTtywho builds orimproves memon.and QTY. PLUMBINGPERMIT FEE sati7g96
who contracts for such projects with a comraaorts)licenser]pursuant m the Conamfores /af
License Law. PERMIT ISSUANCE (Jh L
Ell am exempt under See. ,B&P C for this reason w�[h LINO
Owner nate
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I M1<rehy affirm under penalty of perjury one of the following declarations:
❑Ihavcand will neintama CcnificateofConscnno self-insum for Waders Compen- DRAINS-FLOOR,ROOF AREA.COND.
smion,as provided fur by Section 3701 or the Labor Code,fearm:m
the perforce of the STORIES TYPE CONSTRUC001
work for which this permit i,issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,a;resuirtd by Section
3700ofthe dalror Carlo,for the perf rommo em(the work lorwhich this .it is isued. GAS-EA.SYSTEM-I INC.a OUTLETS OCC GROUP APN
My Work f yomrynsaimflnsuranccpa r sort Policy ugtho
Carver, t O/J me Policy N. 57)44 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This union need not he completed if the permit is formal hundreddollar;($100) BUILDING DIVISION FEES
or le,,) GREASE TRAP PLANCHECK PEE
Loy any'heou the comanyannaneeofs to rk for which'his thePermitWisissuCompn- SEWER-SANITARY-STORM FA.200 FT.
not employ any person in any manner so ossa bemmc subject to she darken'Cnmpcn- ENERGY FEF,
Z sation Laws of California.DateZ O Applicant
WATER HEATER WNENI'/ELECTR
Z r GRADING FEE
be
.N. NOTICE TO APPLICANT:IL after nuking this Certificate of Exemption. mus
you should WATER SYSTE VUUATING
FE
come subject y it Workers Compensation pnision
ws of the Whir Code,you must WATER
E
W fmnhwith<omply with such provisions or permit,hall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
a ,
U 0 Thereby uflionthatthere is a construction lending agency for the performance of Date Receipt#
the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name
U TOTAL:
WnJcr's Address TOTAL:
W 1 cenify that 1 have red this application and.;tate that he dhow information i; BUILDING FEE
It"? ommO.I agree to annsply with ull city and county,,nlinances and late low,relating to QTY. MECHANICAL PERMIT FEE
U Z building comwation,nnd toothy authoriee representatives of this city to carer uptinthe SEISMIC PER
above mentioned propery for inspection parnsAC;, PERMIT ISSUANCE
(We)agree m.;ave,indemnify wd loop harmless tbu City of Cupariino ugainst 1?1,13CTRIC FEE
liabilides,mdgmeala crxu and expect.;e,which at
e, wuyr,cmeagaimss a aid City ALTER OR ADD TO MECH.
ut eonscqucnm of the gaming of this pern'r PLUMBING FEE,
APPLICANT UNDERSTANDS ANI 'LL CO LY Willi ALL NON-POINT AIR HANDLING UND(TO 10,000 CFM)
' CEREGULATIONS. MECHANICALFEE
AIR HANDLING UNIT(OVER 10,000CFM) CONS'1'RUCIONTAX
pplicaMCommmt" De'e EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE ETION FEE
Will the applicant or future buildingoccvpent store or handle haamJous material HEATING UNIT(TO 100,000 BTU)
as defnW by the Cupenivo Municipal CIA,Chapter 9.12,end the Health end Safety
Coda Section 25532(a)^ HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nm
VENTILATION FAN(SINGLE RESID)Will the applicant of future building Occupant use equipment or devices which Receipt R
emit hamrdoua air conmminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
DWL
iR L:
FIN. BOILER-COMP(OVER 100,"BTU)
read the hazvdous materiels AIR CONDITIONER�uiremcros under Chapter 6.95 mf the Cali- ISSUANCE DATE
&Safety Code,Sections 25505.25533 and 25533.1 understand that if the ,yEW RESIDENTIAL MECH. SQ.FT.nm currently have a actual,thus i'is my msponsibili'y m notify tM occupantor which muFriiarKeored egen' Pam TOTAL: ISSUED BY:
OFFICE