29796 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29796 9 7 9 6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L ./b
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: yJ SANITARY NO. APPLICATIONTE
ySUBMITTAL DA
L \�
OWNER'S NAME: PHONE: CONTRACOR'S NAME: LIC NO:
NIC CONTROL p "
v�sclu-TH ML17ENGINEERi LICNO: r ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hertby atfirm ibat Pnnn licensed under provisions of Chapter 9 my license is
�pZ wimllfornSection](KK00f Division]of the Business and Professions Cock,and my license is PERMIT ISSUANCE RESIDENTIAL:
W W O
in a Cls and Affect.
4' � ❑SFDWL L1 KITCHEN REMODEL
'dUUU Data Class Lion APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
G 0.
Data Contractor
I-- ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Z p�Z 1 undersmnd my plans fiat]M used m public rtmrds t MODIFICATION
O Z—C UP DO 200 AMPS
r 4 F" Lensed Profession.] ❑INTERIOR [I CHIMNEY REPAIR
a pS..I OWNER-BUILDER DECLARATION 201 d Of10AMPS IMPROVEMENT
yC M E¢ 1 hereby.firm mat I am exempt from me Contractor's license Law for me OVER IIXU AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
x 3 d U following reason.(Section]031.5,Business Ad Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
47 us O['2 which requims A permit to ro.,Ari.Ree improve,demolish,or repair eny structure '•
ti.J7 Prior to its issuance,also requires the Applicant for such Permit o Cite a signal statement SPECIAL CIRCUITIMISC.
that he is licensed pursuant mhe provisions of the Commences License Law(Chapter9
a00 (eommencing wida Section 7")of Division 3 of the Business unit l4nfesorwo Code)or TEMP.MITER OR POLE I NST. COMMERCIAL:
Il y M C that he is exempt Nercfmnt and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
{XR Isry.
Section 7031,5 by any applicant for a permit subjects the applicanitn a civil penalty of POWER DEVICES
I„Z}
it
mom Nan five hundred dollars($500). - ❑TENANT ❑FOODSERVICE
FC I,ns owAw.f Ae pirmi or my employes with wugcsas now,sole compensation, SWIMMING POOL LLE 1 IMPROVEMENT
3F will do the work,and the sanctum is not intended oroffered for salc(Sec.]044,Bu-mnesr ❑OTHER
and Ptofessions Cade:The Contractor's License Law docs Aon apply to an owner of OITTLETS-SWITCHES-FIXTURES
�' .. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or oHemi for NEW RESIDENTIAL ELECTR SQ IT.
MIe.If,howeveothe building or improvement is sold within one yesrofarmpletion,the SQ.FT.FLOOR AREA $/SQ.FT.
owncr-bui]dcr will have the burden of proving that he Aid not build or improve for Por-
own of uilde
prae
❑1,as owner of the property,am exclusively contracting with licensed com cors to TOTAL:
construct the project(Sec.7041,Business And Professions Cole:)The Contractor's Li. I y
rise Law does not apply to an owner of property who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who contracts farsuch projects wM a contmetons)licensed pumuunuo the Contmctor'.s
License law. PERMIT ISSUANCE
❑I nm exempt un der Sec. ,B&PCftr this re so '
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dae
WORKER'S COMP perpryO DECLARATION BACK FLOW PROTECT.DEVICE
1 hertbyaf(mma penny oeP juryoneof Aefallowing WorkersCo
❑Ihave and Ammonia Se Certificate of Consent osel6imure for Worker'sce of the DRAINS-ELIXIR,ROOF AREA,COND.
' stein.,as provide)for by Section 3700 of the Labor Code,for perfannance of the STORIES TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3700pf the labor Codc.for the performance of me work for which duds permit is issue. GAS-G.SYSTEM;I INC.4 OU'PLETS OCC.GROUP APIAMy Workers Compensation Insurance carrier and Policy number are: a
Cartier: Put icy Nn: GAS-EA.SYSTEM-OVER4(EA) V 4 A �
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASf?nNUUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE UI I GDIVISION FEES
(Thissectinn tical not becompiete if me Permit is foroae nundreddo]lars(SIM) GREASETRAP
or less) PLANCHECK FEF.
I certify Net in due performance of the work for whichsubje this Permit i,issued j ,],hall
not em m any ithownaDa manner so as to become soh'en to the Workers Com n- SEWER-SANITARY-S'fONM EA.np 14.
Z section].awe of Celifarniu.Date 3 pe ENERGY FEE LU/-L t
O WATER HEATER W/VENTMLECTR GRADING FEE
z 0 Applicant - V
NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should a WATER SYSTEMOREATING became subject o the Worker's Cnmpensatitn provisium of the Lahr Code,you until SOILS FEE
fi7 forthwith comply with such provisions or this permit shall he Jeenud revoke. WATER SERVICE
d 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMtl. SQ.FT PAID
V Q Thar by which that Andre issued( ri.30 lending agency for me performance of - Dare Receipa
ly F the Lend klnrwornthispermhmai„ae(s«:3o9].Cie.c.)
Q Lender's Name TOTAL:
Lwww'x Address TOTAL:
cry 1 certify that I have read this application and state that the above information is BUILDING FEE
Vy correct.l agree to comply withal]city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U 4 building construction.and hereby auduorize representatives of this city o enter upon the SEISMIC FEE `CD
above-mentioned property 1'or inspection purposes. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep burbles,me City of Cupertino against ELECTRIC FEE
liahillties,judgments,costs and expenses which may in any way accoe against Mid City
in consequence of the gmnni.g of this Pc.i,. ALTER OR ADD TO MF.CH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TD IQ0a0 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTIONTAX
Signature of Applicant] ontmctor Dare EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theapplicanim future building oecupwtstpmwhandlc lowmadou,..[enol HEATING UNIT(TO 100,0011 BTU)
as defined by me Cupertino Municipal Code,Chapter 9.12,and Re Health and Safety
Cee.Section 25532(a)'I HEATING UNIT(OVER 100,000 BTU)
❑Yee No
VENTILATION PAN(SINGLE RESID) PAID
Will thea Applicant or future building t use a Data Receipt p
pp gby then Area
Quality
Management
BOILER-COMP
emithuardous air contaminants as definM by the Bay Arc.Air Qmlity Mutiagemenl (LHP OR IW.OBB BTU)
District? BOILER-COMP(OVER 100,X01 BTU) 'IDT
❑Yes F1 No
I have read the Ift.ahus awlemAx rtquirement under Chapter 6.95 of the Cali. AIR CONDITIONER 71
ISSUANCE DATE
forma Health&Safe,Cade,Sections 25505,25533 it 25534.I understand mat if And reqNEW RESIDENTIAL MECH. SQ.FT. -
building does nm curendy have a tenant,dust it is my responsibility to madly me occupant p`V/
of me requirements w1akh mobe ti
t nt primo ismwce nf.Ccnilicme of 01 /A
Owner muunannud agent Date ” TOTAL: ISSUED BY:
OFFICE