29294 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO. 29294
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BUILDING DIVISION APPLICATIONIPERMIT
PLUMBING-MECHANICAL L x9 L X9 4
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
2L /� _" .
f O E & PHON : CO 'S NAM 1 O:
(� 57eV d h 5 NIC CONTROL M
\RCHITECT/ENGINHER: LIC NO: V ADD ESS:
CONTACT PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ El ❑
QTY. ELECTRIC PERMIT FEE
ng
1 hereby aRm loin em
rI licensed under prom
visions of Chapter 9(comenciJOB DESCRIPTION
aO xp with Section 70100)of Division 3of NAx
e Rosiness and Professions le,and my license is RESIDENTIAL-
in full farce am effect PERMIT ISSUANCE
L) OSFDWL C1 KITCHEN REMODEL
t;ZH�J License Class Contractor
APPLIANCES-RESIDENTIAL
�Gy Date Convaztor ❑ADDITION - (]PLUMBING RE-PIPE
ARCHITECTS;thanemate DECLARATION - MULTI-UNTT (�. ❑SfRUCNRAL
PANELS \ \?L•l
[[[--01 understood my plain shell be used as public rtcoMs MODIFICATION
OLa UPT02(q AMPS DINTERI IIMNEY REPAIR
�e„V{. Licensed Professional 201-IIIf10AMPS IMPROV F.NT
C4 OWNER-BUILDER DECLARATION
0499 1 hereby affirm that I am exempt form the Contractor.License Law for the OVER I010 AMPS 0 BATH REMODEDREPAIR EMOL ION
3a FU. following.narm(Sectinn]031.5,Busmossand Professimtis Code:Any city or county SIGNS ELECTRICAL 0OTHER
which requires a permit to construct,alter,improve,demolish,or repair any structure
f, prior to in isomer,elan requires the appheantfor such pemdno file a signed statement SPECIAL CIRCUITMISC.
yloathe is licetnedpnrsuam to the provisions ofthe Commetor's License Low(Chamer9
W GOC) (commencing with Section]00()of Division 3ofthe Businessanl Ptofeuores Coda)m TEMP.METER OR POLE INST, 'COMMERCIAL: a
tY oay that lots exempt iherefmm end the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
I� Section 703 L5 byanyapplicam for a permitwbjece,the applicamm o civil port of POWER DEVICES
M ANT ❑FOOD SERVICE
t more than five hundreJ dollar 18500), - ROVEMENT
G ❑Lothe w.rafloe property,nmyot marodoximhwagesrsaleS .c04,Business
ass SWIMMING POOL ELECTRIC ❑ ��
andwill dothework,antlloo he Contractors
Licentlo Law
sole]See.oan Business
and Professions who
Code:The Conactors Licenu law docs not apply to if owner of OIITLCTS-SWITCHES-FIXTUR6.S ,A e
R' his o
property who builds or improves thereon,and who does such work himself m through @�
his own employees,building
nl that such improvements ore not intended or offered for NEW RESIDENTIAL ELECI'R SQ FT
sale.If,hower will have th burdenprovcment issoldhe id mobil or improve for
qJR AREA, S/gQ.P1'.
owner-builder will have the bother of proving that he NJ not build or improve for Aur- j� t^�
poseoLsale.). 19 r
0 1,as owner of the pmpeny,an exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contactors Li- Ur L p+
cone Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE h11hU
whocontacu hersuch projects with a concessions)licensed pursuant to the Commovi0/s
License Law. PERMIT ISSUANCE
l am exempt under Sec. ,B&PCforthisrca.n
Owner - Date ALZER-DRAIN&VENT- TER — LU
WORKER'S COMPENSATION DECLARATION BACK WPROTECT.DEVIC t .,
I hereby affirm under Penalty of perjury one of the following declarations:
❑I have and will maintain o Certificate of Consent to self-insure for Workers Comped- DRAINS-PLO ROORAR ,COND. STORI TYPE CONSTRUCTION
section,as Provided for by Seen..37M of he Labor Code,for the perfmm N
.
work for which this permit is issued. FIXTURES-PER TRAP
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe,labor Code,for the perfoarmare ofthe work for which this Permit is issued, GAS-EA.SYSTEM.I INC.40UTLF`S OCC.GROUP A
My Worker's Compensation Insurance currier and Policy number ore:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA) -
CERTIFICATE OP HXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This sectlonneedno be completed lfth,prnh is forma,hundred collars($100) - BUILDING DIVISION FB
ar toss) GRHASHTRAP PLANCHECK MT E
Icm."y'Nointhe performance of the forwhich this permit is issued,Isha11 SEWER-SANITARY-STORM EA.200 W.
n .ploy any person m any manner u as to become subject to the Wormin Comped- ENERGY FEE'
lion Lowe of California. .at
WATER HEATER WNENTIELECTR -
Itant - GRADING FEE
NS NO CE TO APPLICANT.If,efm making lois Certificate of Exemption,you should WATER SYSTEMIfREATING SOILS FEE
aFa become subject to the Worker's Compensation provisions of the Labor Code,you must
{>a forthwith comply with such provisions or this pcmut shell he demand revoked. WATER SERVICE'
Q
CONS0NLENDING AGENCY NEW RESIDENTIAL PLMSQ.PT. PAID'
U 0 Thereby olfmvhanhem ere is isacomwction R.lending agency for performance of Dale ✓Receipts
4.r the work for which this permit is issued(Sec.309E Civ.C.)
O U Lenders Name TOTAL:
U Lenders Address TOTAL: -
I certify that I have reed this application and state that the above information Is BUILDING FEE
h correct,i agree to comply with all city and county redinancn and shim Laws.].,i,no QTY. MECHANICAL PERMIT FEE
U building construction,end hereby eohtnim reptesentmives of this city to enter upon the SEISMIC FEE
above-mentioned property far inspection purposes.
(We)agree hesave,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way xecm,against said City ALTERORADDTOMECH. PLUMBING PEE
In comequenceo eganting of this permit
AT (CANT ERSTANDS AND COMP WITH ALL NON-POINT AIR HANDLING UNIT IT()10,011 CFM) MECHANICAL ME
Sou CE unof+s.
2�r / AIR HANDLING UNIT(OVER 10,(gp CFM) CONSTRUCTIONTA%
g wre fApploan r Dace EXHAUST HOOD(WoT t) HOUSING MITIGATION FEE
t HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupant store or handle hazardous material HEATING UNIT(TO Hal"RTU)
u defined by the Comedian Municipal Cade,Chapter 9.12,and Ne Health and Safety
Code,section 25532(.)? t HEATING UNIT(OVER 100,000BTU)
❑Yes Otho VENTILATION FAN(SINGLE RESID) PAID
Dme Receipt
Will the applicant a or fume building occupant use equipmca o devices which
emir haN
aous air contaminanl9udefined by the Bay ArcdAir Quality Management BOILER-COME(THE OR I00,000 BTU) t
District?
❑Yes ONn BOILER-COME(OVER 100,000 RTU)
I have rwd the limitations materials requirements under Chapter 6.95 of the Coli- AIR CONDITIONER ISSUANCE DATE
Extra Health&Safety Cade,Sonora 255(15,25533 and 25534.1 understand Not Huhn NEW RESIDENTIAL MECH. SQ.ET.
building dues net cutremly have a tenant,that it is my responsibility,to natify the occupant
• of loe requirements which most he met prior lm issuance of a Coodicare of Occupancy.
Owne,m atbodaedagem Date TOTAL: ISSUED BY:
OFFICE
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