29805 (2) • APPLICANTTO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
CITY OF CUPERTIINO '• BUILDING.ELECTRICAL. PERMIT.NO.
BUILDING DIVIS16N. .'APPLICATION/PERMIT z - PLUMBING-MECHANICAL 29805 O C
-'s BUIL DING PROJECT IDENTIFICA'PION o J
BUILDING ADDRESS: Ir GI ' Loi SANITARY NO. APPLICATION SUBMITTAL DATI
- OWN 'SN PHONE: CONTRACTOR'S NAME:- LIC NO: I(Ilit aro
�/AV-rIx NIC CONTROL#,
ARCHITECT/ENGINEM: LIC NO: ADDRESS: F-7
f�
CONTACT: - PHONE:'
< ', BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECons of hap QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed ander add
Proone of Chapter 9(commencing JOB DESCRIPTION
Mintz with Section,]000)of Division 3.1 The Business and Professidns Cale,end my liceme is
in NIIforceand effect. PERMIT ISSUANCE, WIDE IIAL;
�UZU License Class Lin.p, - - WL ❑KITCHEN REMODEL
DateContractor APPLIANCES-RESIDENTIAL ' - ADDITION" , C1 PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT,. ❑STRUCTURAL
,z O in z I understand my plans shall he usePANELSd as public records MODIFICATION
ORS' UP T0200 AMPS ❑INTERIOR /I,�� fn1 [[��'�
�� ,Licensed Pmfessmnal ' 201 If100AMP5 W U R/ '�GHIMNEY REPAIR
..•]]] OWNER-BUILDER DECLARATION IMPROVEMENT
i4 OVER 1000 AMPS El REMODE P I DEMOLITION
6 I hereby affirm that 1 am exempt from the Contractors Co License Law for the (@� Q
3 W F following reason.(Section construct,
Easiness and Professions Cede:Any city or county SIGNS ELECTRICAL [I ONIG. a
which requires a permit m constrvct,alter,improve,demolish,or repair any structure
�y prior to its issuance,also requires the applicant for such permit toriileasigned somment SPECIALCIRCUIT/MISC.
Y that heislicensed pursoaattp the provisions ofine Comrsemr's License Law(Chapter 9 - +r t"ne a u.''I'I lYr e.l lNV
aC, (commencing with Section 9000).!Division 3 little Business and Professions Crowelm C, ) r TEMP.METER OR POLE INST. COMMERCIAL:
0. o
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION
W y Section 903 L5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES NANT [I FOOD SERVICE
[gg... y five t more than hundred dollim($500).
Q ❑1,as owner of the property,or my employees with wageaas their sole camprown.n, SWIMMING POOL ELECTRIC IMPROV ENT'
will do the work,and the stmetwe isnoi imendedcawfered far sale(See7044,Business THE
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereom'and who does such work himself or through -his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT 52
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FL MOOR AREA $/SQ.FT. '
owner-builder will have the Foden of proving that he did not build or improve for put, ��
pose�eJ. - • TOTAL: -7J
as owner of the property,am exclusively contracting CMc:) he C ntra tors to
r wnarvet the Project(Sec.9044,Business and Professions Cade)The Contractors Li-
se Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBI RMI FEE '
who contracts for such projects with a contractor(s)licensed p rear nt 1.the Contractors t
License law. 1 PERMIT ISSUA CE
_ ❑ lam exempu dere ,B&P C for this reason
Owner - Dae -
ALTER-GRAIN& T-WATER(EA VALUATION
P .. ' V, V/I
O BR'S SATION DECLARATION BACK FLO O' ICE
I hereby affrm under penult of erjury oneof the following declarations:
❑I have and will maintain a Certificateof Consent toself-insure for Workers Cooper- DRAINS-FLOOR,ROO,ARE O
,when,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. - FIXTURES-PER TRAP
El 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS=EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number we
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GNEgSP✓INDUSTRL WASTE INTERCEPTOR UI ING DIVISION FEES
)This section nmd not he win pleted ifthe pwmit is for one hundred dollars($100)
or less) GREASE TRAP PLANCHE E `
I certify Nat in the twommwace of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subjecrto the Workers'Compaw- SEWER-SANITARY-STORM EA.200 FT.re ,ENERGYF E
salon Laws of California.Da �r
O Applicant - WATER HEATER WNENT/ELECfR GRADIN
q y NOTICE TO APPLICANT If,after,making this Certificate of Exemption,you should '
I'y i„I WATER SVS'IEM?BEATING
a become subjecttothe Workers Compensation provisions of the Labor Code,you must 'SOILS _
LTl forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY'
UO Ihominy affirm thm there is acnnnmc0onlending agency for the performance of NEW RESIDENTIAL PLMB. SQ.FT. PAID Dam Receipt
w H the work for which this permit is i.sued(Sec 309],Civ.C.)
Q U Lender's Name - TOTAL:
Lender's Address TOTAL:
y I certify that l have revel this application end sate that the above information is BUILDING FEE �.
V1 correct.I agree to comply with all city and county ordinances end suite laws reaming to QTY. MECHANICAL PERMIT FEE
7
V G building construction,and hereby imhimion epreaudittivea df this city to enter upon the SEISMIC FEE 10
ahove�memioned property for inspection purpmes. -
(We)agree to save,indewiify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,criminal expenses which may in any wayaccmeagaina to City
ALTER OR ADD TO MECH.
in consequence of the granting wild,permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE ��" _
,. AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Signature of ApplicandConOxcor Date EXHAUST HOOD ONMUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theaildissnt or future building necuparttaore or handlehccdous material HEATING UNIT TO 11X1.000 BTU) I.
as defined by the CuPenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? a HEATING UNIT(OVER 100,000 BTU) "
' (]Yes r Atha _ VP.NTILATION FAN(SINGLE RESID)' PAID
Will'the applicant or future building Date Receipt R
PP g by the Bay Ahm Air Quality Management BOILER-COMP OR 100,000 BTU '
emit hazardous air contdminan¢as defined by the Bay Area Air Quality Management )
District? -
TOTAL.
❑Yes - ❑No - BOILER-COMP,(OVER 100,000 BTU)
I have read the hazardous materials re uirements under Chapter 6.95 of the Cali- AIN CONDITIONER -
9 P - ISSUANCE DATE
fomia Health&Safety Cale,S«tions 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
m '
t building does onfcrently have a tenant,that it is my responsibility to notify the occupant „
of the requirements which must be met prionn issuance ofa Cenifiwte of Occupancy. -
Owner or eothonzed agent Dae TOTAL: ISSUED BYi
OFFICE