29971 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - .ELECTRICAL PERMIT NO. 29971^ a
BUILDING DIVISION APPLICATION/PERMIT - PwMRwc. ECIIANICAL ' '2 Ju�JJ 1
RUI CT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
16� 6D L !•kms 1 Duk r � 9C
O JRCNA r1l OSI, / If /E- ZD I gN L1 rvZE1'/4 M�1 LIC IJ L N/C CONTROL It
ARCHITEC/T/11/`ENGINEER: LIC NO: - ADDRESS ❑
26.67 AI 2'rL:ne�'I1►, S,�". '
CONTACT. • / PHONE: - BUILDING PERMIT INFO
' - ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑' C " _ � ❑
LICENSED tic d under p DECLARATION QTY. ELECTRIC PERMIT FEE
O M Z •1 hereby affirm Nm I am licensed mule,provisions of mCCode,f 9 anmmense is 10B DESCRIPTION
400 with Section and
efecDivision3of the Busines>and Pmfeesions Code,and my license is 10u,
� in full force and effect - PERMIT ISSUANCE
RESIDENTIAL
.'
6 U U License Class Lir.M ❑SFDWL ❑KITCHEN REMODEL
o,Z41 Date Carnatinr APPLIANCES-RESIDENTIAL
mQy ]ADDITION ❑PLUMBING RETIRE
p.pm ARCHITECT'S DECLARATION PANELS ❑MULTIUNIT ❑STRUCTURAL"
Z O y❑ 1 understand my plans shall teased as public recoNx n
OZ��-1 UPT0200AMPS 1 -MODIFICATION
ypq Lensed Pmfesstanal - ❑INTERIOR'. [I CHIMNEY REPAIR
.i 201-1000A
MPS
p¢¢p��'' ...4I OWNER-BUILDER DECLARATION IMPROVEMENT
"y U I hereby affirm that I am exempt from the Contractor's License Law for the DYER!000 AMPS ❑BATH REMODQVREeA� [I DEMOLITION
$d 3 d F follo g (Section 7031,5,Business and Professions Comic A y city or county SIGNS ELECTRICAL ❑OTHER f✓�t-'�
LLI which Ha sect pe rant trva her,tic demolish re --T�
µ,O prove t y icemen
y loom t s pursalso uant
requires theisionsofthecant for such Contra permit to file 'g d statement SPECIALCIRCUIT/MISC.
Y that h licensed p a u [Ile p ns of the Contra License Law(CM,mr9
4 QC (mmmennng wrth Section 7000)ofDivismn3 of the Busmeasand Pmfessi.re Code)a, TEMP.METER OR POLE INST. COMM IAL. "
CL p,m y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iYC] tNc Section 7031.5 by any applicant for u permit subjects the alf icam to a civil penalty of POWER DEVICES
not mom Non five hundred dollen($500). ENANT ❑FOOD SERVICE
C ❑1,es ownerof the propemy,ar my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IM RO MENT
e will do the work,and Restructure is not imendedmuffered foreale(See.7044.Roamess
6b oo and Professions Code:The Contractor's License Caw does not apply 1.an owner of OUTLETS-SWITCHES'-FIXTURES
�' .. Property who builds or improves thereoms
n,and who does such work hielf or through
` his ownemployees,provided that such improvements are not intended or offered for NEW RESIDENTELECT SQ ELECSQ FT.-
inbc.ILhoweveqthe building or improvement is sold within one year ofcompletioo,the SQ.FL FLOOR AREA $/A.Fir.
owner-builder will have the bu shan of proving that he did not build or improve for pur- iR
-pose of abet
- - ( r •y
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL.
.as
to the �, IGJrN1 1 11
project(Sec.7044,Business and Professions Code:)The Camnacmr9 Li.
cense Lawdoesnm'.pply roan owner mproperty'who builds or improver thereon,and QTY. PLUMBING PERMIT FEE '
who contracts fossuch Projects withunmmeam(sj li.modipursuumtathe Contractors _ �u1 t p'I
License Law. ,lots a,iv��71
I am exempt under Sea ',B&P C for this' WSYSTEM-1
ANCE '")wner Dote IN&VENT-WATER(EA)� WORKER'S COMPENSATION DECLARATION PROTELT.DEVICEerehy affirm underpenalty of perjury one of Ne following declarationshave and will maintain a Certifcale ofConsent no self-insure forWorker's Crimper- OOR,ROOEAREA,COND. ,arn,as provided for by Section 3700 of Ne Labor Code,for the performance of the
5177 ION
w k for which Nis permit is issued. t ER TRAP.I have and will maintain Worker's Compensation Insurance,as required by SectionOof the Labor Cnde.for'he performance mf the work for which this permit is issued. STEM-1 INC.4 OUTLETS.My Workers Compensation Insurance carrier and Policy number arc:Carter: . PolicyN.: GAS-EA.SYSTEM-OVER 4(EA).
CERTIFICATE OF EXEMPTION TOM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
(This section need mm be completed if Ne permit is forme hundred dollars($MB BUILDING DIVISION FEES
ad less.) GREASETRAP PLANCHBCK PEE
Loy any Not in the any manner as
evoconwhich Nis the W isiss Cooper. SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner w as to become subject the Workers'Compen ENERGY FEE
Applicant
Laws of Cnliforniu.Date
y�O Applicant WATER HEATER WNEM'/ELECTR GRADING FEE
G tG NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 'WATER SYSTEM/fREATINC.
E'! become subject to the Worker's Compensation provisions of the Labor Cade,you must s SOILS FEE '
W�•t forthwith comply with such provisions or thispermit shall be deemed revoked. WATER SERVICE
aQ
U LENDING AGENCY z CONSTRUCTION NEW RESIDENTIAL,PLMB. SQ.FT. PAID
V I here by affirm that them Issued( ee.30 lending agency for the perfornwnceof •Date ReceiptN
ON the work for which this permit is issued(Sac.3097,Clv.C) _
,F, Lenders Neme TOTAL: -
)W1 Lender's Address .A
p� I certify that 1 have read this'application and state Nat the above information is - BUILDING FEE
IA om em.1 agree to comply with all city and room,im inances and Into laws relating In QTY MECHANICAL PERMIT FEE
V building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE '-
abovm
e- entioned property for inspection purposes. - PERMIT ISSUANCE
.(We)agree m ur
save,indemnify and keep hnless the City of Calamine against PERMIT RIC FEE
liabilities,)udgmems.cranium!expenses varlimay in any way.erm,agalnaltand City ALTER OR ADD TO MECH..
in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) 4
SOURCE REGULATIONS, /yf MECHANICAL FEE
�'-r �- . 71_� - � �S �% AIR HAND LING UNIT(OVER Ig000CFM) " CONSTRUCfIONTAX .
of Applleanl/Gontractor AfL2i Date EXHAUST HOOD(W/DUCT) , I - -
HAZARDOUSMATERIALSDISCLOSUREHOUSING MITIGATION FEE
Will the applicant orform.buildingoccupam rm
store.,handle hamrilm, am HEATING UNIT CIO 100.BW BTU)
as defined by the Ctipertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Send..25532(a)f ° HEATING UNIT(OVER 100,000 BTU)
E-]Yes I4No
T'' - VENTILATION FAN(SINGLE RESID) PAID
•Will the applicant or future building occupant use equipment or devices which Date Receipt k
emit hazmdoux air comamiumb,as defined by the Bay Arca Air Quality Management BOILER-COMP QHP OR 100,000 BTU) '
District? TOTA
FI Yes 7 N BOILER-COMP(OVER 100,000 BTU) 140T_ C7)
I have read Ne hazardous materialsAIR CONDITIONER ISSUANCE DATE'
req meets under Chapter fi 95 of Ne C li' '
forma Health&Safety Code,Sections 25505 25533 and 25534.1 malso and that if Ne NEW RESIDENTIAL MECH. SQ.FT.
building doesnot currently hmeamand,Nan it is my responsibility to ready the occupant
of the requirements which must be mu prior to issuance of a Certificate of Occupancy F {
Owner or authorized a gem, - Dice TOTAL: ISSUED BY: AS
OFFICE