29845 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONTERMIT PLUMPING-MECHANICAL 29845 A C
BUILDING PROJECT IDENTIFICATION o 4�J
BUILDFNGADDRF.SS: - SANITARY NO. APPLICATION SUBMITTAL DATI
3
r k, ids. S-�
OWNER'S NAME: PHO CONTRACTOR'S NAME: L NO:
•165Sty I
7 NIC CONTROL
ARCHITEC"VENGINEEB: LIC NO: ADDRESS: J ❑
CONTACT. _ PHONE: - BUILDING PERMIT INFO
❑ Consultant Feu Paid by Applicant(Initial) BLDG ELEC7s, PLUMB MFJX
LICENSEDand Iam
nOR Sderp DECLARATION - QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB D1,0SCIZIPTION
yQWz lth Section 7000)of Division 3 nhbe Business and PmfeWom Code,andmy l sunse is RESIDENTIAL:
FOO in force and effect _ pit
0.h11T ISSUANCE s ❑ ❑
SFDWL KITCHEN REMODEL
�Ut�' LicenseC Lic.M �7����
a DatI I" Conmc a, — APPLIANCES-RRSIDENTIAL ❑ADDITION 0PLUMBING RE-PIPE
F,Dm ARCHITECTS DECLARATION - PANELS ❑MULTIUNIT ❑STRUCTURAL
Z02'4 I understand my plans shall be used as publicFecoNs - MODIFICATION
OZppp UPT0200AMP5 - ❑INTERIOR [I CHIMNEY REPAIR
Licensed Professional - I' -- 201-1000AMPS IMPROVEMENT-'
a
OWNER-BUILDER exempt DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR CI DEMOLITION
yyx I hereby affirm that I 1 exempt the Contractors License Law for the
W 3 d V following reason.permit
to
7031S:Business end Pe.dromns Cade:Any city stcoonry SIGNS ELECTRICAL ❑OTHER _
tItl 4.Ea which requires a permit to uHMS the aper,improve,demolish.or repair any statement
'�wJ hapritaoibcense pursuae,also nt
theapplicantsuch Contractors
Licensfile ae ned Law(Chapter
SPECIAL CIRCUITIMISC.
p, thernmencingwid pursuant mnce provisions of the Conuamr s License Law(Chopmr9
C D that he is ex with land the
Division the al Business exempt ProfessionsAvCnde COMMERCIAL,
gun )or TEMP.METER OR POLE]NST.
6 O�.' that io is exempt therefrom and the basis far the alleged exemption.Any l penalty of NE BLDG/ADDITION ❑DEMOLITION
y Section703 LS by any applicant forupemit subject the applicant penalty of POWER DEVICES ANT ❑FOODSERVICE
Y not more then I,,ve hundred dollars(S50R,
FC ❑Las ownerof the property,or my employees with wages as their mole compensation, SWIMMING POOL ELECTRIC IK
ROVE.MENT
aFP will do the work,and the structure is not intended or offered for sale(Sm.70FL Business ❑OTHER
and Professions Code:The Contractor's License Low dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpersy who builds ur improves thereont and who dtas such work himself it,through -
t• his own employees,provided that such improvements arc not intended or nB'ered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one yea ofcompietion.the SQ.FT.FLOOR AREA VSQ.FT.
caner-builder will have the burden of proving that he did not build or improve far pur.
pose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors toIDi7 ^s
construct the project(Sec.7044,Business and Professions Code:)The Canuactons Li. +a'
cense Law does ant apply torn ownerof property who builds or improves thereon,and QTy. PLUMEHNO PERMIT PER -
whommenmsfor such projects with a contrnmens)licensed pursuant 10 the Counelo's A{/ 7
License taco. PERMIT ISSUANCE Mr 1 1996
❑1 am attempt under Sec. ,B&P C for this reason rsa r a7u
Owner ALTER-DRAIN&VENT-WATER(EA) vi L,,.VALUATION
WORKER'S COMPENSATION DECLARATION •a'l+)IRkJ
Ihereh rffirm under BACK FLOW PROTECT.DEVICE
y peaapyoE of
Conmmofelf-im usfisr akersCo
❑]have and will forbylnaCCN37DO of Consentto salGinsurefar Worker'smofthe BRAINS-FLOOR,Rf30P,AREA,COND.
lotion,as provided for by Seninn 3]00 of the Labor Code,for the performance of the STORIES • TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Instance,as required by Section
37M m dEm 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 Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy Na,: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICA'1'C OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INI3USTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
( s section need not be completed if the permit is for one hundred dallau IS W)
or laudThiGREASETRAP PLANCHECK FEE
I certify that in the perfomnnce of the work for whichRs Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any mannc so to o esuhjcl,m the WorkcWCompen- ENERGY FEE
lifornin.Date
z� Applicant WATER HEATER W/VENTELECfR GRADING PC•E
y NOTICE TO APPLICANT:If,other making this Certificate of Exemption,you should WATER SYSTEM/TRPATING SOILS FEE
abecome subject to the Workers Compensation provisions of the labor Coil,you must
LLI .fotwith comply with such Provisions or this permit shall t,deemed!revoked WATER SERVICE
�O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
I hereby affirm that there is it construction lending agency for the performance of Date R eipt if
OF 'he work for which ibis permit is issued(Sm.3097,Civ.C.)
U Lenders NameTAL:
Lk1 Leaders Address
I certify that 1 have rad this application and emm that the above information is BUILDING FEE
correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V G building concoction,and hereby mnhorim representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PIiRMI'1'ISSUANCE
(We)agree to save,indenmify and keep hartnleas the City of Cupertino against ELECTRIC FEE
Iiabilides,judgmenu,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
n consequence of the granting of this permit PLUMBING HE -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITfTO 10,(100 CFM
SOURCE REGULATIONS. MECHANICAL FEE
r AIR HANDLING UNIT(OVER IQOW CFM) CONSTRUCTIONT
Signature of App]icamoContractor ' Dam RXHAUST HOOD OVIDUCT) HOUSING MITIG ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Witl theapplicaram future building occupant smremlardle hneardnus mammal HEATING UNIT(TO I00,000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health am Safety
Code,Section 23532nd? . HEATING UNIT(OVER 100,00)BTU)
III/ FTYea r-1 No VENTILATION FAN(SINGLE RESID) PAID
Dam Item M
Will the applicant or future building rampart use equipment lor ily Management
which BOILER-COMP(3HP OR 100,0(10 BTU)
emit hazardous air conmminams as Defined by the Ray Area air Quality Management -
District? ATA L:
�a
EJ Yea (]Nn BOILER-COMP(OVER 100,000 BTU)
L I have mail the hamrdons materials remorenems under Cherer 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
Enron Health&Safety Code.Seri ons 25505,25533 and 25534.I understood that if the
r building does not currently have n tenant,that it is my responsibility tu notify therocupant NEW RESIDENT]AL M ECH. SQ.FT.
of Ne tegcommunist, sorrce of a Cm' cnt of upancy.
rmr or euthnizW agent Dom ISSUED BY:
IkI I OFFICE
t