29697 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF„CUPERTINO BUILDING--KLECTRICAI, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. 29697 9 � 9't.
A BUILDING PBOJECI'IDENTIFICATION J J 1
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
lot Ezo - io►53 �ll1 v-� . �4�
OWNER'S NAME: PHONE: CONTRACTOR'S NA ME: LIC NO:
(04• I —9� � C __ x li NIC CONTROL#
ARCHITECT/ENGINCCN; LIC NU'. ADDRESiS'L
rl LiCONTACTPHONE: 1L* [T6O/2BUILDING PERMIT INFO❑ CngW nt F¢e91'ald by Applicant(InHIa - BLDG ELECT PL MECH
❑
IrO Z
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I herefi.m N
by.Iot 1 am licensed under....shms of Chapter 9(commencing JOB LTESCRIPTION
with Section?”)Of Division 3 ofthe Business and Professions Code,and my license is 1 PERMIT ISSUANCE
RENIDENTIAL:
O
W in roll force and efff�t.
Ut' Liens ` oM ❑SFDWL C1 KITCHEN REMODEL.
Contractor
€; ouanor APPLIANCPS-RCSIDENTIAL ❑AUDITION C1 PLUMBING RE-PIPE
Imo„=ren ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O 1 unbersmnd my plain shall be used as public tncoNs MODIFICATION
OZ—pp UP T0200 AMPS (D INTERIOR ❑CHIMNEY REPAIR
�� nl Licensed Profesai.nol - 20111"AMPS IMPROVEMENT
sppyd OWNER-BUILDER DECLARATION OVER 1000AMPS
?fK „I hereby.(Orn thin 1 1. exempt from the Contractor's License Law co the ❑EATH REMOD REP 10Q_LI C 7�.
'sW7 aLU whichinquiresa permit
]03L5;Businesst , and improve,
demolish,
Code:Any city a,countySIGNS ELECTRICAL. ❑OTHER' J
LL which requires n permit re construct,alma improve,h Permit t or repair any ttmmum
prior to its issuance,also rcyuir..the applicant for such Permit files signed statement SPECIAL CIRCUIT/MISC.
u�Wus} that he is licensed pursuant the provisions o(the Contractors License Law(Chapter 9
IyaG0 (commencing with SeNon 7000)of Division 3 ofine Business and Professions Code)or TEMP.ME TER OR POLE INST COMMERCIAL:
a M K that he is exempt therefrom and the basis for the alleged exemption.Any violation of - [I NEW BLDG/ADDITION El DEMOLITION
Mm Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
[[[FFF...... not more that five hundred dollars($50H.
[]TENANT ❑FOODSERVICE
6 Lasawnerofthepmpeny,.rmyemployees with wages us their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
O will du the work,nnJ themructum is not intended or offered bamle(Sec.]044,Business ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an nwner of OUTLETS-SWITCHES-FIXTURES
6 a�' property who builds or improves thereon,and who does such work himself or through
his own employe..,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECTS
sale,If.however.Ne building or improvement is sold within one year ofcnmpletion,the - SQ.FT.FLOOR AREA, VSQ.FT.
owner-builder will have the burden of proving Net he did not build or improve for put
pose orsele.).
❑h as owner of the pmpeny,um exclusively contracting with licensed contractors.. TO
compact Ne project(Sec.7044,Business and Professions Cale:)The Contractor's Li- �( -
cenmlawdcesnot�pplymanownero(pmpeny who bunds or improves thomnn,and QTy, PLIIMBINGPERMIT V\ P ,Q,^ ' ^^V
who conducts for such projects with a condactons)licensed pursuant to the Contmetors ■�
License law. PERMIT ISSUANCE Y#//{�
0 I am exempt under Sec. B&P C fn-his union
Owner Data ALTER-DRAIN&VENT-WATER ICA) VALUATION
WORKER'S COMPENSATION DECLARATION U't f yr WtV1
I hemb affirm under BACK FLOW PSUTECT.DEVICE
y .enelty of perjury one of We following declamations:
ryL]
❑Ihaveaaa will trmimaineCenifieateof ConsenucselGinnurc for Workers Compan- RAINS-FLOOR,BOOR AREA.C I STORIES TYPECONSTRUCTION
..tion,....sided for by Section 37W of the labor Cale,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP _
*I have and will maintain Worker Compensation Insurance,as required by Section
17y)of the Labor Code,for the performance of the work for which
this permit issiissued. GAS-PA.SYS'HIM.I INC.4 OUTLETS (ICC.GROUP APN
My Carieorker's etppenvaf nh ori atl�nce cu erPnHey No.mdPalficy �6I\d�= GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEM TONFROMWORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(Missection need act be completed if the permit is formic hundred dollar(51 W) BUILDING DIVISION FEES
.r less.) GREASE TRAP PfANCHECK FEE
I rectify ohminthe any mannero as t work for subjech ct
to the Worksmed,Lhall SEWER-SANITARY-
nat employ any person in any manner so as to became subject to the Workers'Cnmpem STORM EA.20)IT. ENERGY FEE
Z sution Laws of California.Date
O Applicant WATER HEATER WNENT/ELECTS GRADING FEE
F7 y NOTICE TO APPLICANT;If,after making this Ce ulic,1e of Exemption,yam should
a become object to the Worker's Compensation provisions of the labor Cade,you most WATER SYXFHlvb TREATING SOILS FEE
forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
0
Viz ' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
V work for
which His
Pemerc issued( eeti0nlending agency forme Performance of Dam Receipt.
W f~ me wnrkfor which pis permit is issued(Sao 3(19],Civ.C.)
O lender's Name - TOTAL:
LULL Lender's Address = TOTAL:
I certify that 1 have rcuJ this application and s¢ee ohm the shave ormirr niton is BUILDING FEE
N correct.1 agrm,m,...ply with.11 city and c.unty ordinanew and somehow,udiffir,m QTY. MECHANICAL PERMIT FEE -
U building construction.and hereby author,repreaemmives ofthis city to enter upon the SEISMIC FEB
aboverecommed property far inspection purposes. PERMIT ISSUANCE
f Wel agree tc save,indemnify and keep hmmleu the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses whichmtimay in any way acme against said City .LIES OR ADD TO MECH.
in consequence of the uniting of this pet. PLUMBING FEE
VN
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
r 5� I4q AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
St lure. fill mono- r -n�sc I Date [-] EXHAUST HOOD I W/DUCT')
NAZ DOUS MATERIALS DISCLOSURE
HOUSING MITIGATION PEP.
Will thea icamm building recupantaore w handle hazardous material t HEATING UNIT(TO 100,00)BTU)
as defined by me Cu Mu i I Codc,Chapter 9.12,and the Health and Safety
Cedc,sm0an 8...pd7 rc HEATING UNIT(OVER 100,000 BTU)
❑Yea M. VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Data Receipt#
emit harmilesair continuations as defined by the Hoy Arca Air Quality Management BOILER-COMP(1HPOR 111Q0110 RTU)- .
Dimimp TOTAL:
❑ ��xN
Yea ry . BOILER-COMP(OVER IWpf10 BTU) ,
1 have mad the hmmdeas mztels miAIR CONDITIONER
rdryimtnenR under Chapter 6.95 of the moi- ISSUANCE DATE
form.Health&Safety Cale,Sections 25505,25533 and 8534.1 mderstaM that if the NEW RESIDENTIAL MECH. SQ.PT.
building dans nm cwmmt m
ly have.tenanat it is my resposexhilay mandfYthe occupant
fore expurstrams which.. m rtln.Iiorm issuance.(.CertificamDoc y.
Owner or millions—. tie TOTAL: ISSUED BY:
OFFICE