29716 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 27 1
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L x47 / IIrJ�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l0 U�2,� .1 cT 2-z7
OWNS 'S NAME: PHONE CONTRACTORS NAME: LIC NO:
G Z W}L S/V t s Z NI CONTROL p
�RCHITECT INFER: LIC NO: ADDRESS:
kor,
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'SDECL6RATION QTY ELECTRIC PERMIT FEE
I hereby,firm im 1 am IicemeJ mnJer provisions of Chapter 9(commencing JOB DESCRIPTION
DaZ wire SadonodeffecUivieionJ oObc Buxincs,and ProfrssionxCodaand myliaco,n is RESIDENTIAL,
W OO PBRMI'I'ISSUANCE,
hWl— livemem fall Class
effect. ❑SFDWL �KI'TGHIN REMODEL
e—u Weems Class Lic.M APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Dam Contraanr
Fly ARCHI'IEC'I•S )ECLARAI'ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p in Z 1 understand my plans shall hi,used nc Public fedoras MODIFICATION
0y_0 UPTO200AMPS ❑INTERIOR C3 CHIMNEY REPAIR
N ad Lured Nor.o.r.l 201-1000AMPS IMPROVEMENT
�YS;
4(0
OWNER-BUILDER DECLARATION OVERIXMAMT ❑BATH REMDDF.IJRIiPAIR ❑DEMGLI'I'IGN
'W< 1 hereby affirm that I am exempt treat the Conwemrs License Law far the
X� a U following rcamn.(Section 7031.5.Business and Preenu ns Code:Any city m rummy SIGNS ELECTRICAL ❑OTHER
LLI3 W E' which restore,n permit in mnwrect,alter.improve.demolikh,lir repair any structure
�E•0 pronmimic..ance.dmrefutestheapplies.,m„arhpe.itmrlea.igneestoennem SPECIAL CIRC OfDMISC.
Fy} thin M is licenced pursuant to the previsions of the Contractors Lionse Law(Chaprer9
�aG� (commencing with Section 7")of Division J of the Business and Professions Code)of TEMP.METER OR POLE.INST. COMMERCIAL'
640 ttGG ,hat he is exempt detrcfrom u.d the basis for the alleged r.rni,lora Any lunation of ❑NEW BLDGIADDHHON ❑DEMOLITION
W^N Section 9071.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
t more than five hundred dollars Minn.F Z�• IMPROVEMENT
wi Lose work,the pmpeuctur myemwith wredf rsalei(Sec.70m.f solion, SWIMMING POOL ELECTRIC
O
will do thework,and Twcu.knot intended Licew ow do s net apply of n muncy os ❑OTHER
lau3 m and property
who
CWe The ue,therea License Law does net apply m lf owner d UTLETS-SWI TCHES-IIXTURLS
his own who boil,,or Imereva thereon,and who Jae,such work himself or,mnugh
his own employees,building that such mens is old w arc not iyer,ofJ m,frac,1'he NEW RESIDENTIAL ELECfR SQ IeT
salc.IChown'ep the building or improvement is sold withinone scar of coinflelinn,the SQ.PI'.FLOOR AREA $ISQ.Ief.
tar-builder will have the burden of pmving thin he did not build or improve for Its,
pule of sale). T
1,as owner of the.properly,um exduaivuly ewumning wish liccnxed cont...I In T T51Ur L (7
arose La the es not apply
an
Business and Professions CWr:)The es ducoor,Li
tense
I:Ww Does not apply to nn owner of property who Milds or improves thereon,and QTY, PLUMB PE IT FEE
who trews,for such projects w hit a confamorts)licensed pursuant to the Contractor's FEB n7r
License Law. PERMIT ISSU 6 / 9r1L^
1 am exempt under Sec. .B&P C far this rea.mn �./•� All
Owner Date ALTER-DRAIN&V ATF,H(EA) Vi LUi Lf ALUATI3N
WORKER:SCOMPENSATIONDECLARAHON BACK FIAWPROTECT,D
1 hereby affirm under penalty of to jury one of the following declarations:
.l]I have and will maintain a Crodivene of Consent o self-insure for Worker's Carmen- DRAINS-FLOOR,ROOF ARE CO. STORIES TYPE CONSTRUCTION
salon,as pro,idal]or by Station 3700.,the Labor Cade,forms,ped..mance of the
work for which this permit is issued. FIXTURES-E'ER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the perturmanccofthe work for which this permit is issued. GAS-IA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy harmer are:
Carrier: Policy No.: GAS-FA.SYSTEM-OVER 4(EA)
CERHFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEdINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FIi1S
(This section need not be completed i(the'eosin is Tomos hundred dollars($1100) GREASE TRAP
or lest] PLANCHECK FEE
Icsdify thin in the parf'rmin,tofoework far whiah,hi,Permit is issued,lbhall SEWER-SANITARY-STORM EA.200 FT
nmempiny ypernnn in an m ubeurme.M1jerno We Wnrkcrs'Comlxm ENERGY PEIi
soon
Z catism”
on Iv s Califnmi. nm WATER HEATER WNENT/ELECfR
Z O Applicant GRADING FEE
y NOTICE'T PLIC NT.II',after making this CeniOc.te of Exemption, maslanhould WAq'IiR SYSTEM/TREATING
F > become s ttt m the Worker's Cmmpensnrimn prevision,of lite IaMr Gds.you must SOILS FEE
tonhwim amply widbxtwh previsions.this pe earn shall be distant revoked. WATER SERVICE
Q
p' CONSem isacION LENDING AGENCY NEW RES IUI3NTIAL PLMB, SQ.lel'. PAID
5z Thereby effiwthat them is lending agency for the Perfowance of Uom Receipop
V 0the work for which this permit is issued(Sec.3097.Cie CJ
Lender,Name TOTAL:
L) Lenders Addre,s TOTAL:
} 1 1 unify that I have real this application and state than the above information i.e. BUILDING IEE
Fr V1 correnJ agree to comply with all city and county ordinances and state laws existing to QTY. MECHANICAL PERMIT FEE
C1 Z building construction,and hereby omhorivm reprenoaive,ol lu,airy.inar,moo he SEISMIC FEE
above-mentioned property fur inspection'info... PERMIT ISSUANCE
(We)agree lit.save,indemnify and keep brunt the City of Cupenino against ELECTRIC FEE
Liabilities,judgments,costs and expenses which may in any way arcate against said City ALT ER OR ADD TO MECH.
in nsra mase of the granting of this pennon. PLUMBING PEE
APPLK}�ANT UNDERSTANDS AND WI L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,OmI CFM)
SOI x`V REGULATIONS. f MECHANICAL FEE
2 / AIR HANDLING UNIT(OVER 10,000 CFM) CONS'rRUCI'ION TAX
Signamr pelican onl cm Date (/ EXHAUST HOOD(WANIC) HOUSING MITIGATION FEE
H ZARDOUS MATERIALS DISCLOSURE
Illthea,,liaant or future buildingoacopanlsureor handle hu'znrdaus material HEA'L'ING UNIT(M 100.00E BTU)
az
it re eJ by the Cx,mms Municipal Code.Chapter 9.12,end the Health and Safety
C Section 25532(.)^ HEATING UNIT(OVER 100.000 BTU)
E]Yes ❑No VENTILATION CAN(SINGLE RESID) PAID
U:ne Recciptb
0011 the air costa m future building by de,B use equipment of Mara which
I hazardous air contaminants as,efineJ by Ne Ray arca Air Quality Management BOILER-COMP(3NP OR 100,000 BIL) OT
D ttriel'1 41
E3 Yes ❑Nn BOILER-COMP(OVER I W3,MM)BTU)
L have read the bccallous material,neroremenls under Clepte,6.95 afire Cali- AIRCONDITIONER ISSUANCE DAT
(omit Health&Sentry Code.Sections 25505.25533 and 25534.1 understand thin il'the NEW RISLDENIIAL MECH. SQ.FT.
building does ren emrtnny hast a tenor,that it is my responsibility to notify the occupant
of use re,mann a rs,which most be met Prior a iamnce of a Cti i6cam of Occupancy.
Owner or authorized agent Dae TO ISSUED BY:
OFFICE