29238 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINGELECTRICALPERMIT NO. a.a a.aC8
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL '2 l9JL
Bl11LDINO PROJECT IDBNTIF'ICA'1'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I 10
a arr-
OWRSNAME: COACfORSNA LIC NO
CM :
2-
.;? N/C CONTROL#
RCHITECUHNGINEER. LIC NO: ADDRESS: ❑
ONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby of irm but 1 am licensed under provisions ofehapter 9 Commencing JOB DESCRIPTION
CZ with Section 700(a.fDivlsian3ofthn Businessand Professions Code.andmyliceme is RESIDENTIAL:
in full fnreeandeffc PERMIT ISSUANCE
Wf, c�es S� DSFDWL D KITCHEN REMODEL
�F.UyU License Cl Lic.p APPLIANCES-RESIDENTIAL
❑ADDITION ❑PLUMBING RF,-PIPE
N d E, Dam C.mnutur
FDm ARCHITECTS DECLARATION PANELS ❑MULTIUNIT [I STRUCTURAL
O Z=z 1 understand my plans shall be used as public records MODR'ICATION
Q UPT0200AMP5 ❑INTERIOR [I CHIMNEY REPAIR
��,F'.-W Licensed 11 t'e,,ionul 201-INX)AMPS IMPROVEMENT
ay OWNER-BUILDER DECLARATION
C� -I OVER UWAMPS D BATH REMODEUREPAIR ❑DEMOLITION
Q I hereby affirm that I am exempt from the Contractors License law for the ,
'36 U following reason.(Section 7031.5,Business and Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
1i y which requires a permit to conntrueL alter,tmpmva,demolish,or repair any atmeture
SPECIAL CIRCUITIMISC.
A
prinnoiu ismance.also reyrires the applicant lnr such permin.Rlcusigncd smtcment
E�7that he is licrned pursuant o the provisions ofthe Committers License Law(Chapter 9
�aap0 (commencing with Seemion700U)o1'Division3 nfthe Business and Pmfm...mcci TEMP.MITER OR POLE INST. COMMERCIAL:
d 6 p�' Nm he is exempt thereGnm and the basis for Nc allege)exemption.Any violmion of 0 NEW BLDG/ADDITION D DEMOLITION
I i,t Section 7031.5 by any applicant for a permit subjects the applicant to u civil penalty of POWER DEVICES ❑TENANT ❑FWD SERVICE.
nm more Nan five hundred dollars($5W).
F 2)- IMPROVEMENT
g=6 Dl,as owner of the propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
Ngawill it(,the work,reada,suuameisnotinrendcdo,offercd fnrsulc(Scc.70,D,Business ❑OTHER
3� and Professions Cale:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves Nete.n,and who dos such work himself or through
his own employees,provided that such improvements art not intended or offered for W RESIDENTIAL ELECTS SQ FT.
sele.If,however,the building or improvement is sold within one year ofcumpletion.theSQ.FT.FLOORR R A S/SQ.FT.
owner builder will have the burden of proving that he did not build m improve for put, `r RpJT'
pose of sale.).
gf
0 1.as owner of the property,am exclusively contracting with licensed contractors mo TOTAL:
msunet the project(See,loan,Business and I'rnlessions C(Ac:)'Ihe Contractor's I,i- C
cense Law Jos not apply to an owner of propcny who builds or improves thereon,and QTY. PL t PERMIT FEE C� 1996
who contracts for such projects with a contrsctnrts)licensed Fireman to the Centers, rs is \'//,�
Litems Low. PER NCE ` Vf" Go,
O l am exempt under See .B&P C fm tlnxmaxon 1 �hlllyU
ALTER- �sFM'-WATER IEA) VALUA'T'ION
Owner Date
WORKER'St th
COMPENSATION DECLARATION BACK FLOW POT: ICE
I hereo by ammundo CanaryImlt, (. perjury nuc of e fallowing Jeclamtiona:
] Ihave aalwie for bynetion 37M of theLabto selvd,forthe Worker'sce of
DRAINS-FL.I)nR,R00, .GOND. STORIES 'TYPE CONSTRUCTION
w k f r Provided tri for by Section d. of the labor Calc,for the Performance of Ne
work for which this Contin is issued. FIXTURES-PER TRAP
' 37 1 have and will edenmim hepidm Cmice fine
w Insurance,h N,retleired by Section
J7Wof the lalcn Cale,far the perlormance oflhe work for which Nis permit is issued. GAS-EA.SYSTEM-]LNC.n OUTLETS CCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER Y(EA)
CERTIFICATE OFCXEMPTI(IN FROM WORKEkS' GRGSI%ENUUS'IRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissecuon need not be completed ifilte swout is foronehundmddollars(5100) GREASETRAP
,it less.) PLANCHECK FEE
I eetify that in Ne,normm.cenf Ncwork f..whicnin,permit is ix sued,l shall SEWER-SANITARY-STORM EA.21X1 FT.
m
nemploy any pass in any mao nn so .ca mo Ne Wmksrs Cmn,.- 17NERGY FEE
0 Z cation Lai s of Califomia.Date WATER HEATER WNENr/ELECfR GRADING FEE
'Zr a^ ttprovisions NOTICE 1 'AN'E IL after ma mg this Cetificme of Exemption,you should WAI ER SYSTEMITREATING SOILS FEE
become subject the Worker's Compensation pvisions of the Labor Code,you must
forthwith comply withstich pmviaions or Nis permit shall be domed Invoked. WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDIiN'TIA1,1'LMIi. SQ.FEPAID
0 Z Ihertby aRmuhel Nerc isamnstrvaion lending agency funbe perfo,mance of Use Receipts
V v- the work for which this permit is issued(Sec.3097.Co,C.)
0 Linder,Name TOTAL:
[Ut1 Lender's Adds, TOIAI. BUILDING PEE
1 cenify that I have read this application and state that the above information is
.E. gO correct.I agree to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT P
V Z building conxWction,and hereby authorize mpresenterves of this city to enter upon the SEES MIC FTE
above mentioned propeny fimm,,a Nan putpoaes. PERM IT ISSUANCE \
(We)agree to serve,indemnify and keep hanNess be City of CLpcninn against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way same against said City ALTER OR ADD TO MECH.
in sequence of Ne granting of this p annit. PLUMBING FEE
APPLICAN9UNDERSTANDS AND WELL COMPLY WITH ALI.NON-P INT AIR HANDLING UNIT(TO 10,000 CFN) MECHANICAL FF.Ii __
SOURCE.REGULATIONS.
%15p dI C
AIR HANDLING UNIT 10,000 CFM) CONSTRUHON TAX
Signature of Applicam/Conuactor —aG O tic 7(, EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE/
I Will the applicant.,future buildid,reen carm, ux.r handle hazammi,material HEATING UNIT(TO 100.000 BTU)
as defnal by the Cupertino Municipal Cock,Chapter 9.12,and the Health and Safely
Cale,Section 25532(u)7 HEATING UNIT(OVER 1(140()1 BTU)
D Yes [J No VENTILATION FAN(SINGLE RESIDE PAID
/ s Date R.iptis
Will nsa costa or Tnturc building by the
Am Air Manaerwhich
emit hazardous tar ennmminsu us JelineJ by the Huy Area Air Vualimy Afunugemem BOILER-COMP(3HP OR 111U,fNN1 If1'U) TOTAL:
Drsmd7 BOILER-COMP(OVER 100.001)BTU)
0Yev El No
I hrve mad the hicardouamaterials tryuerements under Chapter 6.95 of the Cali- AIR CONCH'IONER ISSUANCE:DATE
front.Health&Safety Cale,Sections 25505,25533 and 255N; 1 umkrstaM dial if dtc NEW RESIDENTIAL MECH. SQ.I.T.
building dos not currently have a tenant,Nm it is my resin noRniiry to notify the occupant
(it the requirements winch must be stet prior to issuance of a Cenelicam of Oc npuncy.
I Owner or authorized agent Date ISSUED BY:
OFFICE