29219 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-.MECHANICAL A n 9 A
BUILDING PROJECT IDENTIFICATION 9 L 1 9
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'TEAL DAIS
o r Ewr t-t-., 4VC_,
OW R'S NAME: --11PHONE: CONTRACTOR'5 NAME: LIC NO:
/CP. ✓ _ A- IfIns— IHM/ NIC CONTROL
•ARCHITECDENCINN.Ek: LIC NO: ADURIl.'S: Kl ❑
o$ S15
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ l� ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herehy affirm that I um licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
wonwith Section 7")of Division 3 of the Business and Professions Code,artd my license's PERMITISSUANCE RESIDENTIAL,
F,,= n full farce and effect. ❑SEDWI. ❑KITCHEN REMODEL
OF License ClassLi,p
6 V APPLIANCES-RESIDENTIAL. ❑ADDITION 9LUMBING RE-PIPE
y�W Date Contractor
FDm ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT STRUCTURAL
Z O to Z I understand my plans shall he used as public records MODIFICATION
OZ=O UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
F1F-)y Licensed Professional 201-0010CAMPS IMPROVEMENT
G x-4 OWNER-BUILDER DECLARATION
04 C R� 1 hut ereby afLon mI renxc
cmpt from the Contractor, fo
's License Law r the OVER 1000AMPS ❑BATH REMODEIJREPAIk Cl DEMOLITION
HLU following reason.(Section I0315.Business and Professions Code.Any city or comity SIGNS ELECTRICAL ❑OTHER
which requires a .it to c mstmel,alte,improve.demolish,or«pair any lowmre
FLLOJ prior to its issuance,also requires the applicantfor such Permit to file a signed statement SPECIAL CIRCUITIMISC.
;!(Y that he is licensed pursuant o the provisions of the Contractor's License Law lChapterv)
..00 (commencing with Section 90(10)of Division 3 omhe Business and Professions Co1c)or TEMP.METER OR POLE INST. COMMERCIAL:
t1qi5 a e that he isexempt thereliom and the basis for the alleged exemption.Any violation of C:1NEW BLDG/ADDITION ❑DEMOLI FION
Wim
Section 7031.5 by any applicant for a permit nthjecis the applicant to a civil penalty of POWER DEVICE'S ❑TENANT ❑FOOD SERVICE
not marc Nan five hundred dollars 0500).
F Z IMPROVEMENT
_< has owner ulthe pmpeny.or my employttx with wagesmthcir sole cmmpcnsation
SWIMMING PO0I.EL
O will do the wark,and mestrno
ucme,isnot inteodcoraN
dffvfor sale(See 7044.Business [I OTHER
u�13 and Professions Ode:The Contractors License Law does not apply to An owner of OUTLETS-SWITCHES- ES
6' pmpeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such Improvements are not intended or offered or NI?W RESIDENTIAL,ELECTR SQ FT.
sale.If.however,he buildineor improvement is sold withincine,cumcompliamr,the SQ.PL FLOOR AREA $/S'Q.ET.
owner builder will have the burden of proving that he did not build or improve for pur- V N g
,we of sale).
Fl 1,as owner of the property,am exclusively contracting with licensed contmeto,to T FEB 6
conmmet the pm)ce,(Sea 7W4,Business sad Prom,simns Cnda:)The Cmarmon's Li 1996
cense Law rows not apply m an owner of pmpeny who builds or improves thereon,and QTY, PLUM BING PERM I FEE
who contracts for such projects with a contrumods)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE .,ev CITY UI- CUrrnllnv
❑I am ecempt under Sec .B&P C for this reason
ALTER-DRAIN&VENT-WATLR(EA) VALUATION
Owner Date
WORK17R'S COMPENSATION DECLA RATION BACK FLOW PRO F:CT,DEVICE
I hereby affirm under penalty of perjury one of the following declaradom:
n I have and will maintain a Certificate of Camera to self-insum(or WoAces Camped- DRAWS-FLOOR.ROOF.AREA,COND. STORIES TYPECONS'TRUCTION
scion,as provided for by Section 37M of the lahor Cade,for the scifomunce of the 7
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance.as myuired by Section
3900afthe Labor Codefor thcperformamxnfthe work for which this permit is Issued. GAS-EA.SYSTEM-I INCA OVI1.121'S OCC GROUP AIN
My Worker's Compensation Insurance carver and Policy number arc:
Cartier, Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRI!ASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thiswetiomneedmnt be completed l fthe permit is hour.hundrec llars I$In)) GRFASETRAP
in ass.) YLANCHIeCK FLP.
I certify that in the performance of the work for which this permit is osocd,l shaft SEWEk-SANITARY-STORM EA.2W FT.
not employ any)mann in any manor so as to become subject m the Worker'Compear ENERGY FEE
Z cation lawsof California.[)me NATER HEATER WIVENT/ELECTR GRADING FF.E
Z _ Applicant
N NOTICE.TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTIVOGREATING SOILS PEI?
accatum aehjeet re the Worker'.,Cnmpensumon pruvisimns of the Lal)rCode,you must
W forthwith comply with such provisions or this permit shall Fo deemed revoked. WATER SERVICE
= Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID Date RttciplM
U O l hereby affirm that them is a construction lending agency for the perforwnce of
fU. -t the work for which this permit is issued(Sec.3097,Civ.C.)
Fa Lender',,Name TOTAL:
U Lender's Address TOTAL:
O
(-. 1 certify that I have rcaJ this Intl stem that the above information is BUILDING IEE
Ncorrect.)agree tocomply with all city and county ordinances add state lawv mining as QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby aathome mpremmaives of this city to enter upon the SEISMIC FEE
above-mentioned property Ru inspection purpow, PERMIT ISSUANCE
(Wharmless e)agree to save,indanmdy and keep hmless the City at Cupertino against ELECTRIC FI?li
liabilities,judgments,encs and expenses which may in any wayaccme against said City ALTER OR ADD TO MECH.
(01
comaNueracofthegramm"d m"N 't PLUMBING 19Ai
APPLIC UND NDSAND .L COMPLY WITH ALL NON.POINT AIR HANDLING UNIT GO 10,01)CFM) MECHANICAL FEE
S Cl R 'ULA IONS.
I i AI R HANDLE NO UNIT(OVER 10,"CFM) I CONSTRUCTION TAX
S oat rc IicantlCnnvveva Date EXBAUSTHOOD(W/DUCT) HOUSING MITIGATION FEIi
HAZARDOUS MATER)AIS DISCLOSURE:
Will the applicant or future building command store or handle harnnmus natarial BEATING UNIT(TO If (and BTU)
as definal by the Critical Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(m)9 HEATING ONI'1'(OVER 101,000 BTU)
El Vic, DN. PAID
VIWTILATION FAN(SINGLE BESIDE Date Receipttl
Will me applicant or future building occupant use equipment or devices which
emit harardous air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP OHP OR 100.00 BTU)
TOTAL:
District? BOILER-COMP(OVER 100.000 BTU)
p Ycs F7 No
AIR CONDITIONER p/T
11mve rtadmeh Code,Sections
u 533 it
Chapter 6.950l the Caliif m ISSUANCE((/
forma gdoes ri Safety Code,Sections 25505,25533 and 25534.1 mdeay the
occupant if the NEW RESIDENTIAL MECH. SQ,Er
buildingdocsnmcurrently
owhave atenant.matit is my eof. entym assay
of the nequirtments which must be met prinrmizmanre ofa CeniOcae of Occupancy.
Owner nr authnr,ri,gem Doc TOTAL: ISSUED BY.
OFFICE