29383 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION - APPLICATIONIPERMITPLUMBING-MECHANICAL. 29383
BUILDING PROJECT IDENTIFICATION
BUILDING DRIbSS: 0 SANITARY NO, APPLICATION SUBMITTAL DATE
W 'S NAM` \`- 1'H NE: ONRAC OR'S NAME I.IC NO:
.T , NIC CONTROL«
AR ITECT/ENGINEER: I.1 NO: AIIDRI:SS: ' '^ ❑
CONTACT. PHONE: BUILDING PI?EMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1:1 El EDLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 berehy.ftirm Nm 1 ant licensed under provisions of Cade.
9(commencing JOB DESCRIPTION
Yz with Semian](1W)of DivisionJoflhe Business and F'mfessinns Cade,and my license is RESIDENTIAL:
FOO in full force antic `
PERMIT ISSUANCE
-FV, License C,a Lica�7 ❑SFDWL C3 KITCHEN REMODEL
NG
Data Comr APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
AgJ/({ITECT E aRAT10N ❑MULTI-UNIT ❑STRUCTURAL
z pH7NJ. land I �sho ao�s.7 PANELSMODIFICATION
Oz�O - s u UPT02MAMPS El INTERIOR El CHIMNEY REPAIR
rI= Lic afro .to 201-1000AMPS IMPROVEMENT
syl H.exemDIiR DECLARATION OVER 1000AMPS El BATH REMODEUREPAIR [I DEMOLITION
C C 1 hereby affi m 1 em exempt tram the Centractols License I.ow far the
O U follnwing rea.am.(Section 7031.5,Business and Pralesaions Cole:Any city or county SIGNS ELECTRICAL. ❑OTHER
Fa which requirea a pemdt ne conswd.Iter,improve,dcmolnt it or repair any xwcture 1 _
rose
hot
elsienndpursant to ma Prohe visions o fnrsuch Contractors
Limas Law
e(Cmemem SPECIALCIRCNT/MISC.
y thatheislicensedpursuantto the Provisions of theC Br,inoh License Low(Choper9
cls (nd he is ina ,,thectlon](anllof toad,for oft heeled exempt Pm A.,vi Gde)or TF,MI'.MEIF.R OR POLE INST COMMERCIAL:
a c C Nm he is exempt thertfrnm attJ the basis for the ellegM exemption.Any violation of [D NEW BLDG/ADDITION ❑DEMOLITION
+ Yto Section 11131.5 by any applieunt for a penoulmbjems the applicant mocivil pe noIy of POWER DE VICES L3 TENANT ❑FOOD SERVICE
p, not mom Nan Five hundred dollars(ESW). IMPROVEMENT
'Q ❑ I.us owner of Ne property,or my employees with wages as their sole compensation, SWIMMING POOL ELE
1.. will do thework,and the structure is not intended oroBered formle(Sea 70,m.Business ❑OTHER
6 T.6 and Professions Cole:The Contractor's License Los,docs not apply to an owner of OU'rLETS-SWITCHE -F
r property who builds m improves thcrean,and who does such work himself or through
his own employees,provided that such improvements me not intended or offered for NEW RESIDENT[Al.ELECIR ITC O - -
sale.ILhowever.the building or improvement is sold within one yemafcompletion,Ne SQ.FT.FLOOR AREA $ISQ.FT.
owner-builder will have the burden of proving that he did trot build in improve for par- ,
pone of sale.,. MAR 7
❑1,u owner of the See70Property.am exclusively contracting with.,11-:3 contractors to TAL: 1996
construct the project(Sec.]014,Business roti Profevsiom Code:)The Contrectors Li
-
teneLowdoesnotapplytoanownerofpropenywhobuildsorimprovesthemon,and Q'rY. PLUMBING PERMIT FEE /
who contracts for such projects with a contrreams)licensed pursuant to the Contractor's VII I Vf VU, LnI hit
License Law. PERMIT ISSUANCE U
❑ lam exempt under See ,B&P C fomes reason
Owner - Data ALTHR-DRAIN&VENT-WATER HLA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOWPROTECT.DEVICE
• I hereby affirm under penalty of perjury one ofthe following declarations:
❑Ihave mit will maintain.CenIDc.mof Consen0o uif-insure lar Worker.Cramped- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
cation,its provided for by Section J'1 W of the Labor Code,for the performance of the
work far which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the lobar Code,for the ponnnmce of the work for whichum.pemdt is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Workers Compensntlan Iranian.emrier and Policy n lamr,arc:
Carrier. Policy No.: F GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRBASUINDUSTRL WASTE INTERCEPTOR
(Thi—cul .need not ha onnplemJ if the penniNsfnronc hundred dollar.($IfyB BUILDING DIVISION M-ES
or less) - GREASE TRAP
PLANCHECK FEE
Loy any Bad in in any manner
of moi become
which this Permithe Workers s ed,I shallCooper- SEWER-SANITARY-STORM EA.200 PI'.
not employ any Califon n my mmner so as to become subjttno the s'Gumpert- ENERGY FEC
s pLaws of California.Data
7� O Applicant WATER HGTER W/VEN'T/ELI[LTR � ,. 10 GRADING FEE
G cn NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
a become subject to the Worker's Compensation WATER SYSTCMfI'REATING
j pens. provision of the Lahr evoke,you run SOILS FEE
{EI
forthwith comply wish such Provisions or has permit shall be deemed revnkrd. WATER SERVICE '
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
I hereby VQ work
Pe Nitreisaed(See.3097leading agency forthe performance of Data Rceciptp
0 U the work for which this permit is issued(Sec.JW1,Civ.C.) Q
O U Larder's Name TOTAL:
IandcYe Address Tot'AL;
0. I certify mbar 1 have read Nis npplicmimm and slate Not diastase infommion is BUILDING PEE
h cortem.l agme to comply witfi all city and county oNimnces and stem laws reining to QTY. M17CHANICAL PERMIT FEE
V buildineconsvumiutlmd hembyonthorim represenmive.ofthi.city mcam......he, SEISMIC FEE
above-mentioned property for mismomon proposes. PERMIT ISSUANCE
(We)ugreemsave,indent.:fyand keep .less the City of Cupertino against ELECTRIC FEE
liahilitiea,judgmcros,coats mdexpensea w ' to a anyway accrua.gainst mid City ALTERORADDTOMECH. PLUMBING FEE
n�qumnaccofdbe gofthis h.APPLNT ON A ' 'A COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM7SOURREf MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,WO CFM) CONSTRUCTION TAX
Sig real p tractor D e EXHAUST HOOD(W/DUCT)
H LARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEF.
ill the apt mnrfmurt building occupant more,or handle huvNnus material HC•ATINO UNIT(Ter I00,1100 BTU)
as defined by the Cuperuman Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)7 t HEATING ON]r(OVER IW,"BTU)
El Yea El No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
ounlthein,air containmenant or mrt building occupant use Area
Air Qnt at uality deviceswhich
BOILER-COMP(31H OR 100.000 BTU) TT
emit hazmdnus'air conluminunts us def nrA by the Bey Arca Air Quality Management TOTAL: V
District?
E)Via, ❑Nn BOILER-COMP(OVER IW,(Xp ETU)
I have mad the harmdous nmterials mquiremcas order Chapter 6.95 ifthe Cab. AIR CONDITIONER ISSUANCE DATE
Trans Health&Safety Codc.Sectianx 25505.M533 mal S5M.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
huilding chez not conically have a tenant that it Is my resgmsilaity to notify Ne occupant
of Ne requimmcnts which mrot be ton prior m immanent.Cenificate of Occupney.
Owner or monorail agent Data I TOTAL: ISSUED BY:
OFFICE