29395 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRerRICAL PP:RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O 'R'S
CENAM : PHONE: CO SNAh1P LIC NO:
1 a N/C CONTROL
1 HITELT/EN BNEER: LIC 'O: ADDRESS: ❑
CONTACT, PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ •W ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1hereby 11)of that Ium licensedthBlunder provisionsof,Codmi9(commencing JOB DESCRIPTION
GCz with Settle. dAfe;DivisinnJ of the Buxiness and Prof<asions Cade,and my license is
�OO PIikMIT ISSUANCC RESIDENTIAL:
full force vnd f
Fa.UF Licens CW Lm# ❑SFDWL ❑KITCIIPN REMODEL
NQL Date Contra cmr 1 APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE,
I-,py A ,I' :CTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z 0�E a PI. x all he used as Public records PANELS
MODIFICATION
OZ Q en, P UPT02(d AMPS [D INTERIOR El CHIMNEY REPAIR
G� OWNER.BUILDER DECLARATION 201-101MAMPS IMPROVEMENT
6' I y affirm shot 1 am exempt from the Commmor's License Law for the OVER IWIJ AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
li�5 O 4F. followi rommn.(&ilia.]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
FC which mquirexan Permit m construct,vllm,impmve,demolish,or repair any shoelace _
-Jar prior to its issuance,aLat requires the applicant for such permit o file a signed statement SPECIAL.Cl RCUI'T/M ISC.
W{ chat he is l lcemed rr//y�a1y
pemauvisthfe unLicense Law(Chpmr9O commecing with Section]0pBoTDvislo,I otheBusiness - e
and FrofcssinnsCode)m LUMP.METER OR I'OLL'INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
nV.
Section 7031.5 applicant 1.5 by any applanalfor a Permit subjects the applicano a civil Penalty of POWER DEVICES
Z� not mom Than five hundred dollars(S300). ❑TENANT ❑FOODSERVICE,
^< I.asnwnernfthe IMPROVEMENT
❑ thepenymmyempleyecs with wages their sole compensation, SWIMMING POOL ELECTRIC
will dotheumos and the oComistodroenensorowdocx rmle(Sly 1.. Business ❑OTHER
ao� and arty who b Code:The C.nuncwrs License law d«s not apply s an owner of OUTLETS-SWITCHES-FIXTUNFS
progeny who builds at videdvth thereon,and who does such work himself or through
his own employees,s,r.the building
ar m such impms sold within arc not intended mpledio ,far NEW R[SIDLNTIAL IiLECflt SQ
owner-howevee ll hav ildi burden mvement ithat hed ore build
or i comple for,the SQ.Ff.FLOOR AREA LSQ,FT.
pe.of tilde,will have the burden of proving that he did not build.,improv<far par- P �} E
pose of sown).
❑bas ait therofthepmPeny,a exclusively contracting wcdcl)The Cannot
m AL:
construct the projem(Sec.]IH4.Business and Pndasionx CWc:)The Convenor's Li- WAR
pp
close Law does am apply to an owner of property who builds or improves thereon,and QlY PLUMBING PERMIT FEE WAR 7 199
who coronets for such projects with a contmchand licensed pursuant to the Conlowtorh
License Law.
E]IamexemptunderSee. ,B&PCAm0d,mmon PERMIT ISSUANCE CITY Ut GUl'CI'tIIN)
Owner IDate ALTER-DRAIN&VENT-WATER(IA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations
•❑ (have and will mainmin.CmiEcme of C...senuoself-in sure for Workers Co.,.- DRAINS-FLOOR.ROOK AREA,COND. STORIES TVPIi CONSTRUCTION
sutlon,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will mtinutin Worker's Compensation Imnrance,as required by Section _
3700 of the Lnbm Code,for the Pvrfnnnanceolthe work for whichtbis permit is Issued. GAS-VA.SYSTEM-I INC.4 OUTLETS C:A OCC.GROUP APN
I My Workers Compensation Insurance carrier and Policy number are: -
Carrier: Policy No.: GAS-EA.SYSTI?M-OVER 4(EA)
CHRTIFICATH OP EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FIil35
(Thaseuion need not we completed ifthe permit is forome hundred dollars($10d) GRFASETRAP
mlessJ PLANCHECK FEE
1 certify that in the performanceofihe work for which this permit is ismed.I shall
nm employ any person in any manner so as to become suhjecnn Ne Workes'Compen- SEWER-SANITARY-STORM IA.21X1 IT.
ENERGY FEE
Z sationlawsof Califamia.Date �S
z O Applicant WATER HEATER WNENT/ELF.CIR 1. 7.0 GRADING FEE'
r ti NOTICE TO APPLICANT.If,after making this Cenifcete of Exemption,you should WATER SYSTEM(CREATING
became sobject o the Workers Compensation provisions of the labor Code,you must SOILS FEE
forthwith comply with arch provisions.,this petmitsbdl be deemed revoked WATER SERVICE
d
UO CONhem is a IONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date Receipt#
I horwhicby h hi that is sued(mason lending agency for she performance of /b
4.0 U the work for which this pcnnit is issued fScc.3097,Civ.CJ TOTAL:
O U Lender's Name
U Lender's Address TOTAL:
I ceni(y that 1 hove real this application and smm that Ne all information is BUILDING FEE
.r V) correct.l agme tocomply with all city and county ordinances and state laws tdating to QTY, MECHANICAL PERMIT FEE
G 7- building convection,and hereby a.thorm representatives ofthiscirym anteroom the SEISMIC FEE
above-mcroioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep h.mdess the City of Capone.against ELECTRIC FEE 3
IiaM1ilitim,judgments.costs anJ expcm e.,shichmay many way accrue against said City ALTER OR ADD'TO MUCH. PLUMBING PEE
in comequenea oft rnmlmg oft nnit.
APPLICANT RTA# WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITfT01(1,1001CFM)
SOURCE MECHANICAL PEE
AIR HANDLING UNIT(OVER 10,101)CFM) CONS'TRUCION TAX
S' nut
HAZARDOUS MATERIALS DISCLOSU ale EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS -
edbyteCupertnrfMuniBuilding e,Chanlatom2,handle Health
smetfety BEAT INC,11NIT(TO I(XI,INIO ITU)
m deSection
io the 32(a)?no Municipal Code.Chapter 9.12,and the Hea1N and Safety
Code,Scetirn 255J3fn)'/ HEATING UNIT(OVER I00,IX0113TU)
El Yea ❑No VENTILATION TAN(SINGLE RESID) PAID
Date Receipt M
Will the air conalcant nr future building by the Be,use equipment or dMano,Which
irsol
emithtzarduus Dir ronmininamsmJefined by the BArea Air Quality Mnnagemcm BOILER-COME OHP OR I00,001 BTU)
District? TOTAL:
❑Yes ❑Nn BOILER-COME fOVFN IUI,f 1110TU)
I have read the hmaNuu materials requirements under Clopterfi.95 ofdc Cali- AIR CONDITIONER ISSUANCEDATE
Rican Health&Safety Cede,Sections 255115,M533 and 25534.I understand that if tete NEW RTSIIIENTIAL MECH. SQ.FT.
building Arcs nre
curmody have a tenant.shot it is my responsibility to nwdfy the occupant
of Ne re"which must h con Pdnr m iuuanm.f a Certificate of Occupmtcy.
i
Owner or authorized ahem Date TOTAL: ISSUED BY:
OFFICE