29220 (2) i APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO . ,'BUILDING-ELECTRICALPERMIT NO. 2922
BUILDINGDIVISION APPLICATIONIPER"[T PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATI
Ov
OW ER'SNAME: _ PHDNE: I C RACTOR'SNAM /�PWJILb �,✓ LIC NOtl
S7,_(g(� 1 N/C CONTROLM
CHITECT/ENGINEER: - LIC NO: ADD ESS: Li CA6LOc ,
CONTACT PHONE: - BUILDING PERMIT INFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MELD
' LICENSED CONTRACTOR'S DECLARATION ❑ ❑
I herebyaffirm that 1 am licensed under f Chapter 9(cotvnemin Qom' -ELECTRIC PERMIT FEE JOB DESCRIPTION
u and
Professions
p g
Q0IZ with Section]fl(1(O of Division]of the Rosiness and Professions Code,and my license is --- --
00 Y PERMn'155unI9cE RESIDENTIAL,
n full force and effect
Ni. ❑SFDWL El KITCHEN REMODEL
6 V pp License Class Lie.N
�QW� Dam Contractor APPLIANCES-RESIDENTIALEAODITION ILUMBING RE-PIPE
ARCHITECTS DECLARATION
understand El MULTI-UNIT ❑STRUCTURAL
O Z r� J undersnd my plans shall nc aced as public records - " MODIFICATION
0 _ UPT0200AMPS ❑INTERIOR • r El CHIMNEY REPAIR
, j
Licensed Professional -^ 201.1 WO AMPS IMPROVEMENT ..
OWNER-BUILDERDEthe Comment"
OVER 10MAMPS ❑BATH REMODEUREPAIR El DEMOLITION
1 hereby.Seademi 1 oto exempt from the C+unmclCo License Law for the
iqyi5(O y V following reason.(Section 7031.5.oneorn Business and se,demob Code:Any city s m no, SIGNS ELECTRICAL ❑OTHER
tY 3 fL E' which requires.a permit to nmstmcn,alter,improve.demolish,or repair any structure
F�tOn prior to its issuance,also requires the applicant for such Permit file a signed smtemem SPECIAL CIRCUI'r/MISC.
y
that he is licensed pmsoaon to the provisions of[]to Contractor's License Law(Chapter 9
0� bammen ting with Section 1000)of Division 3o Rhe Bueinessavd Professions Code)or TEMP METER OR POLE INST. s COMMERCIAL'
d ryt m y
that he Is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by onyapplicant fora pennil subjects the applicant to u civil penulty of POWER DEVICES, ❑TENANT ❑FOODSERVICE
>> not mora than five hundred dollars(S500).
�Ga 1,as nwnerofthe ro norm
employees with waits as their sole contatior, SWIMMING POOL ELECTRI IMPROVEMENT
O ❑ P Pe Y Ymi. Y B pens . ,
II do the work,end the structureisnon intended or offered[or eale(SeC]044.Business ❑OTHER
Y ' and Professions Code:Tne Crnfinema's License-Law does not apply to un owner of [ OUTLETS-SWITCHES-NI(TU +
property 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 for NEW RESIDENTIAL.ELI7CTR
sale.If,however,the lumnagmimprovement nnld withinone yinrofcorpleti.a,the SQ.FT.uPLOORq�A�, ! §/SQ.FT.
-builder will have the burden of proving that he did not build or improve for put- _ b
putprosaic.).
[:]sl,as owner of the property,am exclusively cmudatia6 with licensed contractors to TAL p.
construct the project(Sea 7044.Business and Professions Codw)Tho Contractor's U- Q r Eft 6 .ra�� ,
cense Low does not apply to an owner of property who builds or improves thereon,and TY PLUMBINGPERMIT %FEE 444 19 ,,.
who contracts for such projects with a con ractor(s)licensed pursuant to the Contractor's C
License Law. PERMIT ISSUANCE "'TY Ur L
L] I am exempt under See. ,B&P C for this reason _ yrchlffvl/
'• ALTER-DRAIN&VENT-WATER(EA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the fallowing declaratiodi -
❑ I have and will maintain o Certificate of Cousentto self-insure for Worker's Conifer- DRAINS-FLOOR,ROOF,AREA,COND. -
setioa,as Provided for by Sm0on 3700 of the Labor Code,bathe performance of the STORIES TYPE CONSTRUCTION
ark far which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insomniac,as required by Section
3100afthe Labor Code,for the perfermined ufine work for which Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS - OCC CROUP APN
- MYWorker's Compensotinn trimmed carrlerand Policy number ore: -
Cartier Policy N., GAS-EA.SYSTEMAVER 4(EA)
CERTIFICATEOFEXEMPTIONFROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This section reaction Is,completed ifthe permit is friend hundreddrllars($100) -BUILDING DIVISION N13E5 -
or less.) CREASE TRAP,
PLANCHECK FEE
Ice anyp t'nN Pert frit Is for itch this the Wows'Con,ha11 SEWER-SANITARY-STORM EA.200 Fp
m employ y person t y as t bac subject m the Workers Ca ripen ENERGY FEC
stomaLmssixCelifichout Data
Applicant WATER HEATER W/VENT/ELECfR GRADING FEB _
h NOTICE TO APPLICANT:If after making hit Crrtlfrate fExempnon you should WATER SYSTEMICREATING r
H
become subject the Wouldn's Compensation pr visions of the Labor Code,you most _ SOILS FEE
forthwith comply with eaehprovisirns or this permit shell be deemed reenkat. WATER SERVICE -
Q
� �. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ.Ff. 'PAID
O I hereby affimUhat there is aconswetion leading afor
gency for the performance of, Date • Receipt if
U
U the work for which this permit is issued(Sic.309].Cie C)
Lenders Name TOTAL: :
LkI .Lenders Address TOTAL:
I ratify that I hove read This application nark entre Nvt the above information is BUILDING PEE
h correct.)agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U building construction,and hereby authorize repfesentatars of this city to enterumrn the SEISMIC FEE
above-mentioned primary for Inspection purposes. '
- (We)agree Ir save,indemnify and keep himena,the City of Cupertino against PERMIT ISSUANCE. ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way dram,against said City ALTER ORADDTO MECH. '
in examequeneeaf the granting ofthis Perini(. PLUMBING PEE -
APPLICANT UNDERS)-ANDS AN i .COPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,000 CFM) MECHANICAL PEG
CER ATI S.
AIR HAND LING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signammd ApplicandCmoramr Dal/am EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEF.
HAZAR5MS MATERIALS DISCLOSURE.
Will the applicant orfumm building rccupanl store or handle hazardous material HEATING UNIT CPG 100,00H BTU) ,
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(ayI HEATING UNIT(OVER 100.000 BTU)
El Its, -p No
+ VENTILATION CAN(SINGLE REBID) PAID -
Will thea licvrt or future bulldin occupant use equipment or devices which Data -Receipt a
PP 6 pun .AirQn
m t hazardous air contaminants as defined by the Bey Area Air Qualify Management BOILER-COMP(3HP OR 100.000 BTU)
TOTAL:
�D19tr1en^ l -
❑Yes (]No
BOILER-COME(OVER IA000 B'FU) .
+
' r AIR CONDITIONER
I hlth ad Safer h ode,Sepa ater255al, 5,255 3 an under 1 and 6tand th,that Cali- - ISSUANCE,DA
forabuilds Heag dee,5.Safely Cale,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH, SQ.IT. r
building dces noir currently hast a facet that it is my responsCtafy modify the occu,am -
oftherequirememswhichmmnhemetprianrissuaneenfaCertifemeofOccupmsy. - ,
Owner or ant dazed agent Date TOTAL: ISSUED BY:
'OFFICE