29221 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMrr NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL 29221
] 9
BUILDING PRODIC'r IDENUFICAIION GJ 1
BUILDING ADDR 'S: SANITARY NO. API'LICATIONSUBMITTALDATF
OWN R'S NA E: PHONE, CONTRAC It'S NAME: LIC NO:
_ G NICIs
CONTROI.p
ARCHITECT GI Ri NO: ADDR SS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG PI.rCT PLUMB MECI I
❑ ❑ ❑
LICENSEDCONTRACTORSw"oo,CfARAT Chaim,
QTY. ELECTRIC PERMIT FEF,
I ion 70 ar6rm met Iran licensed mire,ndIsmirrx tar Chanter n(my lafeme is JOB UBSCRIPTION
C05 with Section 7g9)of Divisimn3ofthe Business and Professions Cnde,and myliccnse is
�0 0 PERMI'TISSUANCE RESIDENTIAL
in full force mrd effect.
�F.UF License Class Lia» ❑SFDWI, ❑K CHEN REMODEL
NQH Datu Contr.cmr APPLIANCES-RESIDENTIAL ❑ADDITION BINGRE-PIPE
.Don ARCHITHCT'SOECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O O 4 Z I understand my plans shall M used as public records MODIFICATION
ZUP10200AMPS El INTERIOR ❑CHIMNEY REPAIR
F"4 t�i Licemed l'..liasimnal - 201-Iota AMPS IMPROVEMENT
�W 1 OWNER-BUILDER DECLARATION OVER]"AMPS ❑BATH REMODEI/REPAIR El DEMOLITION
CC 6 1 hereby affirm that 1 am exempt train the Commctors License Law for the
{iyS O d U following rensnn.(Section 7031.5,Business and prow,mons Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to coushow,alter Intpmve,demolish,or repair any structure
C' prior to in issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC.
>. that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
�� (commencing with Section TXAP of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a p,M e' that he it exempt therefrom and the naris for me ellegeA exemption.Any violation of [I NEW BLDG ADDITION El DEMOLITION
YXI I+y Section 701 L5 by any applicantfar,Amatil subjects the mplicanno a civil Penalty of POWERDEVICES ❑TENANT ❑FOOD SERVICE
11111F........... a.,more than five hundred dollar(5500).
r,6 Las owner ofthe m norm Ise with woes as their sole com nsadion, SWIMMING POOL. LF. C IMPROVEMENT
❑ P vo rt yemp yeas wi g Pe
will do firework,ande:Fire anturera tori eadcal License Law do for not apply to an owner
of El OTHER
and Professions Cade:The Contractor's License Law dors not apply self owner of OUTLETS-SWITC 9XTURF.S
4' property who oyee,or improves thereon,and who does such work himself or through
his own ernnloyees,provided thm such imnrnvcments are not intended or offered for NEW RESIDENTIAL ELE SQ FT. as
,k
sales lL however the building or improvemenl is sold orminene y,mofcamplclion,the SQ.IT.PLO A�EA1 $ISQ.IT.
�owner-builder will have the burden of proving that he did not build or improve for pot- IJ
ma of x.w). gz FES
❑I,as owner or the property,am exclusively coarsening with licensed contractors to
wAL: s �»
nset the pmject(Sin.7044,Business and Professions CodeO'The Cmnaamur's Li- 1/ F1�
erose Law docs not apply to an owner of pmpeny who builds nrimnnwes thereon.and QTY, PLUMBING PER 1 FEE YsITI �a 57 S
who contracts for such Varian with a contmemr(s)licensed pursuaum
nu the Contmefs 13 t OF e LUr'`11 LL�y e�
License Use PERMIT ISSUANCE. t l(�ry�
❑ ex
I.m exempt under Seo ,B&1'C for this reason
ALTER—DRAIN&VENT_WATER(PA)
Owner Date VALUATION
WORKER'S COMPENSATI(IN DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm,tide,penalty of perjury one of the follewins declarations:
❑ I have and will maintain a Cenificam ofComent to self-asure for Worker's Comment- DRAINS—FLOOR,ROOF,AREA.COND.
sation,as provided for by Section 3709 of the Lubar Cole,for the performance of me STORIES TYPIi CONSTRUCTION
work far which this Permit is issued, FIXTURES—PER IRAP »
❑ 1 have and will maintain Worker's Caere...it.Insurance.as required by Section
37M of the Labor Code,for the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS
OCC.GROUP APN
My Workers Compensation Insurance carter and Policy number arc:
Curiae Policy Nn.: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I I GREAMaINDUSTRL WASTE INTERCEPTOR
(This section need not be completed ifthe permit is forms,hundred dollars($100) BUILDING DIVISION FEP_S
nr less.) anGREASE TRAP PLANCHECK FEB
I certify that in the performance of the work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any Permit in any manner subject r so as do become subjeco the Workers Compen- - ENERGY FEE ,
O z indoor Laws or Califomia.�am WATI7R HEATER WNENTIBLECTR
O Applicant GRADING FEE
N, NOTICE TO APPLICANT:IL after,making this Certificate of Exemption,you should WATER SYSTfiS1?kEATING
aharome subject to me Workers Compensation Provisions of me Labor Code,you must SOILS PEE `
4t7 forthwith comply wimsuch provisions or this rennin shall he deemed revoked WATER SERVICE
CONhem is a10NLENDINCAGENCY NEW RESIDENTIAL PCMB. SQ.IT. PAID
L)0 kfin hichbi,hat Noritreisaco (Sce.3 O.Cleadis, agency for performance of Date Receipt»
wU thewces Na which rhos Permiti+issued(Sec.3W7.Civ.CJ _
Lenders Name TOTAL:
O IsnderI Address TOTAL:
G 1 certify that I have read thirty and
y ordinances state that the above ws m1minn is » IIUILDING FEE
rA correct ingreetocommly wim an ciryandamne, ive,ofandxta toawsrelarm the QTY MECHANICAL PERMIT FEE
U ,$ mosingccurram i MmMMy forebymmhedprposes. tativu of thiscltytitenteropen the SEISMICPEE
ohnve-(We)state
1.x.sy for emnifyian purposes. PERMIT ISSUANCE.
(We),grce m save,indemnify and keen harmleex the City of Cupertino against ELECTRIC ITE
liabilities,judgments,cost,nd expenses which may in any way becme against said City ALT17R OR ADD TO MECI.
m center, c of the granting or thispemr1 PLUMBING FEE
APP C N N NDS AND WILI OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,000 CPM) MECHANICAL FEE
50 ONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Sign Mire ofA cm', ` Dam EXHAUST 11001)(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAL DISCLOSURE. _
Will the applicant or future building occupant store or handle hmardous mdleriai HEATING ON IT(TO I La.(g9 BTU)
as defined by the Caperton Municipal Code,Chapter 9.12,and the Ilmdm and Safety
Code.Section 2 532(u)7 HBAFING UNIT(OVER 100.0(10 BTU)
❑Yes
No VENTILATION BANS INGLE RES ID) PAID
Will thea applicant or future building t use Date Receipt#
Pn gby the
e.Air
...Retrain BOILER—.COMP(3HP OR 100,000 BT U)
emir hamNous yr cmnmminands es defined by the Boy Arca Air Quality Management TOTAL:
District^
E]Vas No
BOILER—COMP(OVER 100,000 BTU)
❑
1 have read me harnNous...cials is antler Cha fi 95 of me Cali- AIR CONDI'I LONER
rc.25533n purr ISSUANCE DATA
fomia Health&Safety Code.Sections 25505,25533 and 25534.1 m natiry d that if the NEW RESIDENTIAL MECH. SQ.PT.
hutiding m,ex eats which have a mnam,mm o is era old
dCer ty a:e o ft'the t tinct'.
' nrme requirements which must he met prior to issuance til a Cenificum of Qcup.ncy.
Owner or amhodmd.,cut Date TOTAL: ISSUED BY:
OFFICE