29638 (2) APPLICANTTO FILL IN INFORMATION,WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO%" BUILDING-ELECTRICAL PERMIT NO.
1 BUILDING DIVISION API PLICATION/PERMITPLUMBING-MECHANICAL . 29638
BUILDING PROJECT IDENTIFICATION
.P.11ILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
�� M,
NF 'S NE: PH E. C NTRAC'1'OBS NAME: LIC NO: N/C CO
LTC
IV 1
,RCHITECTIENGINEER: , IDC NO:
t CONTACT: PHONE: C11S BUILDING PERMIT INFO
' t
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB- MEE�CIrH
LICENSED CONTRACTOR'S DECLARATION, ^ I
1 herebyaffirm that I am licensed ander Q Y. ELECTRIC PERMIT FEE JOB DESCRIPTION
a ndistomnsofsCode, 9 myconcmg
�OWO with 9eorcean IXBec DivieionJoftbo Busbtoss vnd lhofecsione Code,and my licwsa is
O O In full force and effect. PERMIT ISSUANCE RESIDENTIAL'
TUU License Class Lie.# ❑SFDWL ❑KITCHEN REMODEL
Dare Contractor APPLIANCES-RESIDENTIAL ... ❑ADDITION El PLUMBING RE-PIPE
ARCHI FECVS DECLARATION PANELS
F-m 1onderamndnt lams shall be used as public records EI MULTI-UNIT ❑STRUCTURAL
ILO Y P MODIFICATION
OZIzO UP T02W AMPS ❑INTERIOR, ❑CHIMNEY REPAIR
��[."fy L' used P..ficWcnal
'h 201-I OOU AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION. OVER 1(100 AMPS
1 hereby affirm mat 1 am exempt from the Contractor's License Law for the ❑BATH REMODEUREPAIR ❑DEMOLITION
following reason,(Section]031.5,Business and Professions Code',Any city(ir county SIGNS ELECTRICAL ❑OTHER
FO I•' which requim summit m u pet conswct,aper,improve,Demolish,interior any surname _
y prlort t ' q tl ap less,Rx,.vhPcnmI to fl g cd t t mens SPP.CIAI,CINCUIT/MISC. _
pxC y that he licensed p personal h provisions ofthe ConlmclorsL La (ChaPter9
W 00 furs e g withSection 7p00)mDMaioa3 ofthe Buenese d fsrnf .' nsC-tel or TEMP.METER OR POLE INST. COMMERCIAL' ,.
d c that he I,exempt thendirrion and the basis for the alleged toecomme Any v olson t of
,^y Sects 7031.5 6 an applicant f _ 11 NEW eLDGIADDITION El DEMOLITION
m y y DP perms bl t me appbe nn the Penalty of POWER DEVICES El TENANT ❑FOODSERVICE
P+ y trot n ro man fve hundred dollars($SIXp
C a0 ❑I fm p petty,mr myemploy -d g e.their sole mpesfon, SWIMMING POOL ELECTRIC IMPROVEMENT
A2
will do che wark.madlh stmemm is rot ime d d r ff df I (Sen.Wyk(Business ❑OTHER
L
and Purifications C I.The Commcmrs Lafroo,Law doe,an applyt prof OUTLETS-SWITCHES-FIXTURES '
.. property who builds or improves moron,and who does such work himself at through - -
his own employees,provided that such Improvements aro at intended or,offered for NEW RESIDENTIAL ELEGTR SQ Ff
'sale.If.however.the building or improvence"s sold within one year ofcompletma,the SQ.FT.FLOOR AREA $/SQ.FT
owner-buridill have the burden of,moung that he did not build orimprove for pur- • - -'
pose f alej
❑ 1,as owner of the pr nearly, exclusively tic IinB with licensed contractors to TOTAL:
-
compact theproject(See,]044 Business and P fes ons Code)f m Contractors L- j X,
se Law docs not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBINGPERMIT FEE
who contracts fill such projects with a cam ctic(s)licensed puraaam(.the Contmemr', ����
License Law. PERMIT ISSUANCE
E] m eMAY'
I axemptuader Sec. R&P C for this reason 1111p�!!A ,
ALTER-DRAIN A,VENT-WATER(EA)
' Owner Dem VACUA ION,
WORKER'S COMPENSATION DECLARATION C/sI
'BACK PLOW PROTECT.DEVICE // I+
1
have
and will affirmundera penalty pejuryomofm-asum following declarations
- Ibaveond will for bynetion 3700 of cons o s
❑ eon self-in.are fur Warkera Cnmpen- DRAINS-F1.00k,ROOF,AREA,GOND.
work(as hick provided for by Section 3)110 of me Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work far and mil pemtit is issued. FIXTURES-PERTRAP `
37 have and will maintain Worker'sodor Compensationceofthw Insurance,h require)by Section
3]00 of the Labor Code,for the performance of m,work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP APN
My Warkpens jpn In trance rand Pnlic numberure: ,
Cartien.(LAT 'i Policy No !L.''t3pJC-eo
GAS-EA.SYSTEM-OVER4(EA)
CERTIFICA OFFXF.MVI'[ON FR WORKERS' '
COMPENSATION INSURANCE- GREASPONDUSTRE,WAS'IT INTERCEPTOR
(Thissection need not be,omplm,d lfthe pemtit is(arca hundred debars($100) BUILDING OPINION FEES
an le".) - GREASE.TRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,I shop SEWER-SANITARY-S'FORM EA.2fq PT
trot employ any person in any manner so as m became subject m mo Workem'Cnmpen- ENERGY PEE
,7sNation Laws of Celifornin.Date
OO7 Applicant WATER HEATER WNENDELECTR, GRADING PBF
Gy NOTICE TO APPLICANT.If,after making this Cenificam of Exemption,you should WATER SYSTEMRREAI'ING
abecome subject to the Worker's Compensation provisions of the Labor Code,you must - SOILS FEE ,
W fonhwith comply with such provisions or this permit shall be decm,drevokeJ. WATER SERVICE -
O CONSTRUCTION LENDING AGENCY NEW RISIDENTIAL PLMB. SQ:FT. PAID
I hereby affire than there is a construction lending agency for the performancem Dot, Receipt#
LTs F the work for which this Permit is iesued(See 3097,Civ.C.)
O U Lender's Name - TOTAL'
W lender's Address ' 'TO PAL
"Icertity thin lhuve read this application and sem that the ahwc information is BUILDING FEE
V) correct.l agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT' FEE
U 7� building construction,and hereby motorize represeinmives ofthis city to enter upon the SEISMIC FgFEE'
`
above-meranare J Property for inspection purposes. PERMIT ISSUANCE.'.
(We)agree to save,Indemnify and keep harmless Oto City of Cupettine agcinn ELECTRICliahilities,judgmen¢.costs and expenses which may In any way accrue against said CityALTER ORADD TO MECH.inconsequence of the granting ofthis pemtit. PLUMBINAPPLICANT U ERSTANDS AND WILL COMPLY WITH ALL NON�POINT AIR HANDLING UNIT(TO 10,000 CPM)SOURCERF TIONS. MECHANI ".air2AIRHANDLING UNIT(OVER 10,000CFM) CONSTRBX
Signature MAppl)a mumpmr t I Dam EXHAUST HOOD OVMUCTj HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE • -
Wlllth applicammfuture buildingtwcupantemem handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,_Chapter 9,1 2,and the Health and Safety
de -
Cn ,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yea ON. - PAID
VENTILATION FAN(SINGLE RESID) - Dale
Receipt#
Will the upplicaat or fmure building oceupa_nt use cqulpmwi or devices which BOILER-COMP(3HP OR IW,000 BTU)
�mnit hworni us air contaminant,os defined by the Bay Area Air Qual'ny Management TOTAL:
District? -
El Yes ❑No
BOILER-COM P(OVER I BQBf18 BTU)
�
I have Mead the mmrdcus materials re o narrons udder Chapter 6.95 of he Cull- A Ik CONDITIONER -
q ISSUA DATE
fomiegdohha Safety Code,Sections 25505,is25533 an, and25534.1 ondersmnd that ifthe NEW RESIDENTIAL MECH. SQ,FF
building,opnotcurrently have a met
it is myecof a Centipede ofytheoccupxm
of me rcquiremems which man he met prionoissuance ofd C,nifcam MtXcupancy. - ..
Owner or authorized agent Dam TOTAL:
ISSUED BY:
OFFICE