29132 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29132_
-
BUILDING PROJFET IDENTIFICATI
BUILDING ADDRESS: - - SANITARY NO, APPLICATION SUBMITTAL DATE
o446 -,S, EYHp IN
OWNSNAME: PH F CONTRACT() E: n �,I�NO', NIC ROLA
L aAI "-E
\RCHI TECTA NGINEER: LIr NO, ADDRESS:I \ � El PHONE: If BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)' Bur ELECq PLUM MEC
[•/ LICENSED CONTRACOYR S DECLARATION TY ELECTRIC PERMIT FEE
1 hereby nffinn that I am lic,reed under pnrvisiom of Chapter 9(commer¢ing JOB DESCRIPTION
FOUZZ LicensecClass O(kO of Uivision9 ol,heLusincea rand lknfcssians Code.nnJ my licenso is RESIDENTIAL
C
0— infill fame and effect. PERMIT ISSUANCE - 0SFDWL "
F W0 KITCHEN REMODEL
a
N6R IAne Contractor APPLIANCES-RESIDF.NTIAh ❑ADDITION ❑PLUMBING HE PIPE
,•]q ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z Oy�• 1 understand my plans shall heated m public means MODIFICATION
OZ 40 UPTO 200 AMPS [2 INTERIOR C1 CHIMNEY REPAIR
,44 :W Licensed Professional 301-Ilgk)AMPS IMPROVEMENT4yE OWNER-BUILDER DECLARATION
rty�-1'PG I hereby afOmt that 1 inn exempt from the Contractor's License Low far the OVER 1000AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
X 3 U following reason.(Section 1031.5,Business and Professions Code:Any city orcoomy SIGNI ELECTRICAL LJ OTHER
aJ O which requires o permit to construct,aline improve,demolish,or repair any structure
priana its lsemmca,alsn requires tue applicant fmxnch permitm filaa signedamtemem SPECI AL CI RCUIT/M ISC. _
ythin he is licensed pursuant ns the provisions;of the Contractor's License taw(Chapter 9
a0�q APR 2
(commencingwith Section]000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INSF COMMERCIAL
F o LL that he is exempt therefrom and the basis for the alleged cscmption.Any violmion of ellL O NEW BLDG/ADDITION ❑DEMOLITION
-,4• Section]031.3 by any applicant far a permit subjecu the applicant to a civil penalty of POWER DEVICES Vr ijue`H Iry OTENANT' C1 FOOD SERVICE
not mom than five hundred dollar(SSW).
OO 1,as owner ofihe property,or my employees with wageeas their wile compensation, SWIMMINGIOOLFLECfRIC IMPROVEMENT
will do the work,wtl the sentare is not intended or offered Tarsale(Sec.]044,Ilusiness 0 OTHER
and Professions Cade:The ContraLicense law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
�"3 cmrs property who but 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 I iSIDP 9'IAL 17LEMR SQ FI',
sale.If,howevcn the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA S/SQ.rE
owner will have the burden of proving that he did not build or improve for put- 1),,Zpose of sale.). 'f
0 1,as owner of the profamy,ant exclusively contracting with licensed contractors to _ TOTAL: !�
construct the project(Sec.7144,Business and Professions Code:)The Contractor's Li-
rams,Law does not apply to anowner of pmpeny who buildsor improves th,asouand QTY PLukv PERMIT FEE
who contracts for such projeOs with aco ancon fs)licensed pursuant to the Contractofs _If
License law. PF.NMI'I'IS
I am exempt under Sea B&I'C formisrea,an
Owner Date ALTIiR-DRAT T- ATER(FA) VALUATION '•�
WORKER'S COMPENSATION DECLARATION BACK ROMICT y
I hereby affirm under penalty of perjury one ofthe fallowing declarations: `6 3 Z/4x -
❑ I have and will maintain a Certificate ofCons,nt toself-insure for Worker's Compcn- DRAINS OR,ROOF,AR ,COND. STORIES TYPECONSTRUCTION
sation,as provided for by Section 37M of the Lahor Coda,for the performance ofthe
work for which this permit is issued, FIXTURES-P
0 1 have and will rutinmin Worker's Compensation Insurance,as required by Sectirnr
3700 ofthe Labor Code,for the performunce ofthe work for which this permit is issued' GAS-IiA.SYS'I'IiM-11 .40 TLCTS- - OCC.OR APN
My Worke`s inion fns nee r r and Policy name.
CortNa
'GAS- A. (NkNs
CER�OE IINNFROMWORK
COMPENSATION INSURANCE
.V{►(\_
GREASFANDUSTRI.WASTE INTERCEPTOR
or less)
(This section need not be,completed Hine permit is far one hundred dollum(S 100) 3 IL NO DIVISION MES
I'LANCFEE
GREASETRAP O
I verify that in the performance office work for which thispermit is issued,I shall SEWER-SANITARY-STORM EA.2W Ff.
sc
not employ any person in any manner so as m become subject m the Warkerd Campem E E .L
,Z sation laws of California.Data
Z2Applicant WATER HEATER W/VENT/ELECTR GR INGP
Iti to NOTICHTO APPLICANT:If,aper making this Cenificate of Exemption,you should WpTCR SYSTIiM/fREATING
H ; become subject m the Worker's Compensation provisions of the Labor Code,you must SOILS Pf;li
Ws.n foMwi,h comply with such provisions ar this p,mtit shall he deemed revoked. WATER SERVICE
O C(INS9'RUCTIONLENDINGAGL'NCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby umnn,hm,here is uconsfinedon lending agency forth,perfnmmnce of - Data Raeiptp
W n-t the work for which this permit is issued(Sce.3W7,Clv.C.) -
O F Lender's Name TOTAL:
L) Lances Address TOTAL:
4 1 terrify that 1 have read this application and state that the shove information is BUILDING FEE A
n-t N cart agree m comply with all city and county ordiraties and sate laws relating it, QTY. MECHANICAL PERMIT FEE
L) Z building contraction,and herehymalsontt represemativesnf this chym enmrupon the SEISMIC FEE 121 .301
above-nrzntlaned pmpeny for insp etian purposes, PERMIT ISSUANCE
(W,)agree to save,indemnify and keep harmless the City of Cuperino against L ELECTRIC FEE 6D
liabilnies,judgmerds,taut,end opened which may in any way accrue a gain,,said City ALTER OR ADD TO MECH.
in consequence of the gmming of this pemtie PLUMBING FEE D
APPLICANT UNDERSTANDS AND WILL COMPLY WIT ALL NO -POINT AIR IIANDLING UNIT(TO I0.0tst CFM)
SOURCE REGU ONS. MECHANICAL FEE Z 0
AIR HANDLING UNIT(OVER IgaIn CFMI CONSTRUCTIONTAX
Signawm i AppliearWCmma Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOS RF.
Will the upplicunt or future handingoccupant care nr handle hismrdom mmcond I IBA'1'INO ON IT(TO 100.000 BTU)
as defined by,he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VCNI'ILATION FAN(SINGLE ItPSID) Date Receipt4
Will the applicant or future building occupant use equipment which
emit hazardous air contaminants as define)by the.Hoy Amu Air Qualidtyty Management BOILER-COMP(3HP OR 1170,000 BTIE
TOTAL:
District? w
❑Yes Otho BOILER-COMP(OVER 100.000 BTU)
1 have mad the hazardous materials is under Chapter(.95 of the Cali- AIR CONDITIONER
re,MID p ISSUANCE DATE
fnmia[health&Stiery Cale,genions movie,or.,11
2553)and 255)4.1 undersand,het if,he NEW RESIDENTIAL MECH. SQ.ET.
building doesnot currentlyhave aare, thinit isu..a responsibility tonotifythepancy.
of the mquiremens which must be act poor m issuance of a Cenificae of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY: C\'Aliildhs'/gQp�$
OFFICE