29837 (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 29837
.. BUILDING PROJECT IDENTIFICATION
„ dU11,DINGA�E55: - - � SANI'I'ARV NO. APPLICATION SUBMITTAL DATE
O ER'S NAME: PHO E: ONTRACU R''SINAMEII:sx_ L y A y� IAC NO',- •��
-1 Je y 'A I�j O„ Ire � N/C - CONTROL M
tCHITEC GINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ EJLICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Charter (commencing JOB DESCRIPTION
Oco with SecOon70W)of Divisi,on3oflhe Bu,cineas end Professions Cade, dmyliunseis RESIDENTIAL:
co
i PERMITISSUANCE
ac-
F m full force and a ct. 1�'� Q� ❑SPDWL ❑KITCHEN REMODEL..
�UYU Licens 1's: Llc.#� � � APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
rF=� Date ConlmClmtRllR
P,7m ARCHITECT'S UECL I PANELS ❑MULTI-UNIT []STRUCTURAL
I understand my plaits shall M1e used as puM1lic recdrds EDIFICATION
OzIO UP T0200AMPS 1:1 INTERIOR HIMNEY REPAIR
[. µ] Licensed Prafbssiorel 201-1000AMPS - IMPROVEMENT
!a-{ OWNER-BUILDER DECLARATION ' OVER ItlIM1AMPS ❑BATH REMODEUREPAIR ElDE OLITION
py, 1 herehy mremt that I am exempt from the Conaaion License Law.fbr the -
�j 3F fallowing reason.(Section]0315,Business and Professions Code:Any city or meaty SIGNS ELECTRICAL LI OTHER
Ia.U which requires a permit to construct,alter,improve,demolish,or repair any structure
prior n its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. _
that he is licensed,ursecare the provisions of the Contractors License Law(Clmptar 9
GD (commencing with Section WWII)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
el,�je y that he is exempt therefrom and the Lasso far the alleged exemption.Any ablation of ❑NEW BLDG/ADDITION [_1 DEMOLITION
'y W Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
^sof, not more thin five hundred dollars(SSW). ❑TENANT ❑FOOD SERVICE
F iL6 ❑ 1,as owner of the property.or tlrY emphlyses with wages as their sole compensation, SWIMMING POOL EL[CTRIC ENT -
willdothework,and the structure is net intended or offered for sale(See.7044,Business. - 44",
mT BR
W�" mtd Professions Code:The Cotncka' LicenLaw does not apply to an or o
wnef OUTLETS-,SWITCHES-FIXTURES
�" .. property who builds or improves thereoq se gt d who dons such work himself or through
his own employees,pr..ro l that such Int mems aro oat Intended or offered I'or NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement tv aaldwithin one year efcompletion,the SQ!Ff.FLOOR AREA, 3/SQ.FT�
caner-builder will have the butJen of proving th he did nut build or improve for par- -
poseofsale).
El 1,as owner of the n y con m,w TOTAL:
props y,am exohuivel nn with licensed emm¢tors to + p p f
omstntut the project(Sac.]044,Business trod Profesfare
Code)The Cnmmnor'a Li-
Genre Law doesnm up[ owner of propeny who bui s improves there on.and QTY, PLUMBING PERMIT FEE
whowntrnal,brsuchprojeetswith acomacmr(s)Incensed,oruam to the Commetor's MAY ,
�/ 9
License Law. - PERMIT ISSUANCE - 11111'1 carr 199
❑lam exempt under Sec. ,B PCfnr this rcasnn
Owner Duta 'ALTER-DRAIN&VENT-WATER IRA) VALUATION
I Y Lit-
WORKER'S COMPENSA'T'ION DECLARATION )� OO L�IJk'PI II v
Ihereb [firm undo It f BACK PLOW PROTECT.DEVICE
hereby Penalty ofComent tonco self-insure
for declarations:
❑on,as and will for by Se Certificateio370 of the Lahr Code,for the Worker's Cornier- DRAINS-FLOOR,ROOF.ARBA,CONO. STORIES TYPECONSTRUCTION
workas provided for by Section 3]00 of the Labor Code,for performance of the
work far which this permit is issued FIXTURES-PER TRAP /
❑I have and will maintain Wnrkeh Carer of c w Insurance,h required by Section l (/
37I0of the Labor Ctxle,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4OUTLETS OCC GROUP APN
C Worgqqq ��yy pe�5ytio�n{{�� mace carzierund Pnliey bg�
;- My WeS%=.YJMJa Policy No.:I }�si-�r GAS-EA.SYSTEM-0VER4(EA)
.� CERTIFICATS OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION-PE69
GEN,ectiounced not e_complded ifthe permit is farone hundred dollars n
b
GREASLTRAP
- or less) - PLANCHECK PEE
I certify that in the perfotanvnceufAth ark forwhich lhispermit is i"red,l shall SEWER-SANITARY-STORM EA.200 FI'.
out ample,any parson in any roarer s9y-'m M1ewme suhject ro the Workers'Compen- ENERGY FEE
r ,Z salon Laws of California.Date �" WATER HEATER WNENT/ELECTR
Q Applicant - GRADING FEE
y NOTICE TO APPLICANT>B;after making this Ciabri'me of Exemption,you should WATER SYSTEM/TREAUNG
N ; become subject to the Worker's Comperration powismas of the Labor Code,you must - SOILS FEE
tr forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
6r
CONSTRUCTION LENDING AGENCY - NEW RESIUGNI'IAL PLMN. SQ,FT. PAID
Z" I hereby aBnrtn thanhcro on consumption lending agency for performance of _ Date - Receipt# -
W 0 me work for which the,permit islssuc c.3097,Civ.C.) _ -
O ULender's Name TOTAL:
{il Lender's AJdress TOTAL: -
1 certify thm Dhav ad this application and state ihm the drove information is BUILDING FEE
V) corzem.lagree me y with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
n: - -
U buildinH coflet.and hereby authorize representm representatives of this ally enter upon the SEISMIC FEE
above-mentioned propeny for inspersion purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenlno against ELECTRIC FEB
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER ORADUTOMECH.
in amsequence of the noting of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT G O 10,000 CPM)
SOURCERF 4 IONS. .../// MECHANICAL PEE,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX t
Signai n Applicant/Contractor I Iae EXHAUST HOOD(W/DUCT) ,HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE-�
Will the applecam or fiuude building careptmt store or handle hazardous material HEATING UNIT(TO,100,000 BTU)
as defined by the Copeman Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)° HEATING UNIT(OVER 100,000 BTU)
❑Yes ( a VENTILATION FAN(SINGLE RESIU) PAID
7 -
Will the vpplicnnt or future building occupant use eyulpnient Date Receipt
or devices which'
emit hmmurders air conmmeoants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,600 BTU)
District? "
L]Yes BOILER CONE 100,000 BTI)
, �Nn - '
$
I have read the huwNous materials requirements ruder Chapter-tS.95 of the Call- AIR CONDITIONER ISSUANCE DATE
fomes Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET. d
building does not currently have a tenvnr.that it is my responsibility to notify the occupant
of the appintmnts which must be met pilar to issuance of a Cetidcate of Occupancy. ..
Owner or maborterd agent' Dam TOTAL: ISSUED BY:
OFFICE -•.