29262 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILMNC-ELECTRICAL - PERMITNO. ^tea
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL L JV 262
BUILDING PROJECT IDENTIFICATION
BUILDINNGAADDRESS: e - - SANITARY NO. APPLICATION SUBMITTAL DATE
O NEWS NAME: PHONE: CONTRACTOR'S NAME N I�� ✓.
• / /dJ� r
61110
N/C CONTROL is
.RCHITECfENGINEER: IJC NO: ADDRESS: ❑
-7. . S / /t/A vx 57w
CONTACT: PHONE: BUILDING PERMIT INFO
.❑ Consultant Fees Paid by Applicant(Initial) L .LF PLUMB MECH
E E/i2�0 ❑. ❑
LICENSED CONTRACTOR'S DE .ARATION QTY. ELECTRIC PERMIT - FEE
1 hereby affirm Jut 1 am licensed under previsions of Charlie,9 homemencing2.
JD DESCRIPTION
W0Z with Section 7")ofDivision 3 ofthe Business and Profeuions Code,and an,license is RESIDENTIAL:
1-Eli= infullimseandcffe... PERMIT ISSUANCE ❑gFDWI. Ll KITCHEN REMODEL,
License Class lick
W Dam Contractor ❑
APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPIT
F.� ARCHITECTS DECLARATION El MULTI-UNIT []STRUCTURALZo`�Z lunderttand nnyplansshall beusedare
spublic cords PANELS MODIFICATION
OZ^Q - UI"102(ItIAMPS
1-�E'W Licensed Professional \ ❑IR C1 CHIMNEY REPAIR
cq Sd 2; OWNER-BUILDER DECLARATION 201-1000 AMPS ' IMPROVEMENT
C Q I hereby affirm that 1 am exempt form the Contractors License Law for the OVER IOOO AMPS ❑BATH REM EUREPAI3.0 DEMOLITION
W
3 y rJ following reason,(Section]1D L5,Raciness and Prrfassinns Ctde:Any city or county SIGNS ELECTRICAL. ❑OTHER
N which requires a permit to construct,alter.improve,demolish,or repair any.structure
� primto it,vioaace,alwrequires the applicant forsoch permit to filoasignedsmmmem SPECIAL CIRCUITMISC.
E y that he is IicensW pursuant to Ne proviaions of the Contractors License law(Chapter 9 L
W�•�0 (commencing with Section 700X0)of Division 3 ofthe Business and Professions Code) TBMP.MEfER OR POLE INST. COMMERCIAL:
6 d cf�C that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W—N Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not mom than five hundred dollars(SSW). IMPROVEMENT
F?Q ❑I,mowneref the properly,or my employees wird wages as theirsolccompensation. SWIMMING POOL ELECTRIC
$y� � will du the work,and the structure is not intended or offered for sale(Sec.7M.,Business DOTTER
w^m and Probes ions Code:The Contractors License Law docs not apply m an owner of OUTLETS-SWITCHES-f-IX"1 t13S' 11 '
d 3^ prIlieny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDEM1TIAL ELE SQ FT.
sale.If,however the building of improvement is sold within one year ofcompletirn.the SQ.PC FLOOR AREA LSQ.FT.
' er-hullderwill have the hurdmtofproving that hedid not build orimprovefor put-
Imo of sale.).
❑ 1,as owner of the properly,am exclusively contracting with licensed contractors to T
construct he project(Sec.7000,Business and Professions Cade:)The Contractors Li-
cense Law does not apply manownetef properly who NOW,m impnrvca thereon,and QTY PLUMBING FEE _
who metates forsoch ptyec,s with a commeogx)licensed pursuant to the Contractors I
,
License Law. PERMIT ISSUANCE '
❑ 1 am exempt under Sec. .B&P C for this reamn
Owner - - Otte ALTER-DRAIN&VENT-WATER(FA) tttt1,, VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affna under peway of perjury one of the following declarations
.�e""_,
l have and will maintain a Certificate of Consent to self-insure for Workers Contain- DRAINS-FLUOR,ROOF.AREA.GOND. STORIES TYPE.CONSTRUCTION
ton s LW for bySection3]00 tthe l br Cd forthper ,of the IE O
is h ht his Permit'. '.: d FIXTURES PER*1'RAI' ,
1 ha d will maintainWorkers C mpe f Insurance, required by Section
700 rfthLabor Core.for the Performance of the workfor which this permit is issued. GAS EA SYSTEM-]INC.4(A TLETS ) l APN
MyWorker's Comp,araction Insurance carrier and Policy be 1 6
Cartier 2�-P n4C/G TND%UE Polley Nq', GAS EA.SYSTEM OVER 4(EA) V
C17RTIFICATE OF EXEMPTION FROM WORKERS' - ls1Yv. -
COMPENSATION INSURANCE GREASIANDUSTRL WASTE INTERCEPTOR .-., ,
-flUICDING DNISIONIFIiES
(This section read not M1e completed,Trio Permit ixfrnnm hundred dollars($100) GREASETRAP
or bra.) PLANCHECK FEE
Loy aythaticethe any mormce rof he stolocomewhichthis peen,,isisxued, "n- SEWER-SANITARY-STORM EA.200T.
not employ any person in any mmmcr so as m become suhject to the workers'Compcn- ENERGY FEB
,Z Iass o(Califomia.Dae WATER HEATER WNENT/ELECTR
Z � A,Applicicant GRADING FEE -
G NOTICE TO APPLICANT.If,after making this Ceniticme of.Exemption,you should WATER SYSTEMOREATING '
? bacon subject to the Worker's Compensation pmvim is of the Labor Code,you ra.o SOILS FEE
forthwith comply with such prmisions or this permit shall ba deemed revoked. WATER SERVICE
Q
.ar7. z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FC PAID
V Q �• E far
nn thauherc isacomvuctionlending.agency for the pert�mtanee rf D mtp
W F Leaders Name
for which this permit is issued(Sec.31Y)],Civ.C.1
0 U Lender's Name TOTAL:
W Isnd<r'I Addmsr TOTAL:
I certify that 1 have real this application and store that the above information is BUILDING FEE
corr«'r 1 agrees m rnmply with all dty and county nrdlnnnces and awm laws miming nt QTY. MECHANICAL PERMIT FEF,
V Z building construction,and hereby authodzem,ar,imativesof this city to Imerupm the SEISMIC FEE
aheve-mentioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamless the City of Cupirino against ELECTRIC IEESTW
liabilities,judgments,costs and expenses which may in any way ademeugerst said City ALTER OR ADD TO M ECIL
in asequence of the ,an,ing of this permit. ' PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT to."CFM)
SOURCE LADONS. MECHANIC . 'E
AIR HANDLING UNIT(OVER 10.000 CFM)
__.:`��� .— CONSTRUC IONTA
Signau o Applicant/Crntmdor ale 13XHAUST HOOD(W/DUCT) HOUSING MITIGATE) FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rccupantstom or handle hazardous material HEATING UNIT(TO I W.Wl BTU)
as defined by the Copal..Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532piP' - I EATING UNIT(OVER 100,000 BI U)
E]Yes Fl No ' VENTILATION FAN(SINGLE RESID) PAID
Will thea licam ur fuwre buildin t use e t nr devices which Date Rt eipt R
pp dh, he
.Air n BOILER-COMP(3HP OR W."BTU)mit hmallous air conmminanF are deGncA by thrBuy Arca Air Quality Mamgcnsnt 'OTAh:
District( .BOILER-COME(OVER 100,00)BTU)
(]yes ❑No
I have read the hmardons materials requirememn under Chapter 695 of the Cali- AIR CONDITIONER ISSU
fomia Health&Safety Code,Sections 255115.25533 and 25534.1 understand that if the NEW RESIDENTIAL MEi01L SQ.FT.
building docs not etinently have a Rnaol,that it is my rcsrym.ihility to notify the aecupant
of the re li iremenu which man be ran Int issaaac ern Certlficom of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE