29710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPRRMIT PLUMBING-MECHANICAL. �2Y! 1 910
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
O GR'S.AME. PH NE: ,a CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
\RCHI'T CT/ENGINEER: - LIC NO: ADD .SS. E:]
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG -ELECT PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm thin I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 0000)of Divisum3afthe Business and Professions Code,and my license is
WOO y PF,RMITISSUANCE RESIDENTIAL
Ha in full free and effect. .
G U U License Class Lic.# ❑SCOWL ❑KITCHEN REMODEL
yQW Data Contractor APPLIANCES-RESIDENTIAL. ❑AUDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTIUNIT []STRUCTURAL
y 0 N Z 1 understand my plans shall be used as public records MODIFICATION
O z-+� UP10200AMPS ❑INTERIOR L1 CHIMNEY REPAIR
F-a.,F'n] LittnscJ Professional 201-IINX)AMPS - - IMPROVEMENT
S�Y I OWNER-BUILDEk DECLARATION OVER]"AMPS ❑RATH REMODEUREPAIR L1DEMOLITION
IY C 6 I hereby affirm that I am exempt from the Contractors License Law'for the
51�1( 6 U following reason.(Section 0031.5,Muscones and Pnddsa me.Ode:Any city or county SIGNS ELECTRICAL []OTHER
Ir]3 C)(A which on,mres a permit m emone,,alter,improve,demolish,or repair any structure - .
C)F"
prior to its issuance..Iwre,wm,theapplicam for,uch permit to fileesigmedstwemem SPECIAL CIRCUIT/MISC.
that he is licensed poonera o the prokum i f the Contractors License Law(Chapter 9
�pSpO (commencing with Section 7")of Division]ofthe Business and Professions Code)or TEMP,METER OR POLE INST. COMMERCIAL
L 1y cthat he is exempt therefrom and the basis for the alleged memption.Any violation of El NEW BLDG/ADDITION ElDEMOLITION
Xm� Section 903R5 by any applicant En a permit xuhje,srom applicant,..civil penalty of POWER DEVICES
W ]TENANT 0FOOD SERVICE
not mom,ham five hundred dollars(5500):fS� IMPROVEMENT C1SWIMMING POOL ELECTRIC
Lu oxner rf the ryopeny.or my employees with wages ac their sole compensation.
F
will do work,and the structure is not intended or offered forvle(SaJBt4,Business ❑OTHER
W 3 m and Prnfe....us Code:The Convenors License Law does no,apply m an owner of OUTLETS-SWITCHES-FIXTURES
4' ..
property who builds or improves thereon,and who does such work himsell'or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT. -
side,If,however,the building or improvement is.sold within one yew ofcompletion.the Sivo.Irr.F'LOOR AREA t $/SQ.FT.
owner-builder will have the burden of pmving that he did not build or improve for For. LI V
paw
❑I,act the project o (Sm.70 Busine s andal,contracting Codc:)TheeC rntr rnrs m Z ���
ave Lz the esro (Sm.]044,Business and Professions d%ori The Convenor',Li- Q
cea¢Inwd«ansuch plytozn ithacofprctorty who
mmedJsorimpto the thereon.and QTY. PLUMBING PERMIT FEE Flo 96
who cummns for such project withaconvanrr(s7licenscd pursuant.the Commnor's /x
License Law. - PERMIT ISSUANCE �� co r Ut-
❑I am exempt under See. B B P C far this mason L'U1-Cfy a IIYU
Owner Tom
ALTER-DRAINA,VENT-WATER( ) ` VALUATION
WORKER S COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE.
I foroday offirmud Initially fie eof y fthe elt-inlh hollowing P r,iom: e N _
❑Lhave ard will maintainSerum 37W oft n:enll . lf-in,u f N k sComf the .DRAINS-FLOOR,ROOF,AREA,COND X�
cation,as provided for by Senior l]W of the lutbor Code,for the performance of the STORIES TYI'Li CONSTRUCTION
work for which this percent is issued. FIXTURES-PER TRAP
❑,I have and will maintain Workers Compensation Insurance,as required by Section
391N1 o1'the Labor Code,forte performance of work for which this permit is is,sam. GAS-IIA.Sys HN-I INC.4 OUTLBTS OCC CROUP APE
My Workers Compensation Insurance carrier and Policy nomher arc:
Cartier. Policy N., GAS-IA.SYSTEMOVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE GREASEANDUSTRL WASTE IN1 ERCEPTOR
HIJILDING DT VI. ONn aS
Tons section need not be completed if the permit is for one hundred dollars 1$IW) GREASETRAP
or less.) PLANCHECK FEE
I certify that in she performance mfam work forwhich this permit is issued,l shall SEWER-SANITARY-STORM HA.200 FT.
not employ any person in any manner so as to become subject m the Worker'Compen- [HERON FEE
z ,Z sn,ion Laws of Calilinnia.Date WA'1 17R HEATER WNENT/ELECTR
Q Applicam GkADING FEE
co NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTESI TREATING
become subjmt to the Worker's Compensation previsions of the Latest Calc,you must RCONSTRUMION
r+ forthwith comply with such provisions or this permit shall her deemed revoked. WATER SERVICE
R Q
CONhem isaDONLENULNGAGBNCY NEW RESIDENTIAL PLMB. SQ.IT. jFEE
V O we Rcccipt#
I hereby affirm thathem is s ed(See on lending agency for the performance of
r
,tin wink for which this prmdt is issued ISec.3092 Civ.CJ
� F Lender's Name TOTAL:
Lundw',Adders, - 101AL.
1 certify thin I have read this application and ,are,ham the above information is - FEE
G Tail cancer.)agree to comply with an city and county ordinances and state laws relating,. QTY. MECHANICAL PERMIT
(� Z, building construction,andhembyauthorize represemativesofthis city menterupun the EE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC 1.
(We)ogfee mm.uvc,indemnify and keep bdmles the City of Calwnino again,, PH
liabilities,judgments,co,tsand expense,which ntoy many waymrmeagaw,I,wd City ALTER OR ADD'TO MECH.
in ecomi uamce of the g.do,of this permit. FEE
APPLICANT( ERSTANDS-AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111(100 CFM) AL
SOURCERE I ATIONS
(f 0� � AIR IIANULING UNIT(OVEN IQUW CF41) ION 'AX
SignatursafaidspWarwConatimpor Date EXHAUST HOOD(W/DUCD HOUSING MITIG ION ME -
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant store or handle hwadous ma¢rial HEATING UNIT(101!X1000 BT U)
as defined by the Cupertino Munn,lial Cale.Chapter 9.12 mind the Health and Safety
Coda Section 25532(x)? _ HEATING UNIT(OVER 100,000 BTU)
❑Yes F1 No VENTILATION PAN(SINGLE RESID) PAID
Will thea applicant or future building cu t use n tri r or devices which Date Receip
pp goc pun 1 Amen
emit hamrdnus air contaminants as def neJ by the Buy Arca Air Quality Management BOILER-COMP(3HP OR HI0.0m)BTU) - TOR
District? BOILER-COMP(OVER HiLocto BTU)
C]Yes C]No
I have read the hazardous materials requirements under Chapter 6,95 of the Cali AIR CONDITIONER ISSUANCE DATE
forma Ileahh An Safety Cede,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL.MECH. SQ.ET.
building does no,currently have;mount.that it is my espnnsibility to notify the occupant
.f the regaim.which must he met prior on ismanre of a Cmificum of Occupancy.
Owner in,mahaizcd agent Doc TOI AL: ISSUED BY.,
OFFICE