29974�APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPENONLY j
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT No. 29974
BUILDING DIVISION APPLICATIONIPERMIT 'PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADD[t - SANITARY NO. APPLICATION SUBMI MAL DATE
'-� 1XXk4U06d �-
OWN AME: PEON CONTRACTOR'S, NAME:� LIC NO:
`Y IVk•JL11'/•, NIC CONTROLp
kRCHITECT/ENGINHER: I-C NO: ADDRESS: ❑
..CONTACT: - PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ X ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT FEE
I herchy a0lfm that I am licensed under provisions mf Chapter 9 mmunencias 'JOB DESCRIPTION
WOZ with 9000)of Division 3 ofthe Business and Profession Code,and my license FWOO-,- wt PERMIT ISSUANCE. RESIDENTIALccc :
F W in full force send affiant.
lLicense Class Lica ❑SFDWf. (D KITCHEN REMODEL
FZWc-u Dat Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FO to ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT (]STRUCTURAL
�Zm Z I understand my plans shall he used as ublic records 1 MODIFICATION
s3q p ! UP TO 200 AMPS. —• El INTERIOR LJ CHIMNEY REPAIR
[-Cod 1=W Licensed Professional 201-1100AMPS IMPROVEMENT
y E; OWNER-BUILDER DECLARATION
wwOVER["AMPS [I BATH RE•MODEI/REPAIR ❑DEMOLITION
w
E:owQ I hereby affirm Nat 1 am ea'mpt from Ne Contractor's License law for Nc
X 3�F following reams.(Section 7031.5,Business and Professions Code:Any Onto,county SIGNS ELECTRICAL. ❑OTHER
y which exams a Permit m conswn,alter,improve,demolish,or repair any structure
y Y.
car primma issuancealso requires the a,licam fia-whpermiuofilaiia,ardstrumnal SPECIAL CIRCUIT/MISC.
¢� y that beis licensed pursuant o the provisions ofthe Contractor's License Law(Chupter9
1+100 (cummencing with Section]000)of Division 3 office Business and Professions Coded or TEMP.METER OR POLE INST. COMMERCIAL'
C.a e that he is exempt therefrom and the Iasis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
XI Section 703 IS by any applicant for a permit subjects One applicanno a civil Penalty of POWER DEVICES , ANT ❑FOOD SERVICE.
F=Qnot mom than five hundred dollars($500). h1PROVEMENT
❑ Lnowner of the property,or my employees with wageswNeir sole compen.mtion. SWIMMING POOL ELECTRIC
' fir will do the work,and the structure is not intended muffored for sale(See.9600.Business ER
and Professions Coale:The Contractor's License Law does not apply to an owner of OUI LETS-SWITCHES_FIXTURES
4'3 property who builds of improves demon,and who docs such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
Me.If,however,the building or improvement is sold within one year ofconpletion,Ne SZ7 SQ.FT.FLOOR AREA $/SQ.Fr.
owner-builder will have the burden of proving Jut he did not build or improve far par- /(l p B
Dx. Lcalc.). •1 jD
f N p openy c I ly t t g th licensed contractors to T
tat{ 'into
nh p l y(S c 9044 Businessunit Purfiessions Cade,)Th Contraclor:Li- �l
senor La does nt apply an ne fpr pony h build. p :N n and QTY. PLUMBING PERMIT FEF. AIN 7whoa tracts for such pro3catswith acommuct Ks)licensed pur. tt the contractor's , 99
LicenseLaw.
I
❑I exempt under See .B&PCfor Nis rcbmn ,ny
PERMIT ISSUANCE yr
O
_
Owner Ilam ALTER-DRAIN&VENT-WATER(EA) 'VALUATION '
WORKER'SCOMI'17NSATIONOHCI,ARATION HACK FLOWPRQI'ECT.DEVICE
_ I hereby affirm under penalty of perjury one of the following declarations:
1�Ihave and will mainiaina Cenifcam oftConsemmfo
mselffnmr Worker's Camper- DRAINS-FLOOR,ROOF.AREA,CONI). CONSTRUCTION
non,as provide)for by Section 3700 of the labor Cale,for the performance of the STORIES TYPE
work for which this permit is vivant MIXTURES-PER TRAP
Fl I have and will muimain Worker's Compeneadon Insurance,n required by Section
3900ofthe Labor Code for she pcifonnanscof the work for which Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Conpcnation Insurance carrier and Policy nomher are:
Cartier: ' Policy No, GAS-EA.Sys'rEMOVP.R 4'(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBISDUSTRh WASTE INTERCEPTOR
BUILDING DIVISION FEES
('lltisxction nceA nmMc�mpleted iftne permit is fortune hundred dollars(5100) GREASETRAP or less.) PLANCI{ELK FEE
Iccnifythm lame perfomuncceffle work for which this permit is issuad.I hall SEWER-SANITARY-STORM EA.210 FT.
not employ nny person in any miner am as in become subject to the Wnrk...C.... cn- 'ENERGY VEE
ZZ avian lawsaf California.Date WATER HEATER WNENT/ELECTR
O Appecaul GRADING FEE
y NOTICE TO APPLICANT.If.after making Nis CeniGcnte of Exemption,you should WATER SYSTEM/TREATING
a ; beenme subject tribe Workefa Cnmpensaeon Provision,of Ne labor Code,you must SOILS FEE
{Ta Northman comply withsuch provisions or this perms shall he teamed revoked. WATER SERVICE
a
CONSTRUCTION LENDINGAGGNCY NIiW RESIDENTIAL I'LMB. SQ,FT. PAID
U � Ihercb Ilirm that Nem is acanx.ciion lending for fnnnance of Data RacxiptM
hereby 6a.)n pct
he work for which his perrNt is issue)(sec.3097,civ.C.).
0 U Lesser',Name TOTAL:
W Isndds AMl.n TOTAL:
F00. 1 certify that 1 have read this application and stem thin the above information is BUILDING MEG
t-s rn cores,1 agree to comply with an city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V ,z building construmina,and hereby authertvc representatives ml'this city roomer upon the SEISMIC FEE
above-mentioned properly for inspection purposes. PERMIT ISSUANCE
(WO)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liebilities.judgmems.coni and expcntts which may in any way accme against sail City ALTER OR ADDTO MECH.
in consequence of the granting of this parent. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY,WITH ALL NON-POINT AIR HANDLING UNIT(TO IO."CFM) MECHANICALEEG
SOURCE REGULATIONS.. '
AIR HANDLING UNI T(OVER 10,M)CFM) CONSTRUCTION TAX
Signature mApplicanVConvacror Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will One applicant or fumm building occupant store or handle Wandous material HEATING UNIT(10 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health uad Safety
Code,Section 25532(x)1 HEATING UNIT(OVER I00,(00 BTU)
Yes El No
VBN'1'1LATION IAN(SINGLE RES ID) MAID Date RecciptW
Will Ne applicant or four.building Occup nt axe eyraponew or devices which
mit haysrdous air conuminams us defined by the Bay A.Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
TOTAL:
District^
L]Yes C]No BOILER-COMP(EVER 100.010 BTU)
I have rend the neawdmu'material,icter is under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomde Health&Safety Cada,Sermons 25505.25533 and 25534.1 to understand that if the NI?W RESIDENTIAL,MECH. SQ.FT
building does mutts which have a,anent.win it no sof. bilitymnotify the amay.
of Jur tryuirements which most be met pdnr to issmnce ofa Cenificwe of Occupancy.
Owner or malmneed agent Date TOTAL ISSUED BY:
OFFICE