29499 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYLOF CUPERTINO BUILDING-ELECTRICAL=1OLN PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICA29499
PROJECT{DN;NT11;FICAI
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW R'S N E: PONE:
N/C C N tlLa
A FECI'/ENGINF.ER: LIC NO: A DRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL� MECIL
LICENSED CO.TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
hereby affirm tie 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CMZ with Scction]INKBafDivisinn3 oft.Buxiness and Professions Cade,and mylicensc iz RESIDENTIAL:
WOOfull force and e1Bn HERMIT ISSUANCE
5UU rn � ❑SFDWL [I KITCHEN REMODEL
Q U U Liansc ass Lic.#
y G 1 Dam Contactor APPLIANCES—RESIDENTIAL ❑ADDITION - ❑PLUMBING R[PIPE
ARCHITECTS DECLARATIONElMULTI-UNIT ❑STRUCTURAL
PANELS
ZpyZ [understand myplicro hall beuwil.,,ublie records HUP TO 2W AMPS MODIFICATION
CZ—
11 INTERIOR ❑CHIMNEY REPAIR
Licensed PI :: ul - 2111-I000AMPS. IMPROVEMENT '
ad E,'4j - OWNER BUILDER ULC[ARAI'[ON OVER I000AMPS ❑BATH REMIODEUR
yqxWtil LL QF I he by alTirm thvt I am exempt G m th C tmemvs Lienze Lvw for the
,
PAIR DEMOL43 TI N
A. fullo tog teaser.(Sec ]315 Ensnare,and Prof::inn,Care:Any ryorcouny
which requires a permito construct,alma improve,Demolish,or report any structurem
; prior to its isvatchi also regains to applicant for permit to file a ugmed zmmmeht SPECIAL CIRCUIT/MISC.
} Nr
at he is licensed puuentto the provisions of the Contractors License law(Chapter9
W L'p0 (commencing wit Section of Division 3 ofthe Business and Professions Code) TEMP.METER OR POLE INST COMMERCIAL:
a a e% that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X It. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT OFOODSERVICE
F=6 no t more ton Eve hundred dollars($500). IMPROVEMENT
(]I,as owner ofthe property ormy employes with wages as their sole compensation, SWIMMING POOL ELECTRIC
EFO will do the work,and the structure is not intended or offered for sale(See70,W,Business ❑OTHER
and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
0. property whooyeas,nr provided
that
u and who dies such ware M1ied or oared for
his own employeese provided tat such mens old w are or Intended or offered far NEW RESIDENTIAL EL[CTR SQ F1'.
own H,however.thb...he
itathadali noneycafofcompla forte - SQ. 'L( RAA: $/SQ.PT.
eof,mr a will M1ave rhe burden nfproving that he did nor huild or improve for par-
C]1 of sated.
❑Lon owner it the property,am exclusively contracting with licensed Contractor,
i TOTAL: AUG 18
�[Rt1I1
<amwct to project(Sec.]041,Business and Professions Cade:)The Contractor's Li- MV HL{J u `
remse law does out apply to an owner cepropeny who builds or improves thereon.anti QI'Y. PLUMBING PERMIT FEE
whucontmcu for such projects with a commands)Iiccusecipumentrulo the Conuacmrs CITY ur uurrnfiNU
License law. PERMIT ISSUANCE
I am exempt under Stt. .B d P e for tis reason r.
OwnerDae AITF.R—DRAIN&VENT—WATER(EAI VALUATION i
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following Jedaretions
❑[have and will maintain aCenificate of Consent to sdfafnxurc tar Workers Conrpch- DRAINS—FLOOR,ROOF,AREA,COt STORIES TYPECONS'I HOC[ON
action,as pnsvldod for by Scction 3700 of the Labor Galc..for the performance of the
w. kfar wblchthis,madisk-ad. IIXIUR17S—PER TRAP
1 a and will nciame.Worker's Compcnsmibn Insunnur,us no,ired by Scction
3nX)oft�e Ls�b�oryr CCp99ode,forthe peyyrfuwmymonse aftc work for which thispermit is issued. GAS—EA.SYSTEM-1 INC.4 UUTLE'S ss OCC.GROUP APN
My Polic
Cum rrG%/JE//!)•as.�J'1`sufi licy No.Y r.
GAS—EA.SYSTEM-OVER 4(EA)
CER F1�-- CAT"fT�E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
is...rich need not be completed rm
if the peit is fee..hundred dollars GREASETRAP
or lay.)([TPLANCHIiCK FEE
I cenifydid in the performance ofte work far which this peat;,is issued,l shall SEWER—SANITARY—STORM FT.200 FIL
not employ any .in any manner was to bcemne subject to to Workers Cnmpcn- ENERGY FEE '
ZZ suction Lawsof California.Data WATER HEATER WNENT/ELECTR
ApplicantGRADING PER.
ti
h NOTICE TO APPLICANT If,after making s Crmfiarc of Exemption,you khoulJ WAI FR SYSTEMITREATING
a ; Frannie uAna,t to he Workers Cimi,nenion po,,kians of the Labor Cosi, on most SOILS FEE
0. Q farthwith<otnPly with such pravizianz or thix lwnnit ahiJl he deemed revoked. WATER SERVICE
U
z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID Ila¢ Rcceip,#
U 0 work
reby which rte that theremm
isaco (Site 097.Ci,agency for the pe0'ormance of
the work for which this permit is issued(Sec.J09],Cfv.CJ
� F" Lcndcr's Name TOTAL:
V Lenders Address TOTAL:
1 certify tat 1 have read this application and store tat the above information is BUILDING Elio
correct.I agree to comply with all city and county ordinances and some laws relining to QTY. MECHANICAL PERMIT FEE
IJ Z building construction,and hereby imhorice re,pasenmtives of this city to enter upon to SEISMIC FEE
abovomemi...d p,.,eny for inspe.rion purposes. PERMIT ISSUANCE.
(We)agree to stoe,indemnify and keep harmless the City of Cupenum against ELECTRIC FEE
Iiahilincs,judgments.costs and expenses which may in any way aceme against said City ALTEROR ADDTO MECH.
asequence of to granting of this pcnnit. PLUMBING FEEAPin PLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)ChM) MIiCHANICAhI EE
SOURCF.REGULATIONS
AIR HANDLING UNIT(OVER CUNNI CPM) r CONSTRUCTION'1'AX
Signumre of4l'ienikIRAttmcar Data EXHAUST HOOD(W/DUCI) HOUSING MITIGATION FEF.
!A DO US MATERIALS DISCLOSURE
Wllteapplican turehuilding¢e....1etore ser handle hazardous material DENTING UNIT(TO UXI"BT UI
as defined by the Cupertino. nwipal ContChapter 9.12,and the Health and Safety -
Cents,Seetion255321a)? HEATING UNIT(OVER 100.001)BTU)
E3 Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Data Receipla
Wit]the applicant or future building ecupant use equipment m devices which
emit hazardous air conuminams as defined by the Bay Area Air Quality Management BOILER—COMP OHP OR 100,00)BTU) TOTAL:
District' ]TOILER—COMP(OVER 1 W,)(y0111'U)
F7 Via, 0 N
'I have read to huaadnus ocamm],.'annanneal,under Chu ter bus of the Cali- AIR CONDITIONER ISSUANCE DATE
famlu Healthan Safety t 25505.25133 and 255341 understand that it
NEW RESIDEMIAL MECH. SQ (T.
building does not currently hae.teren,tut it is my rcxpnsihilry,o notify theeupm
oto rcymarm o,which
must be .prior to issuhnee ofa Caniheh otOe ,pane
(1 am TOTAL: . ISSUED BY:
OFFICE