29809 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING•DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n Q,O
BUILDING PROJECT IDENTIFICATION L o J(];
BUILDINGADDRESS: - '" 'SANITARY NO. �APPLICATI NSUBMTTTALDATE
PHONE: COACCTO;'L NAME: ^ L.. IC NO: NIC CONTROL#,
ARCHITE R� l i✓�S'J�V1LIC Cr0.�� ADDRGSSCi G- 'V Yxi O .0,8���, .
tDNrgw - pxorvE: BUILDING PERMIT INFO
❑ Consultant Fee.Paid by Applicant(Initial) BLDG •. ELECT PLUMB MECH
' LICENSED CONTRACTOR'S DECLARATION of ION g QTY. ELECTRIC PERMIT FEE
QWzI hereby )of that I n3 f hesed
ander provisions of,Code. 9 my licencing JOB DESCRIPTION'v
, 00 with Section and
Division the Business and Professions Code.and my license is RESIDENTIAL:
�F in full force and effect. PERMIT ISSUANCE fie_
�UZV License Class - Lic.# q�FOWL ❑KITCHEN REMODEL
FQW Date "' Contractor' APPLIANCES-RESIDENTIALnriADDITION ❑PLUMBING RE-PIPE
ZO�y ARCHITECT'S DECLARATION PANELS _ []MULTI-UNIT ❑STRUCTURAL ,
V177 1 understand my plans shall tie used as public recoNs MODIFICATION
OZ p Up T020AMPS El INTERIOR ❑CHIMNEY REPAIR
(msstr1. u1 l.mensed Professsnnal 201-IOfM)AMPS IMPROVEMENT
X11 Oat I am exempt
from
DECLARATION
�d[p.qq 1 hereby affirm that 1 am exempt from the Commcmr's License Law far the OVER Iq0 AMPS
Q F1 BATH REMODEUREPAIR [3 DEMOLITION
?p5, d U following reason.(Section 7031.5,Business end Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which o trc ape t to construct, h "mpm a demolish, repairany structure" q .
an pria"m Bs issuance,also mquirelds,applicant lhp rmmto file "g edetatomem' SPECIAL CIRCUITIMISC.
p. that he licensed pursue tt the pon fth Commences L L (Chapter A -
00 (commencingwlth Set 7") fDv " 3 fWe Business dP f Coss)or TEMP.METER OR POLE INST. COMMERCIAL•`N
p, eC that he is exempt therefrom and the ossas for the alleged exempt un.Any violation of NEWJJ31 U (ADDITION. _ ❑DEMOLITION
Section 7031.5 by any applicant for a permit suhjects the applicant m a civil penalty of POWER DEVICES -0 TEIANR(� �� EIFOODSERVICE
`yyy t roam than five handreA dollars($500).' 1
LYG{-1' Q I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC pLNPROVEMENT ` C
will do the work,and the swctumra not intended or offered a(Se44,c 90Business [:1 OTHER
{1
and Professions Code:The Contractors License Luo doess not eat apply owner of OUTLLTIS-SWITCHES-FIXTURES s 4tUNr.
property who builds or improves thereon,end does such work himself or through pY V
his own employees,provided that such improvemvent ents nre not intended i offered for NEW RESIDENTIAL ELECTR SQ Ff.
sale.If,power will have thing o burden
mpf Flown n ithat hewithin,Solidne or ampr pie for the SQ.FT.FLOOR AREA $ISQ.PL,
..eer-builder will have the M1urden of proving that he did not tiuild or improve for Por- 7-2-0C)�� ,
W fsaleJ. c b
h sowner Ohhe property,am exclusively contracting with licensed contractors to •"' %�'
swat the project(Sec.7044,Business and Prium"mr,CWO:)Tom Coatimemr's Li112-0
-
censeLawdoesnotapplytoanownerofpropertywhobuildsorimprovesthereomand QT-Y. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
•v ❑lemexemp n ,B&PCfanhis reesan It PERMIT ISSUA CE
ALTER-DRA & WATER(RAO
Owner Dote VALUATION
MPENSAI'IONDECLARATION BACK FLOWP DEVICE
here affirm and penalty of perjury one,oFlre following declarations:
❑�l have endwill maintain eCenificate of Consentm self-insure forWorker's Compen- D
RAINS-FLO ,ROOrARWCbND STORIES TYPE CONSTRUCTION
station,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PERT
I]I have and will maintain Worker's Compensation Insurance,as required by Section
3900 of the Labor Cale.fonhe performance of the work for which this permit is issued. GASSTE C4'OUTLET OCC.GROUP ARK
My Worker's Compensation Insurance carrier and Policy number are: ,.
Cartier: Policy N.: GAS- YSTEM-OVE 4( )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ' GRASEIINDU. RI.WASTE INTER R
(This section need not ba completed l f the permit is for can hundred dollars($100)' BU N DIVISION FEES
- or lciJ GRBASETR PLANCHECKF �• . "
I certify that in the performance of line work for which this permit is issued,Ishall SEWER-SA41k TORM EA. WPI'.,
not employ any person in any manner so as m become subject to the Workers Copper- ENERGY FEE
sation Laws of California.Date
y�OApplicant WATER HEATER WNR GRADING PE
F7 V1 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTCM/fREAT G
become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
aQ forthwith comply with such provisions or this peoutshall be deemed revoked. WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. - SQ.IT. PAID
U O IherebynlE rldrauhere isaconsauelion lending agency buthaperfmmance of I Date Receipt Or
w E~ the work for which this penial is issued(Sec.3097,Civ.C.)
0-U Lender's Name'? - - ,..TOTAL: '
Lkl Lender's Address-
n, 1 certify that 1 have read this application and state that the above information is - BUILDING FEE
U N rr"
correctm or
.1 agree comply with all city and county ordinances ad state Iaws relating m QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize rcprcsentatives Of this city to enter upon the SEISMIC FEE O
obove•memioned property far inspection purposes.
(Wed agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
' liabilitiee,judgmen¢,costs and expenses which muy in any way accme againaLsaiJ City ALTER ORADDTO MECH.
asequence of the gr ting of thio permit. PLUMBING FEE �'�✓•
• APPLICANT UNDERSTANDS AND WTLL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
- AIR HANDLING UNIT(OVER 10,000 CFM). CONSTRUCTION TAX
Signatu9e of Applicnnt/Cmareator Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
is defined by the Cupertino Municipal Code,Chopper 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 110,000 BTU)
❑Yes E]No VENTILATION PAN(SINGLE RESID) PAID
Will thea applicant or future building Data Receipt# ,
PD gby the
use Air
Management
ant BOILER-COMP(3HP OR 100,000 BTU
emit hazardous air mnmminnms os defined by the Boy Area Air Quality Menagcment )
District? v TOTAL:
❑Yes 7 N - BOILER-COMP(OVER IW.000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DATE'
fomia Health&Safety Cale,e a Lena 25505,25533 end 25534.1 understand Nat if the NEW RESIDENTIAL MECH.•, SQ.Fr. " �s•�
building requesnotcs whichrrently must
Is, net t.pthat it ioroismyes,of aibility in cateofCthe Occupant #►rye'//7
i of the requirements which must he met prior issuance of a Certificate of Occupancy.
Ownermauthorized agent - Date ISSUED BY: Sill
OFFICE