29764APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMTTNO. 2 9l6J4 / ^ /1
L I
BUILDING ADDRESS: D A
s AID C 'if
SANITARY NO.
�U11
APPLICATION 1
�Iy1L DATE
OWNER'S NAME: PHONES
� RG
atol'ee. -ave
C NT C R' NAME', / LIC NO:
G�
NIC
❑
CONTROL#
-
r LICNO:
Ir kW
ADDRESS: //Vn rxp 4
CONTACT. .PHONE:
❑ Consultant Pees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ EJ
uceNSTD coNTRACTORs
I hereby mBrm that Ism licensed under previsions of Chapter 9 (cocin
mmeng
wt th Section 7fg E fDivision 3ufthe Bnsinessond Professions Cede, andmylicroseis
n full farce and offer
License Class Lic. #
1 Dam Camtmaor gyy{k
ARCHITECTS DECLARATION
Iundersmnd my plans shall be nsW as public records
1
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
E SFDWL E KITCHEN REMODEL
,.
EADDITION ❑ PLUMBING RE -PIPE
❑STRUCTURAL.
MODIFICATION
El INTERIOR GCHIMNEY REPAIR
IMPROVEMENT
E BATH REMODE EPAIR O DEMO(tI I N
1� ('
E OTHER
PERMIT' ISSUANCE
-
APPLIANCP,S-RESIDENTIAL
PANELS -❑MULTI-0NIT
UPTO2Q0AMPS
1 Licensed Professional
1{ Oat I ma eU rum from
m the Com arc x �'
1 hereby oftlrm that l am exempt from the Comrvmnls License Law for the
following reason. (Section 7031.5, Business and Professions Codi Any city orcounty
pve, desh, nr repair any structure
i which requires i permit to consite, struct, sl'Imromoli
1 ptlono hs issuance, also reyuires,he npplicam for e,mh pmtnluo filen signet statement
that he is licensed panmanito the pnwisiomid'he Comentorm License Low (Cheprcr9
(commencing with Section 9000)of Division 3 ofthe Business and Professions Code)or
$ that be is exempt therefrom and the basis for the alleged exemption. Anyviolation of
Section 7031.5 by any applicant fora pmndt subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
E1, as owner ofthe property, or my employees with wages as their sole compensation,
will Jo the work, and the swcere Is oet imendivl oreffered for sale (Sec 904, Business
i and Professions Code: The Contractors License Law does not apply loan owner of
' property who builds or improves thereon, and who does mh work himself tar through
his own employees, provided that such improvements are nm inended or offered for
sale If, howavu,the building or improvement issued withinoneyemof c"mplidon,the
owerce-bradider will have the burden or proving that he did not build or Improve for par
poseof ).
❑hasowner ofthe property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70l. Business and Professions Cale:) The Conmacmr9 Li-
ceneeLatehoarctapplytganowner ofproped, wbobuilds nrimprmes thereon,and
who contracts for such projects with a contractors) licensed p ndu antro the Contractors
License Law. -
❑Ism exempt under Sec. ,B&PCfor thisrwsm
201-1000AMPS
OVER I(101)AMPS
_
SIONS N18CfRICA
SPECIAL CIRCGIT/ld,\
-
TEMP. MET )RPO INST. _
COMMERCIAL,
E NEW BLDG/ADDITION S DEMOLITION
ETENANT EDEMOLI FOOD ION
VICE
IMPROVEMENT
E OTHER
POW. DEVICES
SWIMMING POOL ELECTRIC
DOITH'I S- SWITCHES -FIXTURES
-
NEW RESIDENTIAL Ii1.ELT'R SQ FT.
,
-
- -
SQ. FT. FLOOR AREA
.-
�Q
%
$/SQ. FT.
-
-
TOTAL:
QTY PLUMBING PERMIT PE
PERMIT ISSUANCE. -
ALTER - DRAIN &VESIT - WATER (EA,
Owner - Data
/' VALUATION J1
,�(/ �� ���5
WORKER'S COMPENSATION DECLARATION
1 hereby sifiim under penalty of perjury one of the following decimations:
`❑ Ihavc and will nmimein aCertificate ofConsenrto self -insure for Workers Cnmpen-
eaoien, vs provided for by Section 3700 of the Labor Code, for In. perrormnnce of the
wo@rk for whichthia permit is issued:.
?I have and
l maintain
sation Insurance,as tion
70() added Labor lCode, for the performance ofthe work for which the permit is issued.
My Works' C m adoni s mnce2 "fondyN., tam ere;
• Cartier" e MaA, icy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
(This section need not be completed lfinepernitis forone hundred dollars($100)
orl"ssJ '
tenuity that In the performance afthe work for which Nis permit is issued. l shall
not employ any parson in annmao m
y mm�as become subject ,n the Workers' Computer-
salinn Law's of Calif anis. Data
Applicant
BACK FLOW PROTECT. DEVICE({.;
DRAINS -FLOOR, ROOF, ARE
STORIES
TYPE CONSTRUCTION
'FIXTURES - PER 'IRAP
GAS - EA. SYSTEM -II OI TIF. 5
OCC. GROUP
'
,ATN
GAS SYSTBMO R4( )
GREASUIND TRL WATT INTERCEPTOR
,
OUILDMG DIVISION PEES'
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA200 PT
. .d-
ENERGY PEE
,
WATER HEATER W/VENT2LF,CTR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certif me of Exemption, you should
become subject to the Worker's Compensation provisions of the Li le r Code, you mus,
forthwith comply with such provisions or this permit shall he deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this Pardo is Issued (Sec, 3097, Civ. CJ
Lender's Name
WATER SYSTEMITREATING
SOILS FEE -
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. FT.
Data Receipt#
- -
-TOTAL:
Lender's Adtlresa
- "TOTAL:
" I canny that l have mad this application and some that above information is
contact. l agree to comply with all city and county ordinances and state laws relating e
building construction, and hereby authorise representatives of this city to courtroom ,he
above-mentioned property for manicure purposes.' ,.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabili,ter.judgmems. costs and expenses which may in any way income against said City
in meacb enco of the gradting of this pundit.
APPLICANT UNDERSTANDS AND WILL,COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
•
BUILDING HE
SEISMIC FEE
QTY. MECHANICAL PERMIT PEE
PERMIT IS
ELECTRIC PER -
ALTER OR ADD TO MECH.
PLUMBING FEE ^
AIR HANDLING UNIT (TO0,(CFM) �-�
^V.
MECIIANICALPE J ��•
CONSTRUCTION AX
AIR HANDLING UNI VE ,0 1CFM)
Signature of ApplicantlContracmr Unto
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle houndaus material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cordo, Section 25532m)R -
El Yin, ?No
paraWilthe applicant or future bitdefinedding by the B y A equipment or devices which
Dist int' us air comaminan@ as defined by the Bay Arca Air Quality Management
District' ,f�
❑Yes AIN.
Ihnve read,he hazmNtms mnrerials requirements under Chapmrfi95 of the Cnli-
fornix Health & Safety Code, Sections 25505, 25533 and 25530. I understand that if oho
buildia,Ass not cunemly have aten on. did, it is my reR u ribility to notify the occupant
ofthe requirements which must be met p' ,o i o s ole Cenlficnce of//O''c upnuo .
EXHAUSTHOOD(W/ U
HOUSING MH/IA9I
G'ON WE s7
14
-
HEATTIN UNIT (TO l 1000 ED U)
VG
rCr.
HEATING UNIT(OVER 100,0110 BTU)/
`YI/
PAID
VENTILATION PAN (SINGLE RES ID)
Date Receipt#
BOILER -COMP (3HP OR 100,000 BTU)
TOTAL
BOILER -COMP (OVER 100,01h1 RTU)
,
AIR CONDITIONER
ISSUANCE DATE
t '
-
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
Owner or omhoriud gent yVale
TOTAL:
OFFICE