29381 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PFRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT'IDENTIFICATION 29381
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2222'S ii: NE CA-
OWNERS
NAME: PHOCONT# CI'OR:S NAME: LIC NO:
s ^.Q2 L ♦ ' NIC CONTROL#
ARCHITECT/ENGINEER: LIEN ADDRESS: ❑
N 4 ve- 1
Fit
PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEC
y affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
40, 0Mp of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL'
FUad Undnd eftom'~fJ. L PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�UO Lic.#�<S Commctor x APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE '
F,pm ARCHITECTS DECLARATION V ❑MULTI-UNIT EI STRUCTURAL
Z O rlt'Z 1 understand my plans shall be used az blit reconfs PANELS
Pu MODfFICATION
pZ�� UP TO 314 ANTI'S
Q4 Licensed Professitiml C1 INTERIOR ❑CHIMNEY REPAIR
,•,]I OWNER-BUILDER DECLARATION 201-110MAMPS IMPROVEMENT
Q I hereby affirm that I am exempt from the Contractor's License Law for the OVER IM0 AMPS ❑BATH REMODEUREPMR ❑DEMOLITION
yC
ad 3 d F following reason(Section 7031.5,Business and Profession,Qsde:An or count ❑OTHER-_
fiF1=0.0 which requireso snit m construct,alter,int y can y SIGNS ELECTRICAL
Ix improve,dcmnlls t or repair any sweture
qq that heor It,slicensed puIlan rsuant
to thethe
ovisioso tar suchpenninoclnse Law(Cha meat SPf;CIAI.CIkCU1TIMISC. �,..
4C) (surnmtwo, it pursuununthe of Division!the Contractor's License Law(Chapter
or a
0 (commencing withScction 7agp of Division Nosiness anJ Professions Code) TEMP.METER OR POLE INST COM #,IAL.
6 oQ a' that he ie exnnpt Iherefrmn and the basis for the ullegeJ exentptinn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'^y0. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DfiVICFS
norma.tban five hundred dollars($500).mon'
❑FOODSERVICE
ZG I.as owner aftbe property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑TME VEMENT
_ will do the work.and the stmnum is nmamended oroBered for sale(See 7614,Business
2 3 ro and professions Code:The Commences Licen+e Law dada not apply[o an owner of OUTI.EfS-S WITCHES-FlX S
propery who builds of improves thereon,and who docs such were himself or through
his own en+ploy.......ded that such improvements are not intended m offered far NEW RISIDENTIAL ELECIR 91.
sale.IL however,the building or improvement is sold within one year of completion,the SQ.FE FLOOR AREA LSQ.FT.
ownerbuilder will have the burden of proving[list he did not build nr improve for pur-
posafstle.). A n
❑1,.,owner of the pronely,nexclusively clusively contru,no,with ont
licensed cractors m TOTAL: A
cnnsaum the prs9en(Sec.7044.amines and Pon anions Coal—
cerise Law do"'lot
orlecenseLawdo"'lof apply to an owner of prepeny who builds or improves thereof,and QTY. PLUMBINGPERMIT FCC ��� J/. ��96
whn contracts for such projects with a commcroda)licensed pursuant na the Commodesdes
License Low. 1 PERMIT ISSUANCE❑1 nm exempt under Sett ,11&P C for this reason Ct)
Owner Dme ALTER-DRAIN&VENT-WATER(G) "IrAEVATION
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTEGE DEVICE
1 hcrchy affirm under penslty of perjury one of[he fallowing declarations:
C I haveand will mainmina Cewcam ofConunnu ulf-insure for Workers Compcn- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRU ON
.fall.us powd W far by Section 37M of the Labor Axle,for the performance of the
work for which this permit is issred. FIXTURES-PER TRAP
[:]I have and will maintain Workers Compensation Insurance,as required by Section
37M of Ne Labor Cade,for the performance of the work for which this permit is issued. GAS-G.SYSTEM.I INC.YOUTLETS /" OCC.GROUP AP
My Worker's Compensation Insurance carrier and Policy number are:
Comet: Policy No: GAS-BA.SYSTEM�OVER 4(G)
CERTIFICATE OF EXEMPTION FROM WORKERS.
COMPENSATION INSURANCE GRP.ASIYINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FP S
fThlssedion noedombep+mpletediRhepermlt is torose husdml dollars(SIM) GREASE TRAP
or lc..) PGNCHECK FEE
I verify that in the perfonnanceaflhe walk for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.300 Pf.
not employ any person in any manner so as to become subject to the Workers'Camper- ENERGY FEE
z s.it..Lewx of California.Date WATER HEATER WNENT/ELECfR
Z Applicant GRADING FEE
7) NOTICE TO APPLICAFIF:If,after making this Certificate of Exemption,you should WpTF.R SYSTI3M/f1tGTING
a7 become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
Q foruci[h comply with such provisionsanhis pem+itshall the Jectned.voked. WATER SERVICE
a
7X CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
V Iherchy affirm tlmnhert is aconswetion lending agency fanhe performance of Date Receipts
V. L-+ the work for which this permit is issued(Sec.3097,Civ.C.)
0 V Lender'B Name TOTAL:
Lender's Address
P., I certify[hu(I have rutd this opplic,ok and and Ilam the nmoo information Is BUILDING PER
sy y correct.I ngrcemcmnply with all cityond county ordinances und.amte Iowa relating to QTY. M17CIANICAL PERMIT FEE.
G buildnagcangmction,and hcrchy authorize reprcsenmtivca nl[hie city in emterupon the SEISMIC FEE
above-mentionml pommy for inspection Pncaral PERM IT ISSUANCE
(We)agree to save,indemnify and keep harmless[be City of Cupertino against ELECTRIC FEE
lobilitic,,judgments,cas[sald expense,which may many wayaccme against to City ALTER OR ADD TO MECH.
in conuqucnceof[ granringof this i[. PLUMBING
SAPPI,OURCE RE UN[ !RSTANDSA )WILL COMPLYITf1��N�POINT PIR HANDLING UNI I'(TO 10,0op CFM)
SOURCE IONS. //II VV MECHANIC FEB
AIR HANDLING UNIT(OVER HIEM CFM) CONSTRUqHONTAX
Signature of AppllcasuCommcmr s, Date EXHAUST HOOD(W/DUCT) HOUSIN ITIGATION FEE
HAZARDOUS MATERIAL S DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material H HATING ON I'r(TO 100,11fg1 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Cdde.Seutlnm 25532417 HpA'TI NO UNIT((OVER 100.000 BTU)
❑Yee Fl No
VENTILA'I'[ON PAN(SINGLE RESID) PAID
Will the npplicum or future building occupantuse equipment or devices which Dam Receipt#
•emit huzoNous air comamin6nts as defined by the Bay Area Air Quality Management BOILER-COMP(7HP OR 100,1100 BTU)
DimricR BOILCR-COMP(OVER 100.0y)BTM TOTAL:
❑Yes E]No
I have mad the hazardous materials AIRCONDYNONCR ISSU NCE DATE
re,25533 ma underChapter of[heCali-
fnmiu gat.&Safety Code,edea 25505,is my and ushilq25511,1 understand d Ihm if the NEW RESIDENTIAL.MECH, SQ.PT.
building dors not currently have a¢rant.Na[i[is my.arymxihility m nodfy Ne occupant
of the.quirementa which must be me[prior to issuance of a Cenniicate of Decufamoy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE