29187 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - 29187��I1 O
0
BUILDING PROJECT IDENTIFICATION
BUILDINGADDkESS: SANITARY NO. APPLICA'ITON SUBMITTAL DATE
OWNER'S NAME: 'PHONE: CO']$ACTOk:S NAME: PLIC NO
, �G - S0Wj NIC CONTROLa
•49ARCHITELT/ENGL ER: LIC NO: ADDRESS ei II - L��I •""// ❑ -
CONTACT PHONE: BUILDING PERMIT INFO
`
377— ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT ' PIDh1H MF.CH
Soh '�1dhN __/51i Z, E . ❑ ❑ ❑`.
LICENSED CONTRA OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
IherbyaRnn tat 1amlicensed under provisionsofsChapter Code.
my license
JOB DESCRIPTION
CMZ with Sation7000)of UivisionJaf the Business and Professions Code.and myliccnsc is RESIDENTIAL:
FOO ' full force and eRe PERMITISSUANCE
aI-i" a" ❑SFDWL F1 KITCHEN REMODEL
<—U License Cl Lic.p � APPLIANCES-RESIDENTIAL ❑ADDITION - ❑PLUMBING REPIPE-r zul Date Ciumcmr -
C ARCHITECTS DECI. A •TION C1MULTI-UNITEl STRUCTURAL
F O so PANELS
z000z l understand my plur""ll be used as public rcenrd, ,./yIODIFICATION
p'Z 4—M � UP TO 2(m AMPS 71 INTERIOR � LSCHIMNEY REPAIR
F W Licensed Professiowl - 201-10)(MAMPS IMPROVEMENT
ICY�,.,.1 OWNER-BUILDER DECLARATION OVER HWAMPS ❑BATH REMODEVREPAIR ❑DEMOLITION
TL 6
3 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
X6 U following reason.(Section 7031.5.Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
W W H which requires a serail to consumer,stmt,impmve,demolish,or mpair any suucturc
Og porous to issuarcesd,requites the applicant forsuch permiuo file.,,,mdsammem SPECIAL CIRCUIT/MISE.
E y shot he is licensed amcom babe pro.inions of she Contractors License To.(Chapter 9 _
W..00 Qonnenc ng wiN Secf 7UgU fD 3 Oh li 'nd:ardP f ,Cde)nr I EMP METER OR POLE INSTCOMMERCIAL; .
6 q o eL shut he is exempt shere l and lot basis for M1 II b d exemption A y 6,1An I of NEW BLDG/AUDITION '❑DEMOLITION
W—oo Section 7031.5 by any applicant for a penny subjects the applicant to a civil Pmalty of POWER DEVICES TEN ❑FOOD SERVICE
F=6 not more than rave hundred dollars($500). OVEMENT
❑1,azowner ofthe property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
04L will do the work,and NexWcam is not imendedorofkrW fur cale(See.70l 1.Business OCTH.
i3 m end Professions Cade:The Concavities License Law does not apply to an owner of OUTLETS-.SWITCHES-FIXTURES
propcny who builds or improves thereon,and who docs such work himself or through
Macon employees,provided paunch impmvemcnls arc not intended or offered for NEW RESIDENTIAL ELECfR SQ El
sale.If,howavm,the built rte improvement isenld withiaone yrnr ofninWlmiun,the - SQ.FT.FLOOR AREA E/SQ.FT
owner builderwill have the burden of proving that hedid not build mimprove forma- ertI
ppq� 6
pose of sale).
1,as owner of the property,am exclusively contracting with licensed contactors to TOTAL:
construct he project(Sec.70,14,Business and Professions,Code:)The Contractor's Li-
active Use ties not apply to an owner of prop
i-
e «Lewdcesnotapplytoanownerofprop rtywhobui[&orimprovesthemon.and QT'Y. PLUMBING PERMIT FEE MAY 2 n
who contracts for such promct
projects with a comor(s)licmwed pursuant pursuano the Communes
tj
License Law. PERMIT ISSUANCE CI7y 1999g
❑ 1 am exempt under Sec. B&P C for Nis reason
Owner Date ALTER-DRAIN&VENT WATER HLA) / VABUAU
• . WORKERS COMPENSATION DECLARATION BACK FLOW PROTECI DEVICE
I hereby affirm under penally ofperjury rte of the following dcl tions;
Fl I have and will maintain a Certificate ofConscm toself insum f W k sComNa- DRAINS-FLOOR.ROOF AREA COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 37M of the LaMar Code,for Ne performance of the
work far which this permit is issued. FIXTURES-PER TRAP G
O 1 have end will maintain Weaker's Compensation hemaree,as mqulred by Section
37M of the Labur Code,for Ne perfommnce df the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS
OCC.GROUP APN
My Worker',Campenxyh m insuraare carrier and Policy"umhy�a�e
Carrier: S[ed rYl�Policy Na,_y ;(� CAS-Iib SYSTEM OVER 4 EA)
CERTIFICATEOF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GRF:ASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need notMcomplemdif Ne permit is forone bunds%dollars(5100) GREASE TRAP
or leu.) PLANCHF.CK FEE
Loy any Nat in I.any
ca Ne workm which Nis permit rs C(. pvnl SEWER-SANITARY-STORM EA.300 R.
sol employ any person in any manor m as m became subjttuo Ne Workers'Cnmpcn- ENERGY FEE
zZ moon Laws of California.Date WATER HEATER WNENT/ELEMR
0 APPlicara - GRADING FEE.
cO NOTICE TO APPLICANT,if,after making Nix Certiric,oc of Exemption,you should WATER SYSTEMG`REATING
become subject to the Worker's ConaNdsaenn provisions of the Labor Calc,yon nam 'SOILS FHB
Forthwith comply with such provisions or this Perot%hall be deemed revoked. WATER SERVICE
aQ
5Z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. - SQ.FT. PAID Dam Receipt#
U _O Iforw which
ti,
there isacdnsSt constructionlendingagency for the performance of
Nc Lworkeader's
N r which Nis)armors issuW(Stt.](57,Co,C.) •
W. F Lender's Name TOTAL:
W Lender's Address TOTAL: ..''..11
1 eenify,hm I have rend this application mW sate that the above inform:nlun is BUILDING FEE
%1 correct i agreem cmnply with all ehy and cnamy onturnecs and stare laws relating m Q'I'Y. MECHANICAL PERMIT' FEE
V Z building construction,and hereby ammonia represemmives of this city to enter urym the SEISM IC FEE
ahove-mentloned propsny for inspection purposes. PF,RMTT ISSUANCE
(We)agree to save,indemnify and keep harmless Nc City of Cupertino ngainm ELECTRIC FEE
Iiabilities.judgments,eostsand expenses which may in any xayaecrue.gains,said City ALTER OR ADD TO MECH.
in consequence of Ne Boosting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO INp0 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
/ 'AIR HANDLING UNIT(OVER](),(XX)CPM) CONSTRUC910NTAX
a Signalureof ApplicrowComeactur (/ Y" EXHAUST HOOD OVIDUCT) HOUSING SHE PEE
HAZARDOUS MATERIALS DISCLOSURE -
Willeati,licmrtar future building exampanimmear handle hacuJous material HEATING UNIT TO 100,000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9,L2,and Ne Heald and Safety
Code.Section 25534(a)? HEATING UNIT(OVER 100.000BTU)
❑Yes VENTILATION FAN(SINGLE RISID) PAID
_ Date Receipt M
m
Will Ne oppllemn or future building occupant axe equipment or'devices which
emit hardaua tar coman.immas as defined byte Bay Ara Air Quality Management BOILIiR�C.OMP(JHP OR IIXI,IXNI li'EU) - IOIAl. 7. 0
DrNnGI //'' BOILER-COMP[OVER[00.000 BTU) C/
El Yes 0N!
I have rd Ban bacvdouss amerials nu under Chapter&95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
require
(ariaties&Safety Gado.Sections2thadi 25533and 255JJ.1 toncrsfy the
that if the NEW RfS1UENTIAL MECH. SQ.FT.
buildingd t sly haveaanant Nat t yreimnsibil'ryt fry Neaccupana - /\
of ql he met prix l c f a C a1�Z��i
O...... zed ages S- )mc 4 TOTAL: ISSUF,D NY:.
OFFICE