29031APPLICANTTO 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
- PERMIT NO.
' 29031
RUJL NGADDRESS:
XqA Q Cl
SANITARY NO.
APPLICATION SUBMITTAL DATE
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OWNER'S
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AMF.: -7v) PH E:
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CONTRACTOR'S NAME � ^ LIC NO:
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NIC
❑
CONTROL#
4RCHITECT/ENGINEER: LIC NO:
ADDRESS: �•?,} '
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR
under S DECLARATION
I hereby, affirm that 1 am licensed under provisions of Chapter 9 (commencing
f Chap
1 with Section9 it1effecDivision3 of tM1C Boniness and Pr-Inesi-na Code, and my licenso is
Lcene fall rceClass deflect.
License Class Contractor
1 Date Commmor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
t�—µl�'1'Ipli
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION - El PLUMBING HF: -PIPE
[I MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH RP.M � DEMOLITION
❑OTHER .4Z�1 LC3'
Y
/p er
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL,
j ARCHITECTS DECLARATION
i I understand any plans Utall be used.spubtie records
1
PANELS
UPTO20PAMPS
Licensed Professional
DECLARATION
I! Oat I am exempt
1 hereby affirm on 1 am exempt from the Comma's License Law for the
from
1 following reason. (Section ID3L5. Business and improve, de iron Code: Any city or county
i which requires a Permit to construct, aper, improve, demolish, m repair any nmeture
I that he slicenedpuruant Cotherefore, the visions of for Contranch permit to file
ense Law staomem
that he is licensed pursuammNeprovisinna of the Connector's License Law (Chapter9
(commencing with Section 700d) of Division 3 ofthe Businessind Professions Code) -r
that he is exempt theretiom and the basis for the alleged exemption. Any violation of
Seen.. 7031.5byanyapplicant far. pemmilsuhjeen, the applicant tr a civil pit of
am mora then five hundred dollars (SSW).
I, -1 -wool mf the rt y employee, g pc
❑ property, em to nes withwa es rsalei(See. 7044 nsmi-n,
will do theWork,vnd the stmiturs,Contra not Intended oro W do for sale (Sec. 7044, weer of
and Professions Code: The Cunvhereo License Law does not apply s if owner h
properly who builds or improves thereon, and who dues such work himself or through
his own employees, provided that such improvements ore not intended or offered for
sale. If, however r withe hav ilthe burng or en ofpementithat sold bewithin tbuild year
or imprvetionJhe
net -builder will have the burden of proving That be did not build or improve for par-
Free tivele.)
❑ i, as owner of the properly, a., B Ston,., old contrasting with licensed contractors i-
c0nmmn the project (Sec. 2044, Business anJ Podesninns CafaJ The Cnntr.amrs Li-
nse Law dues not apply 1. as owner of pmpcay who builds or improves thereon; and
who v-noaea for such projects with a contmetor(s) licensed pursuant mine C-mmstors
License Law.
Icon exempt under Sec. ,B&P C for this buvm
201-IWOAMPS
OVER AMPS
SIGNS ELECTRICAL
ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST. 3 tt,
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
SQ, PI'. FLOOR AREA
$/SQ. FT.
TOTAL:
COD
QTY PLUMBING PERMIT FEE
P IT ISSUANCE
ALTER— RAIN&VENT—WATER EA)
BACK 110 PROTECT. DEVICE
Owner pea
VALUATION
WORKER'S COMPENSATION DECLARATION
I head will under penalty of of ory enc of elfin In , for declared -
(have and will mountaina Cenifate of Consemnosclf-insure for Wer Cooper-
workas provided for by Section 37M of the luder Code, for the nuaace .1'the
for which thin permit is issued
❑ 1 have and will maintain Workers Compensation Insure required by Section
3700 ofthe Labor Code, f I,he, erhnmance of thewor r which this permit is tseued.
rker Cympins Ij Insnrancecarrcracul cynumberarc:
Carrier ll7iLL�aLL r Po' No.:
WORKERS'
CF.RTIFICATEOFEATIX E INSURANCE
COMPENSATI INSURANCE 1
('LIbsectionneedn-theromplet iflhopermillsfor one hunarca II )
or less)
Toys, perm inany manner tstolec mewM1ide this pe Ia
not employ any person in any manners nsmbec-n bje trs'O6m -
Indian Laws of California. Date /
Applicant
DRAINS — FL R, ROUP, AREA, COND.
STOR[
OCC. GROUP
TYPE CONSTRUCTION
'
APN
FIXTURES —P TRAP
GAS — EA. SYST M -I INC. 4 OUTLETS
-
GAS — BA. SYST -OVER 4(EA)
.FIMDUSTR WASTE INTERCEPTOR -
BUILDING DIVISION FEES
G A$ R
PLANCHECK FEB
SLWC SANITARY—STORM EA.2W FP.
ENERGY FEE
ER HEATER W/VENT/GLELTR
GRADING FEE
NOTICE TOAPPLICANT: If, after mak 91hisCe7fiedIi, Exam i ,ymidimild
become subject to the Workers C-opension provisions 1 Labor e, you mast
forthwith comply with such provisions or is permit shall b eemed revoked
CONSTRUCTIONL NDINGAGENCY
Iberebyaffirouitowee saconsme onlendingagemyforthelerf0 amecif
the work for which this permit is issued (Sec. 097, Civ. C.)
Lender's Name
WATER SYSTEMOREATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. 4.
Date. Receipt is
,
TOTAL:
LenderAddress -
TOTAL:
I certify that I have -ad his epplicminn d sone the-�ab-ve infammion is
cement.I drromoomply with all city and coomy cesandsmtelaw,'mIrPngt-
building consumption, and hereby amhorrm rcpresen etives of Nis city m enter upon the
tim,wmemtl0med property for inspection purposes.
(We) agrco m svve, indemnify tape
d keep harmless the City of Cunioo again-
liabilities,judgments,costs and expenses which may in any way accrue against said City
in -sequence ofthe gmatim, ofthis permit.
APPLICANT UNDERSTAN IND L COMPLY WITH ALL NON -POINT
'DUI.
/ fjl 7 /�
l v
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
i,
PERMIT ISSUANCE
-
ELECTRIC FEE
O.0
ALTER OR ADD TO MECH. -
PLUMBING FEE
AIR HANDLING UNIT(TO W
I0,0CFM)
MECHANICAL FBH(.P
AIzn��R HAND "rG UNIT (OVER IQtIW CFM)
CONSTRUCTION TAX
H I ML GTI 5
namreo AiddeamUCommcar Dote
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)?
- ❑Yes
Will the appli... I or in wrc building-ccupanurse equipment or devices which.
'Demit hazardous air obmaminams as defined b the Bay Area Air Quality Management
Pn
Yes
l'
1 have read the hazardous Inatcrials re uirements under Chn tar 6 95 of the Cali-
q o
f0mia Ith & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
Ing solcu met.thato ismyrespnnsih ,ficoeotifythewcutam
h e met prior m issuance of �if e� f Occupancy.
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
. mr.. .,111v 1114U
HEATING UNIT (OVER 100.000 BTU)
Jr. -
PAID 46L�2aa!i(
VENTILATION FAN (SINGLE R[SID)
BOILER-COMP(3HPOR 100,00013M) _
DoleReceipt#•
TOTAL:rictf
1 BOILER -COMP (OVER W,IIW BTU)
AIR CONDITIONER
ISSUANCE DAV
Fjy,/�Y/
ISSUED BY: S f Oe AAvAOA f. GC♦
NEW RESIDENTIAL MECH. SQ. ET.
.watemmiummear.gint Dale
TOTAL:
OFFICE
PIP76
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