29657'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING - ELECTRICAI. PERMIT NO.
CITY
DIVISION APPLICATION/PRRMIT PLUMBING -MECHANICAL, 1 29657
111111 DING PROIF(]'IInumn FIC.AIYON
ADDRESS, _ _ I_ I __, - _I ❑
OFFICE
❑ Consultant Fees Paid by Applicant (Initial)
BLDG Ef4�13C'1' PLUMB MEC({
❑ /'-"� ❑ ❑
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LICENSED CONTRACrDR;SDEdon,of hap -
Iion7 )offif1thatIamlicensed undernd Professions Code.ter 9(my licam is
with section70001on>roision3,nbe Business and Professions Code. and mylicense is
in lull Porte and effect as
Lmense C�ss `` 'Clap -J �
Dme Camra ++ B-_- -�3—�•
QTY. ELECTRIC PERMIT FEB
JOB DESCRIPTION
RESIDENTIAL
❑SFDWI. ❑ KITCHEN REMODEL
'CIADDITION (I PLUMBING RE -PIPE
❑MULTI -UNIT OSTRUCTURAL
- MODIFICATION
OIN'PROV I{ [:1 CHIMNEY REPAIR
IMPROVEMENT
[I HATH kEMODEUkEPAIR ❑ DEMOLITION
[]OTHER
PERMIT ISSUANCE
APPLIANCIES- RESIDENTIAL
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apo
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ESCactuate
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Nproperly
ARCHITECTS DECLARATION
u.s 1 understand my plans shall be used public records
-
Licensed Pmfesslonal
I hereby affrun that 1 um exempt from the Convncmr'e License Law forms
Oat I am BUILDER mDECLARATIONorsam
following reason. (Section 7031.5. Business and Professions Co& Any city or county
which requires a permit to construct. alter, improve, demolish, or repair any swetum
prior to its issuance, also requires the applicant for such permit to file a signed statement
that hell licensed pursuant to the Provisionsofrhe Cnnuacmrs License Us, (Chapter 9
(commencing with Section 7001 of Division 3 of the Business and Professions Codoor
that he is exempt therefrom The the basis for c alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
than Eve hundred dollars ($.5BB)'
❑1, as owner ofdeproperty, or my employees with wages as their sole compensation,
will do [be work, and the structure is not intendedoioffcred for sale (Sec.9044,Business
and Professions Code: The Contractor's License Law does not apply to an owner of
who builds or Improves thereon, and who does such work himself (ir through
his own employees, provided tom such improvements are not amended or offered fear
sale. If, however, the building or improvement is sold within one year of completion. the
ownerdailder will have the burden of proving that he did nut build or improve for pear-
pme of sale.).
E] 1. as owner of the properly, am exclusively contracting with licensed cnmracmrste,
continue, the project (Sec. 7030, Business and Professions Code:, The
vectoc se Law does not apply to no ow tier of property who builds atlmprovcsdnereon,and
cerise
wbbcontrects forsuchis meas with a commcior(s) Iicen.sedpurwatn mthe Conna
aor's
License law,
O vat attempt exmalar er Sec. . B & P C for this reason
PANELS
UPTO NO AMPS
201-1100AMPS
OVER 100(IAMPS
SIGNS ELECTRICAL
SPECIAL Cl RCUIT/MISC.
3MP. MET'13R OR POLE INST.
❑NEW BI )G I
❑TENANT []FOOD SERVICII
IMPROV(3MP.NT
'
[]OTHER
-
('OWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDE+NTIA1. 13LEC9R SQ FT.
SQ. FT, FLOOR AREA
py
4" P
FE815' 199 6
V
0/
$/SQ, IT.
_
-
QTY, PLUMBING PERMIT FEE
P13RMIT ISSUANCE
ALTER -DRAIN&VENT -WN'ER(EAT
Owner Data
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r Ia LVAI:yA.11lly(�
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0ULender's
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'
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of pe jury one of the following declarations:
Clisig<te and will cleintsin u Carl ificate of Consent to set l'-insum lir Worker's Compcn-
cation, as provided for by Section 37M of the Later Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, m required by Scenes
3700.f1he Lidam Cade. battle perfomnance al lhework forwhiefIbis perunit;e uad.
My Workers CompensxtionJn r cd Policy num�Ij l¢�
Carrier: W policy No.: 11-0
CA.L CO
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSA'T'ION INSURANCE
Mix section nadrom be completed if the .it is parent, hundreddollars ($I(0)
or less)
I cenify that in the petforeancuoftbnwork for which this permit is mood,(chat(
ploy any Persian in any rammat s, as I, m
not emro becoe sobjecrm the Wmken.' Compen
smion Laws of Califeram. Date
Applicant
BACK FLOW PROTECT. DEVICE.
DRAINS- FLOOR, ROOF, AREA, COND,
STORIES
'I'VPF: CONSTRUCTION
'
FIXTURES- PER TRAP
GAS- F.A. SYSTEM. INC. 4 OUTLETS
CQ GROUP
'
'
APN
GAS - FA. SYSTEM -OVER 4(HA,
GREASII/INDUSTRI, WASTE IN'I ERCEPI'OR
BUILDING DIVISION FEES
GRF.ASETRAP
PIANCHECK FEE
S17WER- SANITARY -STORM EA. 200 IT,
EE
WATER HEATER WNENTMLECTR
GRADING 113E
NOTICE TO APPLICANT aL after making this Certificate of Exomption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such pmvi,wrou"Iis permit shall be deemed resulted,
CONSTRUCT a'ION Iu3NDINGAGENCY
IhercbY affirm that them
en isconstmnion lending agency for the performance of
0he work for which this permit is issued (Sec. 3092 Civ. C.)
Name
WAI ER SYS'TEM/TREATING
SOILS FEE
WATER SERVICE
PAID
Dem Raeiptp
NEW RESIDENTIAL 1'LMR. SQ, IT.
'TOTAL:
TOTAL:
Lender's Address -
-
BUILDINGFEE
1 cenify that I have rami this epplicatiun and num that the about information is'
correct. I agree to comply withal) city and county ordinances and state laws relatingm
buil ingcen.struction. and hereby uutherve represemmatives ofthiscity to enter upon the
above-mcnfmned property for inspection purposes.
(We) egra m save, indemnify and keep harmless the City of Cupertino against
Iivhlldies,judgmaux. costs and expenses which may in any way accrue against said City
in omoyuance of the granting,f this penial.
APPLICANT'UNDER STAND$ AN WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
QTY. MECHANICAL PERMIT FEE
SEISMIC FTSE
PERMIT ISSUANCI3
ELECTRIC IME
ALTER OR ADD TO MECN.
PLUMBING FEE
AIR HANDLING UNIT (TC) 10.01(1 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER IhIXO CPM)
CONSTRUCTION TAX
Signvm pplicvntlConwc r Dote
HAZARDOUS MAT12RIAM DISCLOSURE
Will the applicant orfuture building oecupam sure or handle hamrdom mpteriul
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Soley
Code, Section 25532pd?
❑Yas ONo
Will the applicant or furore building occupant use ripromot or devices which
Divi hazWemnt
ous air mminvx as defined by the Bay Area Air Quality Manment
Distinct?
❑ Yee FIN.BOILER
I have read the haradous materials requirements under Chapter 6.95 ,(the Celi-
Tomia Health & Safety Code, Sections 25505, M533 and 25534. I understand duan Ne
building dors not currently have a tenant, mm it is my responsibility ur notify @e occupant
of the requirements which most he met prior to issuance of Cenificale of Occupancy.
EXHAUST FLOOD (WIDUCT)
HOUSING MITIGATION FEE
HIINFiNG UNIT (TO 03,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
S�-
PAID
Data Receipt p
VENTILATION FAN (SINGLE RMID)
BOILER- COMP(3HP OR 100,010 BTU)age
TOTAL: -
- COMP(OVER 100,000 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
Owner or umho i,ed ngcnt I Dare
TOTAL:
OFFICE