29674APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
PERMITNO. ^ ^ ,.S
296
BUILDING PROJECT IDENTIFICATION
Pb74
MOO ADDR
114 N rq LUG( PCu P&k T-1vatE:
SANITARY NO.
APPLICATION SUBMITTAL DATE•GWNER'S
N73
PHONIi: CONTRACTOR'S NAME: LIC NO:
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r2CHITECf/ENGINEER: 1.{�N AP- ADDRESS,
1040
CONTACT: - PHONE. -
BUILDING PERMIT INFO
' - ❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I ase licensed under provisions of Chapter 9 (commencing
tb Seeioo]f10E.I'DisNim 3a(Ihe Busimewand Professions Cwle.mal myli,anwis
wt - PERMIT ISSUANCE
n full forte and effect.
License Clens. Lice APPLIANCES -RESIDENTIAL
Dme Cement., APPLIANCES-
- JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL - E7 KITCHEN REMODEL
El PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
ARCHITECTS DECLARATION - PANELS
lundemtand my plans ,hall be used as public records r
PANELSaBAMPS
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Sa5.4
7 W a
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OW
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❑ INTIiRIOR EPAIR
IMPROV ENT
❑ BATH R ODEUREPAIR EMOLITION
❑ OTHIiR
-
Licensed Professional
OWNER -BUILDER DECLARATION
OVI7R IIIW AMPS
I naso affirm that 1 am exempt tram the Comcois Co License Law for the
following rcusnm (Section ]031 5; ITuxinesx and I'rofesxiuns Code: Any city or cony SIGNS HLECIRICAL
which raryires a permit to construct, alcor. improve, demolish, or repair any structure
prim miuissuance, also requires the applicaat forsnch permit to file nsigned statement SPECIAL CIRCUIT/MISC.
p
that he is licensed pursuant o the provlaons tithe Contractor's Limme L. pCuqucr9
COMMERCIAL:
❑ NEW BLDG/ADDITION C1 DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
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7CC
•e
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(commencing with Section 7")of Division 3 ofthe Business and Professions Codc) or TEMP. METER OR POLI; INS
that he is exempt comfmm and the basis for the alleged exemption. Any violation of
Section IDJLS by any applicant fore permit whjects the applicant macivil Penalty of POWER DEVICES
not moradend Ove hundred dollars(5500).
❑1, es Osvnerof the pmjmrty. nr my empinyea with wages as iheirsnle compenmtinn, SWIMMING POOLELECfRIC
/
will tlothe work. and Neswemrcis notimendeJ oroffertJ forsale (Sec.]BW, Business
-
3 m
and Professions Code: The Contractor's License Law does not apply to an owner of oLknLKs-SWITCHES-FIXTURES
'
properly why hand, Or Improves thereon, and who Jura st¢h work himself or through
his own employees, provided that such improvements are not intended or offered for NEI RB. IDRNI'IAL ELEC'I'it SQ FT.
sale. If, however the building or improvement is sold%obin one year ofcompletioa, the -
builder will have the burden of proving that he did not build Or improve for par-
t.00R/ARH
S/SQ. FT.
piter-
s1 of s
I, Owner of the prnpeny, um exclusively romraaing with licensed con0uceirs m TOTAL:
E] 1. owner
construct the project (sec. 7044. Business and Professions Code:) The Contractor's Li. ++�.a
acne Law does not apply roan owner ofpmperty who builds or improves thereon, and QTY. PLOMBIN4 f. FEE
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C� x7 k�s
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wbt contracts lar sail, Pmijme, ,lhacommctur(s) liccmed pursuant to theCoutracmr's �"°` vsd:e
0 l am exempt under Sec. ,B& P Licensw C for this mason PERMIT ISSUANCE
owner Date ALTEiR -DRAIN&VENT-WATER )
• W ER'S COMPENS N DECLARATION BACK FLOW PROTECT. DEVICE
)fIV,U
^ VALUATION
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1 hertby aRrm under penalty of perjury one of the following dedamtions:
Ibaveond will maintain a Certificate of Consentto self -insure for Worker's Compen- DRAINS- FLOOR, ROOF. AREA, COND.
tion, as provided for by Section 9]00 of that Labor Coale, Itnhe per6mmn<c rot the
S ORIES
TYPE CONSTRUCf10N
work for which Nis permit is ismeaL FIXTURES - PER TRAP
❑ 1 have and will maintain Wakefs Compensation Insurance, as acquired by Section
37M of the Labor Code, for the performance of the work for which this permit ix issued. GAS - EA. SYSTEM -I INC. 4 OUTLETS
My Worker's Compensation Insurance carrier and Policy number arc:
OCC. GROUP
APN
Cartier: Policy No.: GAS - EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEONDUSTRL WASTE INTERCEPTOR
'(Thisswtion acednot be,candeted fthepermit is forone hundreddollors(SAID)
orlecs.) GREASETRAP
- BUILDING DIV151 17E
PLANCHUQK FI
znotion
1 certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any memar sat as ea become suMiect m the Wnrons'Cam SEWER -SANITARY -STORM EA. 200 FT
Las,of California. Date cert-
ENF,RG PEE
WA'IER HEATER WNIiNf/ELECTR
Applicant
GRADING PEE
NOTICE TO APPLICANT. If, after makingthisrtsmn,of of F..,shut odyoushould Wq'll?µ SYSTIiM?REiATING
become suompy the Warker'o GmIDent pmvisitnx of themed Code, you most
y 0
-
SOILS FP.R
�
this
forthwith comply with Such provisions or this permit shall be deemed revoked, WATER SERVICE
Q
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L.D
CONSTRUCTION LENDING AGENCY NI?W RESIDENTIAL PLMSQ. ET.
B. Iherah affirm that there i,uaannstructlan lendln name Pommnee of
Y 6n.) per
under's for which this permit is issued (See. 31N], Civ. CJ
Lender's Name
PAID
Data Receipt is
TOTAL:
Lender'sTOTAL
w fU
y y
V)
�z
BUILDING
toffy t:
I certify that 1 have sad this npplicmion trod Satre shot the ubnvm in[omtotinn is -
coram. l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
building construction, and herebyemhodse repmuntutiveaofthis equi emcrupon the
SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE.
(We) agree m indap save, indemnify and kharmless the City of Capetian against
ELECfRIC FEE
Iiabili0es,judgmans, contend expmeeswhich mayinany wayacemeagainst.aid City ALTER OR ADD TO MECO
in consequence of the granting of this permit
PLUMBING FEE -
APPLICANIUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT(TO 10,100 CFM)
SOURCE REGULATIONS.
MECHANICAL FEE
AIR HANDLING UNIT (OVER I0,011U CFM)
CONSTRUCTIONTAX
Signionanf Applicant/Commcmr Date EXHAUST HOLD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEE
Will the applicant so future building Occupant store or handle scissions material HEATING UNIT (M 100,00) BTU)
as dented by the Cupertino Municipal Calc, Chapter 9.12, sad the Health and Safety
Code, Section 25532(u)'f HEATING UNIT (OVER IIXl,flOU BTU)
I ❑Yes ❑No VENTILATION PAN (SINGLE RESID)
Will the applicant or future building by the B use equipment Qor uotas Maces which BOILER - COMP DHP OR 100,000 BTU)
Tait hamrJnm air contaminants as defined by the Buy Arca Air Qmlity.Munagem°°t
•District^
PAID
Data Remits#
❑Yes C] No BOILER - COME (OVER 100,000 BTU)
I have mud the hazardous anuarials requitement under Chapter 6.95 Of the Call- AIR CONDITIONER
ISSIIANCEDATE-
basis Health & Safety Cade, Sections 25505,15533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ. FT.
Wilding does nm curently have a tenant, that it is my responsibility m notify the occupant
of the requirements which must he met prior ai issuance of a CeriOcme of Occupancy.
ISSUED BY:
Owner or authorized agent Date TOTAL:
OFFICE