29905 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERSHING. w
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL {9�9O
5
Itl1IlA1NG PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
s 631�S-S' ltsl�
ONINEM NAM(` PHONE: C NTRACTON'S NA '044 LIC NO:
AN . 1 N/C CONTROL as
1RCH1 /ENGINEE LIC NO:! ADDRESS ❑
,CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑
I hurtle,-Toon that 1 ore licensed under roviocns of Chu ter 9(commencin QTY ELECTRIC PERMIT FEL
es p p g JOB DESCRIPTION
�O000 with Section foces do)of Division 3 o the Business unit Professions Code,and myliceaeis R SI-,F p$NTIAI
O h ` PERMIT ISSUANCE ,
in full force and effort.
� �UZ V License Chis Lia.k ❑SFDWL ❑KITCHEN REMODEL
�QL Dam Convenor APPLIANCES.RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION '0 MULTI-UNIT ❑STRUCTURAL
,Z O t2 Z I understand my plans shall To used as public records PANELS MODIFICATION
OZ— UP T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F� Licensed Professional 201-1000AMPS I PROVEMENT
• OWNER-BUILDER DECLARATION OVER IBr11AMPgTH REMODEI/REPAIR ❑DEMOLITION
6 I hereby affirm that I um exempt interim Contractors License Law for the
g0 V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which".an a permit to construct,sue,improve,demolish,or repair any mucmre
0,
pd.,to issuance,alsonequires the applicant(castrate pmmirao fileasigned,uncenent SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9
(commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
e z that he is exempt aemfmm and the limit for Ne alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
Section 703L5 by onyapplicam for a permit subjects the applicant to a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
Qnm ream Nan fisc hundred dollars($500). IMPROVEMENT
0La,ownerofthepropeny,or myemployu.with wages.,theirsolecnmpensation• SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended ondfeted for sale(Sec.7044.Business ❑OTHER
end Professions Code:The Contractors License law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
L .. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL CLEM SQ FT.
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.IT.F15100R,AREA $/SQ.FT.
owner-builder will have the burden of proving Ilan he did not build or improve for put.
pose of sale.).
❑
I.a owner of the property,am exclusively commar ing with licensed convectors m TOTAL:
coavust the project(Tec.7044,Best..and Profanities Cade,The Cammctar's Li- MAY.l 4 1996
cense taw does not apply to an owner of property who builds or improves thereon.and QT-Y. PLUMBING PERMIT FEE
who convects for such project,with a contmctor(n)licensed pursuant to the Connector's
❑clrearLow.
pts crSec. ,B&PCftinhix reason 'PERMIT ISSUANCE C11 Ur I'UrCtll i1
vu
Owns te ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATIDaON , BACK FLOW PROTECT.DEVICE
I hereby affirm under penahy of petjaryne oof the following ifcclmalums:
Hhaveandwillmainuina CenificmeofConsentloulf-imumfor Workers Comps- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCfION
smion,as provided for by Section 37M of the Labor Code,for the perfonmence of the
work On,which this permit is issued FIXTURES-PER TRAP
0 1 hove end will maintain Workers Compenx.line Iaumnce,o,nominal by Section
37M ofthe labor Code,for the performance ofthe work for which this permit is issued. GAS-PA.SYSTEM-I INCAOUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRI,WASTE INTERCEPTOR BUILDING DIVISION FEES
(This sealants need not becomplcled ifthe permit is forom hundred dollars(SIM) GREASETRAP
err less.) PLANCHECK PEE
I cenify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM PA.200 FT.
em
not ploy any person in any manner so a tom become subject the Workers'Compen. ENERGY FEE
zZ smion laws of Califrmen Dam WATER HEATER WNEM/ELECTR
Applicant - GRADING FEE
p) NOTICE TO APPLICANT:If,after making this Certificate of Esemption,you should WATER SYSTENINREATING SOILS FEE
become subject to the Workers Compensation provisions of the Labor Code,you must
L1aforthwith comply with such previsions or this parent shall he deemed revoked. WATER SERVICE
Ck' Q PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT.
V^ I hereby affirm thin there is a construction lending agency for the performmae of Date ce' to
fA l0 the work fair mi
r which this pert is i...ad(See 3097.Civ.C.)
0 P Lender's Name TOTAL:
Lenders Address TOTAL:
1 certify that d this at 1 have mail application and sure that the above information is BUILDING Mi
fes/) correct.I sate to comply with all city and coumy ordinances and sum laws relatingin QTY. MECHANICAL PERMIT FEE
building construction,and herehy outhouse representatives of this city to enter upon the S[ISMIC FEE
above-mentioned property far impaction purposes.
(We)agree m ave,indemnify and keep harmless the City of Cepcnino against PERMIT ISSUANCE ELECTRIC FEE
Iiahilities,judgmems,costs and expenses which may in any wuymeme against said City ALTER OR ADDTO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO lgflW CFM) MECHANICALFE
SOURCE RE LATIONS.
V AIR HANDLING UNIT(OVER IE0110CFM) CONSTRUCTIO
t re.A n an Contract at EXHAUST HOOD(W/DULT)
c BAZAR I MATERIAL. DISCLOS E HOUSING MITIGATION HE
Will Ne applicant or future building occupant store or andlehazarkeemamtial HEATING UNIT(TO I OEM BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) -
❑ves ❑No VENTILATION FAN(SINGLE RESID) PAID
W 11 the applicant or future building occupant use equipment or devices which Dae Receiptg
:mit htuarous air conuminares as defined by the Bey Area Air Quality Management BOILER-COMP(3HP OR IOL MA BTU)
TOTAL:
District?
OYes ONO BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements an&-,Chirpier 6.95 it]the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL Tel SQ.FT.
building does or currency have a mwnt,that it is my res potability to notify the occupem
of the reqummenu which must be met prior to issuance of a Certificate of Occupancy.
Owner or amhorimd agent - Date TOTAL: ISSUED BY:
OFFICE