29892 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEi RTINO ' BUILDING-ELECTRICAL PERMIT NO. ^^ a�a a�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL L 59 (SLI 9 L
BUILDING PROJECIADENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
11595 �Is-7 UPel')NO w
O ER'SyNAME� F'HONH:/ CONTRACTORS NAME: LIC NO:
S N CONTROL#
•ARCHITECGEN INFER: Ir LIC NO: ADDRESS ❑ r
IsC.)
CONTACT.
I'V ^�^� .C7 E: ' ' l BUILDING PERMIT INFO
2
7 J ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ 4 . ❑ ❑
LICENSED COM'RACfQR'S DECLARATION QTY. ELECTRIC PERMIT FEF.
M o: I hereby affirm that 1 ant l tlic Bd under provisions on,Ccac, 9(commeire is JOB DESCRIPTION
F,OWZ with9armadde)ecDivision TtfibeBmincs,Bsad Pmfexsionx Cmle,ImA mylicense is ' q0 RESIDENTIAL:
r in full farce and effect. PIiRMI'1'ISSUANCE ..J ❑SFDWL ❑KITCHEN REMODEL
�UU License Class Lie.# APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE.
NQ 6 Uale - Contractor
ARCHITECTS DECLARATION El MULTI-UNIT []STRUCTURAL
ZFot,r I understand my plam,hill be used.,able,records PANELS MODIFICATION
pZ=t� UI'T02fp AMPS [I INTERIOR ❑CHIMNEY REPAIR
F SFW LicemsN Professional - 201-1000AMPS IMPROVEMENT
�y F,�j OWNER-BUILDER DECLARATION OVER ION)AMPS C3 BATH REMODF:IJREPAIR ❑DEMOL ION
C C Q I hereby xffiren that 1 am exempt from the Contractor's Licenm Law for the
3 W Ufollowing deacon.(Section 7031 5.llusiness and Professions Coda.Any city or county SIGNS ELECTRICAL. ❑OTHER
W m which¢quiets a pemut)o construct,alter,improve demoheh,m repair Imy xtsuca m -
prior to itsalsorequires the applicant forinch comil toIle a signed:tatement SPP:CIALCIRCUIT/MING
} (hath edp ream D th provisions fth C vat :L L (Ch pmr9 '
�CLpO fmmmen ng .tu Settisn]OaB of Di is sn3 (the Beeinessund Pmle.,ion:Code7m TEMP.SINTER OR POLE INST. COMMERCIAL'
6 i c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Ise0 Section by snyapplicantfarapermit subjects Ne applicannu a civil penalty of POWER DEVICES ❑TENpNr ❑FOOD SERVICE
ESQnot more than five hundred dollars($500). IMPROVEMENT
❑L.nwnerof Ne proMny.or my employees with wages as their sole compcnsadon. SW'IMMINGPOOLELECTRIC '
[-• will do the work,and ma,marde,is not imerdeJotofTered fersale(Scc.IlW,Business []OTHER
4 3 m and Professions Code:the Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who build,or improves thereon,and who di such work hinxself or through
his own employees,pmvldcd that such improvements are riot intended or offered for NEW RESIDENTIAL ELECTR SO Fr.
sale.If,however,the building or improvement is sold within one year edcompletam,the SQ.FT.FLOOR AREA ss/SQ,rr
,see,.vile.)'will have the burden of#owing that he did nut build or improve for put- r r
G 4
1,as owner of.theproperty, y g wi T TAL:
❑ am esdusivel Pa5fe,clin N licensed contrenors to �/�00
oto,,Lew it.,oc not ,tytoad Businessandrty wh in ild,or)The Canaawart,and Li- q •I(]p
Li--
car,,,Wwdoesrotapply Rs un with
aof popery whosedporimt toIhc unmcx*; QTY. PLUMBING PERM] FEE .MAY i" IJJ
who cuntmcu for such pmjeds with a amtmcmr(s)licensed pursuant m the Commaots
License Lew. PERMIT ISSUANCE
❑E am exempt order see. ,D&P C lot this reason _ GI I Y Ur A.urcrii IN,)•
ALTER-DRAIN&VF,NT-WAI2 7 VALUATION
•Owner - Data
IO
WORKERSCOMDECLARATION HACK PLOW PROTECT.UCVIC'
I hereby affimt under pcnuhy of Perjury one of the following ledur;niunr .
❑ (have and will maintain uCenificme of Consenuoself-insurefur Worker,Compem- DRAINS-MOOR,RODE,AREA,COND. STORIES TYPE CONSTRUCTION
section,as Provided for by Section 3700 of the tabor Code,for the Performance of the
week far which this permit is issued. FIXTURES-PER TRAP
❑1 hove and will mainmin Workefs Compensation Insurance,as normal by Section
3700ofthe lvMrCNe.for the pcdorromu,.O c work for whichthis permit is iscuW. GAS-F.A.SYSTEM-I INC.4 OUTLETS ' OCC.GROUP APN
My W'orker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy No, GAS-EA.SYSTEM OVER 4(EA) "
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(this xeciiou need not be completed if the permit is(Deane hundred dot ars(510# - -
rzlexa) GRIiASE TRAP PLANCHECK FEEcertifythatinthepcfnrmanceoftheworkforwhichthispemtitisissued,Ishall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner m ae to become subject to the Worker:Comped- ENERGY FEE
zZ cation Laws of California.Dam WATER HEATER WNEiN` E-LECI'R
Q Applicant GRADING FEE
= NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMTREATING
a , became subject to the W'orkeex Com tion f the Labor Code,you must SOILS FEE '
1 #ensu provi hall th
CS7 forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
7Z CONSTRUCT ION LENDINGAGENCY NIiW kBStDEN'TIAI.1'LMIL, sQ.FL PAID '
I hereby affirm that there is a construction lemling agency for ibc prdommor,at _ Dam Receipt U the work for which this permit is mused(See3097,Civ.C.)
U Lender's Nana - TOTAL:
V Lenders Address TOTAL: -
'S" I«rif thm 1 have rival a t store that the above information is BUILDING FEE
(.. a rapplication iond an
to burdingco recto comply with all introns coumyotative,esvnJ smm laws relating to QTY. MECHANICAL PERMIT FEE
V z al,evingeotioned construction,and hereby amhonprepreconaria.of this city turner upon the SEISMIC FEE
vbtwGmendan re property for inspection purposes. PERMIT ISSUANCE
(We)agree to.ave,iNemniry and kre harmless the City of Cupertino against ELECTRIC FEE
Imbill 1dg cro,ent I es hie ymany way ace meagrit5tsadCa, ALTER ORADDTO MECH. PLUMBING ItiE
nm. q f e, fg t .pcma a
AIWI ANT FIR.�TANI sNUW COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111.100 CFM) MECHANICAL FEE
SOU re rlWs,
LAIN HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Sib awes of pvplicant/Conv emr Dme I?X1,AUST HOOD(WMUCD HOUSING MITIGATION FEE
LS
HAZARDOUS MATERIADISCLOSURE
Will theapplicant or home buildinguccupantsmrembandle hazudousmmenal HEATING UNIT(TO 100.000 BTU)
as definul by the Cupertino Municipal Cgee,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? - r HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VEM'ILATION FAN(SINGLE RES ID) PAID
Will the ticunt or future huildim cert11 t us.e t nr devices which Dam Receipt#
pp go pun yuipinmt 'HOILER-COMP(3HPORI(X).(XX)Ii'E'U) /
mit iet? ue ar conmminams a..JdneJ by the tlay Arta Air Quality Muwgemert TOTAL:
Uisvicfl
❑Yes � ❑Nn BOILER-COMP(OVER IIXI.I)%1 ITT U)
I have read the hamedeus may
erialzruimmcm,under Chapter 6.95 of thee Cali-- AIR CONDITIONER ISSUANCE DATE
madia Health&Safety Cade.,Sectio.'-5505,'_5533 mrd 25511.1 m derstmd that if the NEW RESIDENTIAL MECH. SQ.ET.
building dines run mtremly have a Leman.that it is my respomibility to ratify the seaward
of the rcqulmments which must be and prior to izsuwm of a Cedificam of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE