29516'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY'
CITY OF CUPERTINO ." •, -, - BUILDING -ELECTRICAL
PERMIT NO.
BUILDING DIVISION M APPLICATION/PF IT' PLUMBING. MECHANICAL'
_ BUILDING PROJECT IDENTIFICATION
29516
t
BUILDING ADDRESS. Y' '• '-- - -
2- z a : 4
SANITARYNO.
t
APPLICATION SUBMITTAL DATE
OW 'S NAME:`/ PHONE:,,
O/1 t �c s�
CO�NT/J'q�1STORS NAMG: LIC NO:
VJtF. - rfff Y 4rw,�r
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CONTROLW -
ARCHITECT/BNGINEhR-.' LICNO'. x-
ADD5ESS.
Lt #19r CAI. ai.44
CONTACT:: -, -PHONE:; ',
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BUILDING PERMIT INFO
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❑ Consult Pees Paid by Applicant (Initial) ' t
tan
BLDG ELECT PLUMB SUCH -
�. ❑ � ❑
LICENSED CONTRACTORS DECLARATION
,E 1 -hereby M. that I licensed trader provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Section 7010)afOrGstoo 3ofthe Business andProfessions Cod d mylicirears
n full finee ant;B�f 3 ^�3 6� ,
License Cl Lic4 A -i
Dale # or
RESIDENTIAL:
❑ SFDWL .- L1 KITCHEN REMODEL
[]ADDITION PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
PERMITISSUANCE T
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APPLIANCES -RESIDENTIAL.
L.
ARCHITECTS DECLARATION
1 utiderstanJ my plans shall hn used as publicrecords
PANELS 'p "-
UP TO200 AMPS n
�
❑INTERIOR OCHIMNEV REPAIR
IMPROVEMENT,
HATH REMODBVREPAIR (-1DEMOLITION,
[I OTHER i
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 703 L5p Business and Professions Code: Any city or county
which requires a permit to construct, alter, Improve, demolish, or repairvany dencmre.
201-1000AMPS'
OVER IfMp AMPS'
SIGNSELFCTRICAI,
Prior to its issuance, also requires the applicant for such permit to rite a signed statement
thal heislirenuJ pursuvnuothe provisionsofthe ConOacmr'e License law (Chenais
SPECIAL, CIRCUIT/MISC. -
�- - -
TEMP. METER OR POLE INT.
_ ,,,
COMMERCIAL:
(commencing with Section 700th of Division 3 of the Business and Professions Code)or
that he is exempt therefrom teed tho basis for mr alleged exemption. Any violation of
Section 703 1.5 by any applicant for a Permit subjects the applimentto a civil panahy of
....bore dean five hundred dollars($500),
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will dodm work, and the structure is not intended oroffered for sale Piece. 7004, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
❑ NEW BLDG/ADDITION'❑ DEMOLITION
TENANT [I FOOD SERVICE
IMPROVEMENT e
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES-FIXTUR1
property who builds or improves thereon, and who does .on work himself or through
his own employees, provided that such ievprovements ire'nm (mended or offered for
sale. If, however the building oriaiprovemem is soldwithin aneymoofecmpletion,the
owner -builder will have the burden of proving thus he did not build or improve for pvr-
NEW RESIDENTIALELECTR SEJ 07.'
- '
SQ. FT FLOOR AREA
$/SQ. FT.
you of aeleJ.
'
..
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
TOT
construct the projecl(Sec 7044 Business and Professions Code) The Contractors rt Li-
cense Law does not apply to an owner of property h builds or. mproves thereon, and
who examines for such projects with a contract Gs) licensed pursuant to the Contractors
OL
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QTY PLUMBING PP-RMITTL PE � (
- .IYs
ISSUANCE 6
ALTER'-BRAIN&VENT -WATER (EA)
License Law.PERMIT
❑IamexemprunderSec.- ,B&P C for this reason
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Owner Date
-VALUATION
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-WORKER-SCOMPENSATIONDF-CI.ARATION'
BACK FLOWPROTECT.DEVICE
1 hereby afford under penalty of pe Jury one of the fallowing declarations:
O l have and will maintain a Certificate of Consent o self -insure for Worker's Campen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which thispermitisi.ssued.
DRAINS- FLOOR, ROOF AREA, CONED.
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STORIES
TYPE CONSTRUCTION
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D FIXTURES - PER TRAP
❑ I have amid will maintain Worker's Compensation Insurance, as required M1y Section
'37M of the Labor Code, for the permnnanee ofthe work for which this permit is issued.
My Worker's Coinpemnionlnmmnce carrier and Policy number are:, .a
GAS' G. SYSTEM I INC. 4 OUTLETS
OCCGROUP
APN
"
Carden Policy No.: 'rGAS-EA.SYSTEM-OVER4(EG
CERTIFICATE OF EXEMPTION (ROM WORKERS
11 COMPENSATION INSURANCE a
(This section need not be completed f0 p n is forao hundred dollars ($100)
mle .) -
I cemfy that ey�efflpoperi oftheworkfarwhrhla ounit sseed,ishall
not employ ami an di tee ec eublwn theW k rs' Compco-
GREASDINDUSTRL WASTE INTERCEPTOR
BUR.DING DIVISI'UN PE&S'€
GREASETRAP - '!
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PLANCHECK FEE "
SEWER -SANITARY -STORM EA. 200 PT. .
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ENERGY FEB
WATER HEATER WNENTIfiLECTR
cation Law. C, i oat' a Y
f
Applica -
.GRADING •E
NI TIC APPLICAN, If, after adding this Certificate of Exemption, you should"
becomn jecno the Worker's Compensation provisions of the Lahor Code, you must
WATER SYSTE VTREATING
SOILS FE
forth in comply with etch provisions or this permit shall be domed revoked:'
WATER SERVICE
CONSTRUCTION LENDING AGENCY.
. I hereby affirm that there is a construction lending agency for the perfounidce of
NEW RESIDENTIAL PCMB. 'SQ. FT.
PAID.
ReceiptA -
.i
the work for which this permit Is issued (Sec: 3097. Civ. C:)' r
Lender's Name{
-
TOTAL::
Lender's Address
- TOTAL:
I comfy that l have read this application and slate that the above information is
BUI G -
QTY. �. MECHANICAL PERMIT .,jt FEE,Q
correcl'l agree to comply with all city and county ordinances and.tate laws mining to
building construction, and herebyavthonze representatives ofthis city to enter upon the
_r
SETS 1 P - t
above-mentioned propenyfar inspection purposes.
(We) agree m save. indemnify and keep huemless the City of Cupertino against
" PERMIT ISSUANCE
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ELECTRIC .E
liabilities,judgromes,costs' and expenses which may in anyway acme against said City
in consequence of the gaming of this permit
ALTER OR AUD TO MECH.
PLUMBI 'FEE '
.. AIR HANDLING UNIT (TO Il1,IXq CFM)
.n ..
MECHA ICAC FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT,
SOURCE REGULATIONS.'
AIR HANDLING UNIT (OVER 10,000 CFM)
CONST UCTION TAX
Simon. of Applicant/Conaacmr P--- Dare
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUI!N MITIGATION FEE.
HEATING UNIT (TO 10f" BTU)
Willthe applicant or future building occupant more crucial hazardous material
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as defined by the Cupertino Municipal Code, Chapter 9. 12. and the Health and Safety
'Code, Section 25532(a)'f -
HEATING UNIT (OVER 100,000 BTU)
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.1,. ny's []No
_ _
Will'heapplicantntar rlumrebfired pmuAetjvp for douses which
mit hazardous air conmm ars as deleted Fy,the Bay Area Aj. Quality Management
District?
❑yes ❑No Ai,
PAID - Uat ReceePtW .
VENTILATION FAN (SINGLE RESID)
BOILER- COMP(3HP OR 100,000 BTU)
TOTAL.
"'BOILER-COMP(OVER 100,000BTU)
AIRCONDITIONER
'`s
4+'
(have reedflue hazardousstentisrequirements under Chapterrsta of the
ISSUAN ATE' -
- NEW RESIDENTIAL. MP -CH. SQ. PT.
Card, 25533 and 25534 1 understand that if the
if
fomie Health &Safety Code, Sections 2deal it
oftheq nswhillych have be met that'n.myresponsibilityof aec notify the dccupant
of thercqutreme t which be met poor to fa Certificate ofOccupant y
1
a -
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P
ISSUED BY..
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Owner or authonzed agent d Ore-
TOTAL: -
�. OFFICE