29024APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY -7
CITY OF CUPERTINO BUILDING • ELECTRICAL
PLUMBING-MEcn
PERMIT NO. 29024 ^ ^ ^ q
10 L 4ANICAL-
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BUILDING DIVISION APPLICATIONIPERMIT
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BUILDING PROJECT IDENTIFICATION
DING ADDRESS:
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SANITARY NO. -
APPLICAq'ION SUBMITTAL DATE
933 3c bin �2a
It :Z.k-�15
OWN NA E: HON': CONTE CTOR'S NAME: �� LIC NO:
NIC
CONTROLk'
❑
.,, ��
HITELT/ENGINEER. LIC NO: ADDRESS:
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CONTACT. PRO -.
BUILDING.PERMIT INFO
1. ELECT PLUMB ,MECH
❑Consultant Fees Paid by Applicant (Initial)L
LICENSED CONTRACTOR'S DECLARATION'QTY ELECTRIC PERMIT FEE
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I hereby am that I am licensed under provisions of Chapter 9 (commencing
with Section]000ffir) ofpivision 3 ofthe Business and Professions Code, and my license is
JOB DESCRIPTION ,
RESIDENTIAL
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Wr,
fill force and effect. „p PERMIT ISSUANCE.
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❑SFDWL ❑ KITCHEN REMODEL
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joy ZD IUjy�
Lice Class Lic.Y - APPLIANCES -RESIDENTIAL
e Contractor
❑ADDITION El PLUMBING RE -PIPE
❑MULTI-0NIT ❑STRUCTURAL
_
fnQF ARCHITECTS DECLARATION PANELS
Zy r 1 understand my plans shall be used as public records y
MODIFICATION
:1 UP In 200 AMPS
L1 INTERIOR OCHIMNEY REPAIR
Licensed Professional 2OW000AMPS
IMPROVEMENT -
Spdy•J] ,OWNER -BUILDER DECLARATION OVER lo00AMPS
El BATH REMODEVREPAIR El DEMOLITION
6 1 hereby affirm that 1 am exempt from the Contme nes License Law for the
-
[]OTHER
15 b y U following reason. (Section 7031.5, Business and Pmfessions Code: Any city or county SIGNS ELECTRICAL
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_
which requiresa perm t t t t It p e dem hdh or repair any structure
+� O Prato itsicamose, almoc,om.flac.pIdemitf h inamat to file asrgned stammem SPECIAL CIRCUIT/MISC.
Z y that he is licensed pursuant to the provisions of the Commences License Law (Chapter 9
7 aE (commencing with Section 7") ofDivision 3 oftheB iness and Professions Code) or - TEMP. METER OR POLE INST.
COMMERCIAL
q o e�G that be is exempt mendriono arddfir,basis for the alleged exemption Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
WX V. Section 7031.5 byany applicant for a permitmhim" the applicant to a civil penalty of POWER DEVICESNI
0FOOD SERVICE
Z t more than five hundred dellars (5500). -
IMPROVEMENT
SW E3 1. as ownerof Ne property, or myemployees with wages actheirsole compensation, SWIMMING POOL ELECTRIC
❑OTHER
will do Nework, and the structure is not imm�ded or offered fursale (Bac. ]044, Business
'
and Pmfessions Code: The Contractor's License Law does not apply to an owner of OUTLETS — SWITCHESI URES t
3
-
property who builds or improves thereon, and who does such work himself or through
his own employees; provided that such improvements are not intended or offered for NEW RESIDENTIA L SQ PT.'
SQ. FT. FLOOR' AREA P
sISQ. PT.
- sale. IL however, the building or improvement is sold withinone year ofcnmpletl.. the
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owner -builder will have the burden of proving that he did not build or impress, for par-
pose of sr
1 Kv
❑ 1, to Owne owner of the property, exclusively contracting with licensed am
2 2 19
['
, B Commences i-
' construct the project (Sm. Business and Professions Code:) The Contractors Li-
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xi
use Law does not apply to an owner of property who builds or improves thereon, un Q PLUMBING PERMIT FEE
na
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who contracts forsuch projects with a commetoruo licensed punuanuothe Contm
Glli VF VViL
License law. PERMIT ISSUANCE
lamexempturrim Sec. ,B&PCfurthEncom
ALTER— DRAIN & VENT — WATER (EA) a
-- VALUATION
Owner pare
WORKER'S COMPENSAT ON,D CI.ARATION j BACK FLOW PROTECT. DEVICE
I hereby affirm under penalty of Firm one of the following declarations:
❑' I have and will maintain a Cmifficam of Co scramself-inure f01W DRAINS— FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
nation, as provided for by Section 3700 of to Labor Cade, for e e of the(
work for which Nis permit is issued. FIXTURES—PER TRAP
"
E]1 have and will mainmim Worker's Co., soft. To. ce, quired by Smtm
r
,OCC. GROUP
APN
370)ofthe Labor Coal for the performance thew thispermitisv d. GAS—EA. SYSTEM -1 INC. 4 OUTLETS
My Wurkees Compensation Insurance carrier and Polic her me:
Carrier/ olicy No: GAS —EA. SYSTEM -OVER 4 TA)
CERTIFICATEOFEXEM IONFROM ORKERS'�
(/
COMPENSATIO INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
-
BUILDING DIVI NFEES
(Thissection need not be completed if he permit is for tine hundred dolls Stop)
PLANCHECK HE I
GREASETRAP mlessJ - / - '-
I certify that in lie performance of the mimetic ch this permit is issued, I shall SEWER—SANITARY—STORM EA. 200 FT.
not employ any person in any manner so as w subject a the Workeri Cumpen- -
ENERGY FEE
Z station Laws of California. Date WATER HEATER WNENTIELECTR
O Applicant
GRADING FEE _
rA
NOTICE TO APPLICANT: If, utter making this Certificate of Exemption, you should WATER SYSTENITREATING
SOILS FEE
sation provons of the Labor Cade; you most
become subject to the Worker's Compenisi
forthwith comply with such in this shallbe deemed resulted. WATER SERVICE
ir
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W
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provisions permit
Z
ONLENDINGAGENCY NEW RESIDENTIAL PLMB. BQ. PI'.
CONSTRUCTION
PAID
Receipt
U Q
U
meperformance
(hereby affirm that ere is isaconsttion lending agency for the perrmance of
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- TOTAL:
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the work for which this prmut is issued (Sm. 3097, Civ. C.)
Lender's Name
U
Lender's Address - - TOTAL:
BUILDING FEE"
1�" a
I certify that I have read thi's application and state that the ntiove information is
fr^ V7
correct. 1 agree to comply with all city and county ordinances and stare laws relating to QTY. MECHANICAL PERMIT FEE
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building construction, and hereby authorize representatives ofthis city to enter upon the
SEISMIC FEE
LAA
ELECTRIC FEF,
above-mentioned property for inspection purposes. PERMIT ISSUANCE-
(We) agree to save, indemnify and keep harmless he City of Cupertino against
PLUMBING FE
liabilities.judgments, costs and expenses which may inany way accrueagausliamd City ALTERORADDTOMECH.
in onsequence of the granting of this permit
MECHANICAL E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 109(100 CFM)
SOURCE REGULATIONS. ,
CONSTRUCfI TAX
AIR HANDLING UNIT (OVER I10,0013CPM)
natureof ApplicanUConVactor Date EXHAUST HOOD OVIDUCT)
HOUSING MITI TION FEE
'
HAZARDOUS MATERIALS DISCLOSURE-
'Williheapplicanmrfumre building rccupantsmre or handle hazordeus material HEATING UNIT TO 1010,000 BTU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532m)] HEATING UNIT (OVER 100,000 BTU)
O Yes ❑No
VENTILATION PAN (BINDLE REBID)
PAID
Date Receipt '
•c
Will the applicant or future building occupant use equipment Or devices which.
BOILER' COMP (3HP OR 100,000 BTU)
it transitions air contaminants as defined by the Bay Area Air Quality Management
TOT
BOILER— COME(DVERd00,000 BTU)
District❑Yes
❑No
t
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE D
forma Health & Safety Cure, Sections 25505, 25533 and 25534. 1 understand that if the NEW RESIDENTIAL MECH. -SQ. FT.
'
:ISSUED
building does not currently have o tenant, that it is my responsibility to notify the occupant
•
of Ne requirements which must he met prior to issuance ofa Cenifcam of Occupancy.
.
O.ommmolm zedagent Date TOTAL
OFFICE A