29372 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
~• CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. '//� I�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - 29372
BUILDING PROJECT IDIiNTIF'ICA'1'[ON
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
o a-(, a � ���eH7o PXM a-8 4a/ 6 .3.9
OERM'SNA : PHONE: CONTRACTOR'S NAME, LIC NOi
ion Negag rs yosr g8s=6000 6u kl en 3 OC/att !.� NIC CONTROL#
RCHITECTMNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
it, ee Cao e� y0br 9'Sss-ILL / 1W ' 19 ® X
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby urian,that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CQwith Section 901X0)of Division 3 of the nosiness and Professions Cock,and my license is PERMIT ISSUANCE
in full force and ef@ct.
W F L C KITCHEN REMODEL
� RESMENTIA
17
V U Data Class LIC tr APPLIANCES-RESIDENTIAL
FF a Dam Contractor ❑ADD ION C PLUMBING RE-PIPE
pN.,Dm ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
to l understand m 1 still be maul to Public records PANELS
O Z^7�. y plans s n pu
UP T0200 AMPS MODIFICATION52 .❑INTERIOR ❑CHIMNEY REPAIR
�s4: Licensed Profcssiowl ]BI-I(100AMPS IMPROVEMENT
Oat lam exempt
from
tOVER 10MAMPS C BATH REMODEURF.PAIR El DEMOLITION
q� Q 1 hereby affirm that I R.exempt from theContractorsDECLARATION
License Law for Ne
p(�6 V following reason.(Section 7031.5.Business and Professions Code:Any city or county C OTHER
413 LLF which t to construct,alter,in, SIGNS ELECTRICAL
LL O rcyaires n issuance,also
for ch
demolish, file
repair any structure
fn
prior he is licensed
its rtyairee lowitiicad for Corrector License Law ned
SPECIAL CBCUIT/MISC.
} Net he is licensed purnuem m the provisions of the Contractors License Lew lChapter 9
GOA (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
6 d n that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicentfor.permit subjects the applicant to u civil Penalty of POWER DEVICES ❑NEW BLDG/ADDITION ❑DEMOLITION
Zi• not more than five hundred do][..(S500). ❑TENANT ❑FOOD SERVICE
OC Las owner of Ne property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC c IMPROVEMENT
will do the work,and the structure is not intended ormffered formic(Sec.1044,Business C OTHER
ti and Professions Cade:The Contmnors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds of improves thereon,and who does such work himself or through
his own employees,provided door such unprovernce.are not intended or coffered for NEW RESIDENTIAL ELECTS SQ FI'.
aide If.however the building or improven.n,is sold within oncycor ofcumplelion,the SQ.FT.FLOOR AREA VSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
poen of soled.
C L 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL, l
construct the prnjmd(Sec.7144,Business and Professions Cmlc:)The Commoner's Li. .�(,
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE p///f/
who contracts for such projects will,a connaciods)licensed pursuant lm the Contractor's
License Law. PERMIT ISSUANCE
C 1 am exempt under Sce. ,B&P C fnr,his reason
ALTER-DRAIN&VENT-WATER(RA)
Owner Dade VALUATION J�
WORKER'S COMPENSATION DECIARXfION BACK ROW PROTECT.DEVICE S / 9
nd L/J f���• /f/1
• Ihereby uffrto under penalty of perjury one of the following declam"an' Z J v-+
❑I have awill maintain a Cenifm .m caofConxsdLinsum for Worke .,.- DRAINS-FLOORROOF
ra Co , ,AREA•GOND. STORKS TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Lata Gude,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
® 1 have and will maintain Worker's Compensation Insurance,as required by Section
Iof the Lamm Cade for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP It 45 ANN
My Works' pensat a faturggf{ carr er and Policy nu b[ ...ef. [� R 0
Carrico: 1Y/NL T�Policy No.: fT 6rp I-TO -O] GAS-EA.SYSI EM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
ffhis section d
ion need note completed lithe _ ILD( D FEES<permit in(Drone hundred dollars(SIM) GREASETRAP �0
or less.) PLANCHECK FEE
I certify that in the perfom,anee of dhewgrl for Ric t ' permitnifstud,l hill $EWER-SANITARY-STORM EA.2INI FT. VI Y7f L tf IIVV
nod employ any pcwn ny man {� —NJ`s Ne Workers'Compere ENERGY FCC
Z sound laws of Cal' m.Daty/,y/� �`�/
z O A licam �"G a WATER HEATER WNF:NT/FiLECrlt
pP GRADING FF.E
tr In NOTICE.TO PI[CANT,If.after bilking this Certificate of Exemption,you should WATER SYSTEM/1'REATING
abecome subject do the Workers Compemaod provisions of the Labor Rule,you mead - SOILS FEE
Da forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
V p I hereby affirm that there is a construction lending agency for the performance of D. Receipt#
LL H the work for which this pemut is issued(Sec.3097,Civ,C.)
0 U Lenders Name 'TOTAL:
Lenders Addfrss TOTAL:
y I certify Nm
at 1 have rend this application and state Not the above inforation is BUILDING
N correct lugrcc to comply wish ell<ity end county.Minancesancistmclawsrelatingm QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby admuriu representatives of this city to enter upon Ne SEISMIC F q�
r above-mentioned property for inxpcction pimpat PERMIT ISSUANCEe (/r
(We)agree to save,indemnify and keep headless the City of Criterion against F.LECIRI r 7J 7v
ludilities,jconsequence of the udgmcma,tuitionalmatimg of Nis ermit.
tuitional expenses which may many way wemeagainsdsaid City ALTER OR ADD TO MECH, PLUMBING FEE /73 /u�
if gp
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT g
AIR HANDLING UNIT(TO 10,000CFM) '73.
SOURCE REGULATIONS MECHANICAL FEE U
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION T X 3 6 O a
Signature ofAWlicandCormosear Data EXHAUST HOOD OV/DUCf) HOUSING MTIIGATIO. FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hareNdus material HEATING UNIT(TO 100,000 BTU)
ns defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes 7N VENTILATION FAN(SINGLE RESID) PAID ---
Dem Rx d p
Willes applicant.forme defining occupantuse ea Air Quality
device.,which
BOILER-COMPAHPOR 100,000BTU)
emit hamrlous air contaminants az defined by the Bay Area Air Quality Manegemem T L:
Dielriclt
Q Yes CNo BOILER-COMP(OVER 100,000 BTU)
I have reed the haaardous materials p AIR CONDITIONER
tequirednems under Chapter 6.95 of do, ISSUANCE DA
fornin Health&Safely Rule,Sections Z505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not cur ntly have..neat.Not it is my responsibility 10 modify be nmparl
o[Ne rcyui ms which an me priamJ�ecuW(
Uwner or authorized agent a Dole
TOTAL:
($$ULD BY:
OFFICE