29324 (2)' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29324
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - L 9 3 /�,
BUILDING PROJECT IDENTIFICATION xJ L
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: Ip\ y4` CEATRAC R'S ME: - LIC NO:
V
ARO.bm) ' `-�•� rzL \C . 4 6 NIC CONTROL#
ARCHITTECCTIE� E�ENNGIINR: - LIC ADDRESS NO: ADD
. q�-3 sp As'coE _ S:s ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG., ER PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECCRIC PERMIT FEE ❑ El 1:11 I hemby affrm s In.licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
P02 with Section 7000)ofDiviivision3 of the Business end Professions Code,and my,license is RESIDENTIAL: ,
is full force and effect PERMIT ISSUANCE
�UV License Class C—Fu Lac' -bRESI
bar, un LSFDWL' [D KITCHEN REMODEL
yZ W Date 'Z %,L-- • Contra s„ ' !'� s s[ APPLIANCES— DENTIAL ❑ADDITION El PLUMPING RE-PIPE
7m ARCHITECTS DECLARATION _ ❑MULTI-UNIT ❑STRUCTURAL
2j8PANELS
r�y I undemmmd my plans shell be used es public reconis � h � MODIFICATION
OZ^+p�p UPT020JAMP5 �V
022 W Licensed Prafesai...I El INTERIOR L1 CHIMNEY REPAIR
^� OWNER-BUILDER DECLARATION 201-1pWAMPS 'IMPROVEMENT
/hereby affrm the,I am exempt Wm the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
U followingreason.(Scluon]031,5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
W F' which requires a permit to commtct,alter,improve,demolish,or repair any structure -
I" pdmmitsiasuance,also requires theapplicamt fnmeh permiuo Flea signedsmmmentSPECIAL CIRCUIT/MISC. 064 C-5
that he is licensed pursuant in the provisions of the Contractor's License Law(Chapter 9
aea 0 (commencing with Section 700)(B.Mivim..3df Ne Bminessund Probox,mo,Code)., TEMP.METER OR POLE INST, COMMERCIAL:
d CC that he is exempt Iherefmm aad the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION [I DEMOLITION
"+t Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not more than five hundred dollars($500). ❑TENANT [I FOOD SERVICE
6 L L.sow.erofthe properly,or my employess with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
yG will do the work;and Meswcture is notintended proffered for sale(Sec.]044,Business []OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES i
p'3 property who builds or improves thereon,and who does such work himself or through -fix two employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ BE
sale.if,however.the buil ding or improvement is sold wild. no year ofcmildetipn,the SQ.FT.FLOOR AREA. $/SO BT
owner-builder will have the burden of proving that he did not build or improve for par.
p0se of selene pq A B
❑Les riche roe-the properly,,B exclusively contracting with licensed contractors m C'
consumer the project(Sec.7044,Business and Professions Cade:)The Contractors LL
cense Law does not apply to an owner of properly who builds or improves thereon,and QTY, PL MBING PERMIT FEE FEB
who contracts G
cts forsuch projects with a mountains)licensed pursuant to the Contractor's 12 1996
License Law. ' PERMIT ISSUAN
i L'I am exempt under Sec. - ,B&P C for this reason C)
Owner - Date ALTLR—DRAIN V WATER(EA)
tJ VyAE7jATIpN.0
WORKER'S COMPENSATION DECLARATION' BACK FLOW PROTECT.U V " IPI
I hcrebys(f under penaltyofperjury one of the following declarations:
❑Ihave and wiff":mMamn a Certificate,ofConsenno self-insure for Workefs Compen- DRAINS—FLOG DEAEA, N STORIES
TYPE CONSTRUCTION
samm as provided for by Section 37W of the Labor Code,for the performance oldie
work for which this permit is issued, - FIXTURES—PER TRA
L I have and will maintain Worker's Compensation Gsurnnce,us required by Section '
37M fine Labor Code,far the performance of the work for which Nis permit is issued. - GAS—EA.SYSTEM-I INCA L OCC.GROUP APN
My Worker's Compensation Insurance trader and Policy number are:
41/Cartier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is pursue hundred dollars($100) BUILDING DIVISION FEES
or less.) GREASETRAP
PLANCHECK FEE
Ioyanymatin the inanymannce rso stine work for co"insd, this permit is issued,I'Comeall 'SEWER—SANITARY—STORM EA.200 FT.
not employ any Person me,any manner ,s es m bac blem m the Workers'Cnmpen- ENERGY FEE
,Z sodium Ent C11=13.Dam
O Applicant •+ef WATER HEATER WNENT/FLECfR ,GRADING FEE '
.y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENITREATING -
'become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
Forthwith comply with such provisions or this permit shall Is,deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.FT. - PAID
U1,1 Q Thereby affirm lhm there iseconswction lending agency forthe performance of Dam RxeiptIt
F me work for which this permit is issued(Sec,3097,Civ.C.)'
Q lender's Name TOTAL:
4VS7 Lender's Address TOTAL:
Iy 1 certify that 1 have mead this application and state that the above Information is BUILDING FEE
Ir to correct.I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
U building convection,and hereby audience representatives of this city to enter uponthe SEISMIC FEB
move-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep harmless the City of Cupenlno.,most ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way same against said City ALTER ORADD TO MECH.
to consequence of the granting of Of,permh.' PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) IMECHANICAL FEE
RCE REGULATION
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of ApplimnuContracmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupam storecr handle hoxardous matermel HEATING UNIT TO 100.000 BTU)•, e
as defined by the Cupenino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)] HEATING UNIT(OVER 100,001)BTU)
❑Yes �No - PAID
VENTILATION FAN(SINGER RESID)
Will the applicant or future building occupant use equipment or devices which Date Receipt#
emit hamldous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP IMP OR 100,000 BTU) -
District? - L'
L Yes ,�/—/A,' - BOILER—COST(OVER 100,000 BTU)
I have read Mme hamrdous materials raluarmicats under Chapter 695 of the Cali- AIR CONDITIONER- ISSUANCE DATE
i forma Health&Safety Code,Sections 25505,25533 and 25534.1 undemmnd that if Ne ,NEW RESIDENTIAL MECH. SQ,PT.
building does not currently have a tenant.that it is my responsibility to notify me occupant "
of the requirements which must he met poor to issuance of a Certificate of Occupancy. '
Owner or amhorind agent Date TOTAL: ISSUED BY:,
OFFICE