29030 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO ' BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29030
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I losI 1 r
Lane
1 O -NAME: PH E: CONTRACTOR'S NAME; LIC NO:
NIC CONTROL#
ARCHITECUENGINEER: LIC NO: ADDRESS. ❑
S. SS
CONTACT. PHONE: BUILDING PERMIT INFO
1�Fd 52IV ICSy� 1_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MELD
❑ ❑ sia ❑
LIC'NNrD CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aZ with Section 7000)of Division3 ofthe Business and Professions Code.and my license is RESIDENTIAL;
�O i PERMIT ISSUANCE
Li full e0ae and Bec
License Class Lic.N rAFDWL ❑KITCHEPLUMBINREMODEL
InQ� Dote Contractor APPLIANCES-RESIDENTIAL � ADDITION El PLUMBING R&PIPE
Oy ARCHITECTS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL
Ov5.Z. 1 understand my plans shall be used as public records MODIFICATION
Z-.00 - UPTO200AMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed Professional " 201 OOK)AMP$ IMPROVEMENT
y ,.1 OWNER-BUILDER DECLARATION
e4 a I hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
iqq�55 0.0 following reason----tion]031.5,Business and Profession,Coda:Any city or county SIGNS.ELECTRICAL ❑OTHER
0++4 F' which requires a permit to conswet alter,improve,demolish,or repair any structure Li �,L
prior m its issuance,also require,thmapplicant for such permit to file a signed statement SPECIAL CIRCUITMISC.
} that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chlpter9
00 (commerncing with Sedion]WO).f Divisian3of the Business and Proksxions Cast I r TEMP.METER OR POLE INST. OMMER IA �-
06 q q Nat he is weird thcref on and me basis to,the alleged esemplam.Any vielption ❑NEW BLDG/ADDITION ❑DEMOLITION
iC W -ectian707 LS by any applicant forapermit aubjanthe epplicont toacivil pen alt o PO VICE- (]TENANT ❑FOOD SERVICE
Onut more than five hundred dollars BlifuB,
p l,asownv.fthepmp ny,ormyemploymswithwagese,their sole cs IN POOL ELECTRIC IMPROVEMENT
will do the vock.and the income.knot intendedor-nBered fur salt(Sec.] n,tl ons ❑OTHER
L and Prefcesi.ns Code:The Contractor's License Law does not o mer OUTL -SWITCHES-FIXTURES
pmpeny who builds or improve,thereon,and w m docs sac r f or,HmWq
his own suld.ysa,provided Net such improv its t i ffe NEW RESIDENTIAL ELECTS SQ Pf.
sale,If.however the building orimprovemant' o i one year f pJeuo _ SQ.FT.FLOORAREA $/SQ,PI'.
cr-builder will have the burden of proving tha dnntbuildot�inam6ve Torpor. _
preofele.). \d `
❑1,ai owner of the pmpedy,am esche ively cant. if g with license contractors to TOTAL:
on,trum the project(Sec.]004,Business and Profcs' na Cade)The Cor tmcmr'a Li-
censeLawduesnotapplytoanownerofpropertywhobuild,or improves thereon.and QTY. PLUMBING PERMIT FEE
whocomrazts for such projects with a connotations)licensed pursuant to the Contractors
Licmrac Law.' s' PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this remit
Owner
ALTER-DRAIN&VEN'r-WATER(EA) VALUATION
Date
WORKER'S COMPENSATION DECLARATIONBACK FLOW PROTECT.DEVICE QO
I hereby affirm under penalty of pe jury one of the following declarations:
❑Ihave and will mainmin,Certifies--of Conserv to self-irt,ure for Workers Compcn- DRAINS-FLOOR.ROLE AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. _ FIXTURES-PER TRAP
1 has and will maintain Workers Compensation Insurance,as requited by Section
3 .f the LaborCafq for th<perfomwnce of the work for which Chia permit is issued. GAS-EA.SYSTEM-I INC.40UTLENS OCC GROUP pPN
My Workers Compensation Insurance carrier and Policy number are'
Carmar:U 61C('fe4 Policy No.:��a GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION PROM WORKERS1&I ISCOMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
or ex,.)
(This section readout he completed ifthe permit is pursue hundred dollars S IINp GREASETRAP BUILDING DIVISION FEES
l
PLANCHECK FEE
Ioy any that in the performance ro the so
for which this the WorxixmO.ar'ell nl SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any moonset so vs m become subject to the Workers'Compen- - ENERGY FEE
0Z ammo.Laws of Cnlilnrbill.Data WATER HEATER WNENTMI-ECTR
Z Applicant GRADING FEE
y NOTICE TO APPLICANT,If.after making this Certificate of Exemption,you should WATERSYSTEMTREATING
a ; become subject to the Workers Compensation provisions of the Labor Code,you mum SOILS FEE
w
forthwith comply with such previsions or this permit shall be deemed revoked.' WATER SERVICE
d Q
�Z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.pT PAID
U/1 I for
nis Permit I iaacon(Sol.construction leading agency for the pertotmunccof Date ReceiptIt
!f-•'r
,he work for which this Permit is issued(-mJ091.Civ.C.)
Lenders Name TOTAL:
C U
k1 Lender's Address TOTAL: Q
C 1 ccniy the,1 have read this application and stem that the above nomination is BUILDING FEE
Us const 1 agree to comply with all city and county oNinaneea and site laws relating to QTY, MECHANICAL PERMIT FEF,
C.) building construction,and hereby authorize representatives of this tiny to enter upas the SEISMIC FEE
`t shove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ears m save,indemnify and keep harmless the City of Catalina.agoing ELECTRIC FEE T
Iiabifirics,judgmenb,casts andexpenses which may in any way accme against said City ALTER ORADDTOMECH.
in consequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM)SOURCE REGULATIONS. - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Sigvmre of AMEcant/Contracmr Date EXHAUST HOOD(W/DUCT) HOU-INC MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicnntor turn.buildingoccupamatere or handle hmardous material HEATING UNIT OT)100,000 BTU) i.
as defined by the Cupertino Municipal Calm,Chapter 9.12,and the Health and Safety
Cade,Section 2553$0)^ HEATING UNIT(OVER 100,000 BTU)
❑YesNo /
VCM'ILATION FAN(SINGLE RCSID) PAID
Will the applicants foam building scupant use yvipmem or devices which RU41pt g
emit h .ban,yr conteminams u defined by the Bay Arca Air Quality Mamgemem BOILER-COMP(3HP OR 100,000 BTU)
District! BOILER-CDMP(OVER 100.000 BID)
Is•
_ ..TOTAL:
Y.
".a
I have read the hmmduus materials to under Ch fi.95 of the Cali- AIR CONDITIONER
ra.2553 a aper ISSUANCE DATE
fomia Health no Safety sim GMC,Scab--25505,25533 end 25534.I understand the if the NEW RESIDENTIAL MECH. SQ.FT.
building Jas na<urrendy have o tenmL unit in is my responsibility ns notify the occupant
p.
o rya rerrcnu which t be ren m voce ofa Cenifcae f Ore past' (�(•'s
I- _� O 111114$— w �
wne�r nr aaTo ze,�Sge�I ;TOTAL: ISSUED BY�V Qe /•7 M1/Nk�CCi
OFFICE