29698 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. L^9 6 9 8
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDF.NTLFICA71'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: ONTRAC"OR'S NA E: LIC NO:
�,tort. - •1
ARCHITECT/ENGINEER: 1`l LICNONIC CONTROLp: ADDRIiSS: ❑
CONTACT: PHONE: 3p \ s(ne) BUILDING PERMITINFO
❑ CongBllenI Fees Puld by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ aas�f, �•
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
2CZO with Section 7000)of Division3ofthe Business and Profcsiov Code,end myliceveis ' PERMIT ISSUANCE RESIDENTIAL
f W- in full force and et
114-
U1E.�. License Lica CSFDWL C KITCHEN REMODEL
fT....Z ul DateComrncmr APPLIANCES-RESIDENTIAL CADDITION [I PLUMBING RP-PIPE
Fly ARCHITECTS DECLARATION PANELS CMULTI-UNIT []STRUCTURAL
Z024Z 2 4j 1 unceremnd my plans shall be used as public records - MODIFICATION
:J UPT02W AMPS
❑ - - ❑INTERIOR E3 CHIMNEY REPAIR
Licensed Professional 201-1000AMPS, IMPROVEMENT
�z ,�j Oat Lona exempt fo DECLARATION OVER ISMO AMPS ❑BATH RE j IR (- 40 JT+9
yy W,< 1 hereby.(Sent that Lam exempt from the Cssionsou License Lew for Ne i.9�
ke3aU following reason(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECITtICAL []OTHER
YY17�OLL which require,a permit to construct.alter.improve,demolish,or repair any stnnum
�Im priorto its isausaceaHn requireatheapplicarat fortach pe.as.file.signedstatement SPECIAL CIRCUIT/MISC. -
�S<� that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 -.-
(commencing with Section Wall)of Division3of the Business and Professions Code)or TEM('.METER OR POLE INST. COMMERCIAA�s Y
❑ that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
4 2 Section 7031.5 by any applicant for a permit subjcctathe appliminI..civil penalty of POWER DEVICES []TENANT_ []FOODSERVICE
mnr
t ethan five bnndrea dollar,($500).
fG ❑I,as owner of the progeny.or my employees with wages as their sale mmpevation, SWIMMING POOL ELECTRIC IMPROVEMENT
R• will do the work,and the structure is not intended or oBered for aide(SeeBIkL,Business []OTHER
W and Professions Code:The Cmurectois License law does not apply to.n owner of OUTLETS-SWITCHES-FIXTURES
4i property who builds to improves thereon,and who does such work himself in through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
aide If.howevar.the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.). '
❑1,as owner of the property,am exclusively contracting with licensed contractors to O y�
construct the Project(Sec.70H.,Business and Professions Cade)The Conwcmea U. a p 1 11
cense Law does not apply to an owner of property who builds or improves theuon,and QTY. PLUMBING PERMIT EE Q+
who contracts for such projects with a commetm(q licensed p rravanuo the Commences �
l'iven's°Law. I
PERMITISSUANCE
❑ 1 am exempt under Sec. ,B&P C fonhia reason
Owner Data
Ai:MR-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Cllti U•F VUT t't r o 0
1 hereby affirm under Penalty of perjury one of the following declarations: V 1
❑I have and will maintain a Certificate ofConunuo self-insure for Workers Compen- RAINS-FLOOR.ROORA ,GOND. STORIESIf TYPECONS*MUCTION
cation,as provided for by Section 37M of the Lehr Cede,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3 of the Labor Code for the performance ofthc work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCCGROUP APN
My Wo�,er'x rQ`•9 ens a 1surance darner unit Polio nu her re: �..
Carrier:CAlx r.�Maal.. policy No. GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OFEXE ON FROM WORKERS' -
COMPENSATION INSURANCE GRP.ASI%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
phis section need not be completed if the Penton is for ore hundred dollun(f1On GREA$E TRAP
or lax.) PLANCHECK FEE
I certify that in the perfmmastccofthe work for which this permit is issued,Ishdl SEWER-SANITARY-S'T'ORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
,.tion Laws of Celif ema,Date
y�O Applicant WATER HEATER WNENT/ELF.C'TR GRADING FEE
Fly NOTICE TO APPLICAN'E If,after snaking this Cenifcate of Exemption,you should WATER'SYSTEMTREATING
abecome subject to the Worker'a Compensation provisions of the Labor Code,you most SOILS REE
foMwult comply with such provi.s mom this .Italian be deemed revoked. WATER SERVICE
Uz CONSTRUCTION LRNnlNGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PALO
V T for which thi thin thereissued(Sec.Y len ding agency farthe performance of Data ReceiPtp
F the work for which this Permit is is,ued(Sec.3(197,Co,C.)
Lender's Name - - TOTAL:
U
w Lender's Address TOTAL:
1 certify that 1 have read this application and state that the above infmmmion is BUILDING FEE
N correct.l agree to comply with all city and county ordinances end state laws satiating to QTY, MECHANICAL PERMIT FEE
V& building construction,and hereby submarine representatives of this city to enter upon the SEISMIC FEE
.Mwe-mentioned property for inspection purposes.
(We)agree to save indemnify and keep harmless the City of Cupertino against ' PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,cows and expenses which may in any way.cane against said City ALTI7R OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR I IANDLINGUNIT(TO IIk000CFM)
MECHANICAL FEE
SOURCE Rj:GULATIONS. ,
I9 f1, AIH HANDLING UNIT(OVER IIhtYJI1 CFM) CONSTRUCfIONTAX
Signature of ant/G wcmr em[' EXHAUST HOOD(WA)UCq
HAZA OUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will em ar foliate,building occupant store or handle hazardous materialHEATING UNIT(TO 11),00(l BTU)
as defined by the Coped i el Cale,Chapter 9.12,and the Health and Safety QL
Coda,Section 25532ml'I HI?ATTNO UNIT(OVER I1),IIIXI BTU)
[]Yes Wit VENT'ILA'TION FAN(SINGLE RESID) PAID '
N
Willthe applicant or future bulletins..part in equipment or Devices which Date Reeeipt
BOILER-COMP(3NP OH 1 W,tXp Bill
emit hazardous air contaminants at deftnal by the Bay Area Air Quality Management )
District? TOTAL:
❑Yes XNo BOILER-COMP(OVIER 100,01)BTU)
1 have read the hazardous tmWrists reuitentents under Cha AIR CONDITIONER
q andera95ofdtt Cali- ISSUANCE DATE
build.Health&Safety Code,e i Sections 25505,255JJ and 25534.1 to notify the
that if the NEW RESIDENTIAL MECH. "SQ.PT.
building repoes not cusrtnfly heveutenen0 that it is my rtxrymsihilitymnmify the occupant a `a `f/
o the to-luiremenu which must t primtoissu.nce of a Cenificmea Occu racy.
) or authod Date TOTAL: ISSUIDBY:
OFFICE