29956 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. /1/1 /N�/1
BUILDING DIVISION APPLICATION/PERMIT2
PLUMBING-MECHANICAL 9 V4 6
BUILDING PROJECT IDENTIVICATION
aU1LUING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
MID
OWNER'S NAME: PHONE: �P ACI'O ' ME: LIC NO:
]•, OS gq N/C CONTROLN
is�ARCHITECTIENGINEER: LIC NO - E.:: ❑
So
CT: PHONE: I ILDING PERMIT INFO
� �� El Consultant Fees EA by Applicant(Initial) BLDG CT PLUMB MECH
'del /"G1i s 731/- 3� -// E:] ED 1:1
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affino that 1 ton licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�OCZ with Sceti.n]IXpJ of DivixionJof the Business end Pmfessitms Cale,aM mylicenu is
0 0in full force and effect, PERMIT ISSUANCE RESIDENTIAL:
�
UU ❑SFDWL ❑KITCHEN REMODEL UZU License Class onor
hQi DateContractor APPLIANCiiS-RESIDGNTIAL ❑ADDITION C]PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULIFUNIT []STRUCTURAL
Z0r2z yp..ss a pts PANELS
1 understanJ m I h II be used us blit reronis MODIFICATION
O Z UPT0 200AMPS
Licensed ProIIXq AMPS
OWNER-BUILDER DECLARATION lesxional - 20t ❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
K PG 6 1 hereby affirm,that 1 nm exempt frommthe Contractor's License Law for the OVER 1000 AMPS El HAW REMODEIIREPAI .MOLU70N
{iy5 6 U following reason,(Section 70315,Business and Professions Code:Any city nr county []SIGNS LLEC'I'RICAI. OTHER
W 0.O[- which requires a permit to construct,alter,improve,demolish.or¢pair any structure _
prior to its issuance,Alan requires the applicant for such permit to file a signed statement SPECIALCIRCUODMISC,
6E that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 1 q
DO (commencing with Section]00(Eof Division]ofthe an
e Business d Professions Cade)or ` TEMP.METER OR POLE INST. `V COMMERCIAL:
A. c p• mbar he is esempm therefrom and the basis Foran alleged nemptinn.Any violation of ❑NEW BLDCa/ADDITION [I DEMOLITION Section]N I.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DE VICEg
} []TENANT ❑FOOD SERVICE
Esol mord than Is hundral dollars(5500). IMPROVEMENT
Lasowner.fthepropeny,.r my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
O will do the work,and the structure is not intended oroRered forszle(Sec.9B14,Business []OTHER
M and Professions Ccdc:The Contractor's License Law does nm apply to an owner of OUTLETS—SWITCHES—FIXTURES
-� propenY who builds nr improves thereon,and who does such work himself or through
his own employees,providedthin such improvements are not imendedor off"rul for NEW RESIDENTIAL ELECTR SQ ET.
,ae If,however the building w milmvement is sold within.,"yearafmmpletion,Ne SQ.FT.FLOOR AREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for par. T) ,) a
Iwse.faale,. • s.•. 9 iP
❑ I,as owner of Ne pmp"ny,am exclusively contracting with licensed contactors to
mrmuatt the,muco,(Sec.701a,Businessand Praf stions Cade:)The Contactors U. q
cense Low does not apply to an owner of prepeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE ex MAY d o
who contracts for such projects with a contractions)licensed pursuant to the Contractor's 1JJ
License Low. PERMIT ISSUANCE
l am exempt under See. ,B&P C(at his reason ✓I'�
A I:1 ER-DRAIN&VENT-WATT'R(EA) VALUATION
.Owner Data
WORKER'S COMPENSATION DCCLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm antler Penalty.lPerjury ane.(the following declarations:
L]I have and will maintain a Cenifcate of Consent t.self insure for Worker's Compem DRAINS-FLOOR,ROOF,AREA,COND, S'T'ORIES TYPE CONSTRUCTION
cation.as provided for by Section 37M of the Labs Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,es required by Section
370)ofthe Labor Cala,for the Performance of the work for which this peril is issued. OAS-EA.SYSTEM.I INC.4 OUTLETS
OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number arc: GAS-EA.SYSTEMOVER4 CA)
_'t:arrier. Policy NOT: 1
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
or less.)
(This section need not hecompletM if NGREASETRAP
e permit is(gone hundred dollars(5100) BUILDING DIVISION FEES
PLANCH[CK FEE
Loy any Perhat in the anyma nerve,as
becomealk for
to perthe WorkesuCompeall SIiWBR-SANI'1'ANY-STORM PA. FI'.
not employ any person in any manner so as m become iuhjccuo the Workers Camper ENERGY HE
0 sation La ..f California.Data WATER HEATER W/VENT/ELECTR
Applicant GRADING FEE
V1 NOTICE TO APPLICANT:It, it,,making this Cenific.le of Exemption,you should WRIER SYSTEMOBEARNG
a ; become subject to the Workers Compensation provisions of the Labor Cole,you must SOILS FEE
LTI forthwith comply with such provisions,or this permit shall be deemed revoked. WATER SERVICE
IL Z d Q
CONSTRUCTION LENDING
AGENCY
agency
NI:W RESIDIiNTIAI.I'LMB'. SQ, PAID,
V. p Ihercbyamrthat Nem isaca construction lending7,Cis,C.) for the performance of Uma R¢eiptp
0 F the work for which thio p"rit is issued(Sea.3119],Civ.C.)
Q U lander's Name 'TOTAL:
Lender's Address 'TOTAL:
y I certify Nat 1 have read his y and court and dine that rhe starve laws
Taking is BUILDING FliF.
rn coracblagree mcomply
and with all city and countyordinancesand site enter u,"side QTY. MECHANICAL PERMIT FEE
U aturvangcttioned.mand herebyauthorizepurporesemativ"s of this city rarer npnn the SEISMIC FEE
aMwe-mentioned property for inspection purposes' PERMITISSUANCE(We)agree to nave,indemnify and keep p M1alethe City of Cupertino again, ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way intoe against said City ALTERORAUUTOMECH.
in consequence of the gmming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,fkq CFM)
SOURCE REGLyJITIONS. `-�� MECHANICALNT
' � 5 AIR HANDLING UNIT(OVER IO.IXIO CFM) CONSTRUCTION TAX
Milano.of ApplicanUContac Dam EXI IAUST l I00D(W/DUCT) HOUSING MITIGATION FEE
HADA US MATERIALS DISCLOSURE
Will the applicant or future building occupant slam or handle hazardous material HEATING UNIT(TOU10,000 BTU)
as defined by the Cupenina Municipal Cole,Chapter 212,and the Health and Safety
Cafe,Sectio 25532(.)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt N
emit hazardous air containments as defined by the Bay Arca Air Quality Manegement BOILER-COMP(3HP OR 100,008 BTU) -
District? TOTAL:
Yes 0N BOILER-COME(OVER 100,000 BTU)
I base read the hvard.us materials uiremnts under AIR CONDITIONER ISSUANCE DATE
meq Chapin roa .f the Cali
fuilia Health&Safny Cede,Sections 25505,255JJ and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my rcsmmsibility m nmify We occupant
.f the requirements which t run he mer,dor to issuance of.Cenilicme of Occupancy.
Owner or nuthanzed agnDate TOTAL: ISSUED BY;
OFFICE