29371 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
• ;A&CHITECTIENGINIffut:
ITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 29371
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /Q { I1
BULLRING PROJECT'IDENTIFICATION L J V 1
UILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
/ 067a V 'a. Ser ren7�e
OWNER NAME: PI10NF.: CONTRACTOR'S NAME: LIC NO.
S ? N/C CONTROL#
LI NO: ADDRESS: ❑ONTACT: PHONE: BUILDING PERMIT INFO
��� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ee oo r 8S- 6D6 / CK 0< X X
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
1x2 with Scction]IKKpofDivisiun 3ofthe Businessmll4nfessi,ns Csule,nnlmy license is
Wr in full forceand effect. PERMIT ISSUANCE
WL ❑KITCHEN REMODEL
�UUU� License Class Lica
Date Contractor ppPLIANCFS-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
a
7 m ARCHITECTS DECLARATION U MULTI-UNIT ❑STRUCTURAL
Z 7a lundersund my plans shall he medic;public rcc.rds PANELS MODIFICATION
UP10200AMP5
O Z q [I- INTERIOR 13 CHIMNEY REPAIR
�to t,Wky Licensed l'rofessiowl 201.11100 AMPS IMPROVEMENT
pe(Yf3 OWNER-BUILDERDECLARATION
I hereby affirm that I am exempt from
Ne Contractor's License Law for the OVER 1000 AMPS [I BATH REMODEUREPAIR El DEMOLITION
p(a 4 U following reason.(Section 7031.5,Business and Pmfnsions Code:Any city or county SIGNS ELECTRICAL []OTHER
447]
y 0 which requires a permit to commuct,after.improve,demolish,or repair any swcame
� prior to its issuance,also requires the applicant for such pemdno file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed purauamno the Provisions of the Contractors License Law(Chapter 9
q�2C (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEM P.METER OR POLE INST.
that he is exempt mctefmm and the basis for Ne alleged exemption.Any violation of DG/ADDITION ❑DEMOLITION
Second'0I IS by any applicant fora permit subjects the applicant m u civil penalty of POWER DEVICES
m 'I'[iNAN
», not more than Eve hundred dollars($51X1). ❑FOOD SERVICE
IMPROVEMENT
O C]1,as owner aline property,or my employers with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do me work,and the strucure nom maradedornffcted battle(Sec.9600,Business []OTHER
3 and Professions Cute:The Contractor's License Law dors not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thi and who dues such work h arch'or through
his own employees,provided that such improvements are not ime.dcJ or offered for N17W RESIDENTIAL ELECTR SQ FI'.
sale.ILhnxever,tbebuilding orimprnvcmern issold within one year of cnmpletinnnhe SQ.PT.FLOOR AREA $/SQ.FT.
owner will have the burden of proving that he did not build or improve for put.
poseof sn.
❑ L asowner of the property,am exclusively contracting with licensed co.._vs m TOTAL
constmct the project(Sec.9044,Buxinuss and Prnfesxinnx Codc:)'The Gmtracmr'x IJ-
cense Law does not apply to an owner of mopeny who builds or improves themon,and QTY, PLUMBING PERMIT FEE (—
who co^trecu forsuch projects with a coneracmr(s)licensed pormanuo the Contractor's .J
Lunate law. PERMIT ISSUANCE
❑1 um exempt under Sec. ,B&P C for this reason
Owner Dam .ALTER-DRAIN&VENT-WATER(EA) /s VAI.UAF ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /O� t 8, ,•
I herebyaBirm under penalty ofperjury one of me following decs: Ok Vlarminn
❑ I haveand will maintain a Certificate of6mentto sdf-imare for Worker's Confam. DRAINS-FLOOR,ROOF.AREA,COND. STORIES 11 TYPECONS'fRUCION
satinn,as provided for by Section 37M of the Lubar Code,for the perfmmamc colic
work for which this permit is;sued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
00 orda,�$Labor
CCode,
for me Perforrmanncce�of the work for
�which this Permit ids issued.
/ GAS-EA.SYSTEM-I EJC.4 OUTLETS OCC.GROUP APN
my Cvrier:h.;LjL `-µ��y�c` rPoldy Policy
na7T b/atq0 ✓7 GAS-EA.SYSTEM-OVER 4IRA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE IM'ERCEMR
(Thisaactinn mead not becompleted if thepmnit is for.hundred dollars(A00) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE Q (�
I,xmfy that;.the Performance offlin,work for whitish tb' Peuni,is issued.i shall SEWER-SANITA BY-STORM EA.200 FT.
not employ uoy person y mannertyin M1u to . be Workers'Crampon- IiNERGY FEB Q
Z satinn laws of Calif.) .Date
z O Applicant // — �` L WATCH HEATER WNF.NT/BL[GTR GRADING FEE
h NOTICE. MAPICAPL NT.If,attar makimidiis Certificate of Exemption.you should WATER SYSTEMRREATING ri
a ',^ became subject to the Worker's Compensation provisions of Ne labor Code,you must SOILS FBEJUN `, /
[✓aG forthwith comply with so IS provisions or this permit shall be deemed revoked. WATER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. ,SQ.FT. PAID -Doc
'�
UO I hembynffam that mere is a construction lending agency for the performance of Doc Recci #
W H the work for which this pcnNt is issued(Sec.3097,Civ.CJ
O U Lender's Address
TOTAL:
Lender's Address TOTAL:
4 1 certify met 1 have read this application and state that the aMvc infommtinn is BUILDING 9 r�
N tamest lagree to comply with all city and county omi...or,andsmtelawsrelatingm QTY. MECHANICAL PERMIT FEE
CJ buildingranmcsion,and hereby authorize re rescmutives of this city toenter upon me on
1s
above-t(We)road pmlt we for inspection purposes. PERMIT ISSUANCE
(W7 agree m save indemnify orad keep histories,the City ol'Cupetino ugninst E LncTJJ PBC 192,31
liabilities,judgmcnu,cusu andexpenses which may many way aremeagainst said City ALTER OR ADDTO MECH. PLUMBING FEE
in asequence of the granting of this pe nit.
8-2
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS, MECHANICAL FEE Uau#31
AIR HANDLING UNIT(OVER 111,1X%1 CFM) CONSTRUCIONTAX 6OaAs
Si gnuturc of A,,fraaUCmmawbr Date EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhoule hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cmamino Municipal Code,Chapter 9.12,and the Healer and Safmy
Code,5.14m 25532(09 HEATING UNIT((EVER 100,M)BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RLSID) PAID
Date Ra #
Will the applicant or future building mNouse equipment or devices which BOILER-COME'(3HP OR 100,000 BTU) '+
emit htus air tttmaminants as defiby,he B
ned by the Buy Area Air Quality Management
Distdn'I TOTAL: a TO.(6 Dyes E]N. BOILER-COMP(OVER 100.0000TU)
I have read the hazardous materials refoiremenu under Chapter6.95 ofine Cali. AIR CONDITIONER - ISSUANCE DATE
parts Health&Safety Coll Sections 25505,25533 a^J 25534.1 understand But if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdsxs tcurmn11,haveat...nt,that itomy tespmsibility amotifythrow,mumt
oftheregm ante which met'dor m issuance of.Cert'¢ue of Occu nc
agent
-3—��
OwtTlf or outhonzeJ,gem # Date TOTAL: ISSUED BY:
OFFICE