29375 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. n C
BUILDING PROJECT IDENTIFICATION L J
BUILDINGADDRESS: c� - tttt SANITARY NO. APPLICATIONSUBMITTALDATI
908' VAZ sorrQn IF
OW EI R'S NE
CODRONAM&
Q e1n'/7O�p + D WOis
LICNONIC; CONTROL
0MB9
RCHITECUENGINEER: LIC NO: ADDRESS: N
PH
CONTACT: - PHONE: BUILDING PERMIT INFO
Co B& D� ' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ' MUCH
l•' OATION~ LSI L'JI L'il Is01
ucees mNTRAcnder p o CLARAnON QTY ELECTRIC PERMIT FEE
I hereby.Baan that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OC with SecrceandYRoc Divisi..nJof the Business and Pmfeesions Cnde.and mylicemeis
lWE, infall cCla.nd effect. PERMIT ISSUANCE
V License Class Lic.# L ❑KITCHEN REMODEL
rF H Dem Crouncor APPLIANCES—RESIDENTIAL. ADDITION El PLUMBING RE-PIPE
FPnwy
ARCHITECT'S DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
O''�O iy.,4 Fj 1 understand my plans shall he used as public recordsMODIFICATION
2 uPT02W AMPS El INTERIOR DCHIMNEY REPAIR
Licensed Pssroml
.yCCi
OWNER-BUILDER DECLARATION 201-IOW AMPS
IMPROVEMENT
OVER IOW AMPS El BATH REMODEVREPAIR DEMOLITION
I hereby.(Bon that 1 am exempt from the C..nions C s License Law for the
a0'U U following reason(Section]031.5,Business and Professions Care:Any city or county SIGNS ELECTRICAL ❑OTHER
O Va which requires a permit in construct,alter,improve,demolish,or repair any mmcwre
priormulf's...ce,also requires the applieunt for such permit m file.signed statement SPECIALCIRCUIT/MISC.
y that he is licensed pursuant...the provisions of the Conuncmr's License Law(Chapter 9
d0 (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or A TEMP.METER OR POLE INST. COMMERCIAL
d p, that io it exempt therefrom and the basis fns the alleged ox lieimon.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
fzXl N bylay hundred
permit mhjecm the appliwm toe civil penalty of POWER DEVICES
ps not more thou flue hundred tlnllars($SIXq. F]TENANT El FOOD SERVICE
I,es ownerofthe prmpeny,..r my employees with wager os their sole compensmion, SWIMMING POOL ELECTRIC ' IMPROVEMENT
will do the work,and the structure is not intended or offered fors.le(Sec.]044,Business ❑OTHER
and Professions Code:The Commerce,License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who hands or improves thereon,and who does such work himself or through
his own employees,provided that'mch improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FTr
owner-builder will have the burden of proving that he did not huild Or improve for par-
Imse..fsaleJ.
L] 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
consumer the project(Sec.7044,Business and Professions CW,:)The Convectors Li-
cense Law due,nor apply to an owner ofpropeny who builds or improves daemon,and QTY. PLUMBINGPERMIT FEE ��0
' whocontrams forsuch projects with acom ntructugs)licensed pursuant thre Contmerods G
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for this reason
OwnerALTER—DRAIN&VENT—WATER(G)
Date VALUATION
Y
Wm under penalty
DECLARATION BACK FLOW PROTECT.DEVICE J '0
O
I hereby affirm under penalty teperjury one of the followingorke'declarations:Cri
❑I hove and will for by
a Cion 37 a of the entLab r Code,for
forWorker's ce of er-the DRAINS—FLOOR,ROOF,AREA,COND.
winkfas provided for u Section 3]W of me Lahr Code,far 0c performance of the STORIES TYPE CONSTRUCTION
rk for which this permit is issued.' FIXTURES—PER TRAP
DYrI have and will maintain Worker's Compensation Insurance,as required by Section
�My of the labor Code,fur the performmaneeofinework for which t5hsis�permit is issued'mallinfiey . GAS—EA.SYSTEM-1 INC.40UTLETS OCC GROUP APN
My Work CySpe n 1 sum�L�VPolcyhfa /LC/Q�B� GAS—EA.SYSTEM OVER4(EA)
Cartier�� ��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASE/INDUSTRL WASTE INTERCEPTOR
(This section need not hecompleced if the permit is forone hundred dollars S Pap BUILDING DIVISION FEES
oro less,) GREASE TRAP PLANCHECK FEE
Icenify Oat inthe in perhouran,diameter
thew rk eeconewhich this permitrkesCompn- SEWER—SANITARY—STORM EA.2W FT. OI�
nota employ any person is any manner so as m hec..me subject m the Workers'Cnmpen- ENERGYFEE"ie c
satiorn Laws of California.Date
O WATER HEATER W/VLNT/ELECfR GR I GTE
O Applicant
y
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMII'REATING
become sobject ro the Worker's Compensation provisions of the Labor Care,you must SO '
a+ �
forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
� z I;lllr Ut-
'CONSTRUCTIONLENDINGAGENCY NEWRESIDENTIALPLMB. SQ.PT. PAID ' �hluYU
U I hereby action that there is a conswction lending agency forte Performance of at Ree pt#
W
the work For which this Permit is issued(Seo.309].Cie.C.)
Lender's Name
O U TOTAL: -
W Lender's Address TOTAL:
P i Icenify thm I have read this upplicmion and state that the above information is BUILDING FEE
rr lA content,I agree to comply with all city and county ordinances and sure laws relating to QTY, MECHANICAL PERMIT FEE /�•�
U 7, building constrnenlon,and hereby summiu representatives ofmisoy mercer upon the SEISMIC FEE
above-nicadmnal property for inspection puryoses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep howlers the City
of Cuperhou ngoinm ELECTRIC FEE 'J3#(�S"
liabilities,judgmems,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH, 1/3e1 r
in consequence of the grunting of this permit. PLUMBING FEE .l
APPLICANT U DERSTANDS AND WILL COMPLY WITH'ALL NON-POINT AIR HANDLING UNIT(TO IQ(100 CFM7
SOURCE RF ATION. MECHANICALFEE 'I
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX �Lp
Spillane of Al,luourtiCteraillom v Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION E
Will theappineubm future huildintimcupant,ome handle hozmdous amend HEATING UNIT(TO I Fiff"BTU) -
as defined by the Cupenin..Municipal Code,Chapter 9.12 and the Health add Safety
Code,Section 25532m)? - HEATING UNIT(OVER 100i"BTU)
[-]Ye.: Mal. 1
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or turn.building occuponr use equipment or devices which Dam Receipt#
emir hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(3HPOR IW,000BTU)
District? TOTA : p
FI Yes *m BOILER—COME(OVER I Off"B'ru)
I have read me hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCEDATE
Formal Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
buildin does Leurenif have tenant,that it is my responsibility mn..tif rho wcupnnt
of there mems iron I e men prior m issoanee of a CeniJf�m
�� p� �\ I\��
O orau
rlunzed.geo xDate TOTAL: ISSUEDBY: �+
OFFICE