29357 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'BUILDNG-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 29357
BUILDING PROJECT'IDENTIFICATION
UI NO ADDRESS: tSANII'ARYNO. APPLICATIONSUBMI'ITALDATE
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OW Falt'S NAM : PHONE: C RACIpR'SNAME: LIC NO:
t O -�s• 7 Nd S n1d �IvLtk.�t`AU NC, CONTROL#
RCHI I'ECl'/ENGINEEIL LIC NO. RIiSS: ❑
&3 (3o rA r 1))Z, S .C. c Ft qJ
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ElF-1
CONTRACTOR'S DECLARATION 9 QTY ELECTRIC PERMIT FEE
MXZ I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Stttion]IXlp)ofDivision3ofrhe Business and Professions Code,and myliccnse is
F.0 0 PERMIT ISSUANCE RESIDENTIAL:
F it full forces effect. -
IUU License Class Licp OSFDWL ❑KITCHEN REMODEL
NQd Dale Contractor APPLIANCES-RESIDENTIAL OADDITION '. El PLUMBING RE-PIPE
1_7m ARCHITECTS DF,CL RATION PANELS OMULTLUNIT OSTRUCTURAL
Z O y Z dors my Iany�hall MODIFICATION
OZN� ✓. UI'T0200AMPS OLNTERIOR C)CHIMNEY REPAIR
IF�FW X015awal Professional 201-1(I(st IMPROVEMENT '
aa OWNER-BUILDER DECLARATION OVER NMAMPS O BATH REMODEUREPAIR OUEMOLIT[ON
C� ,
% Q I hereby affirm abut I um exempt from the Contractor's License Law hrr the
X3 i U following reason.(Section]031.5.Business and Professions Calder.Any city or county SIGNS ELECTRICAL ❑OTHER
W "N which reyaim,a perarm to c.Ntmcl.alder,improve,demolish,err repair any,tmatre
0Q prior to its issuance.also requires the applicant for such Permit o file a signed statement SPECIAL Cl RCUIT/MISC. '
U) Natheixlicensedp...art to the provisions ofrhe Comactor's License Law(Chapter 9
X0.00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)err TEMP METER OR POLE.INS . COMMERCIAL: _
0.0.e that he is exempt there(m and the basis for the alleged etlioulnn.Any violation of ❑NEW BLDG/ADDITION O DEMOLITION
th
^m
Section]031.5 by any applicant for a permit subjects e applicant to a civil penalty of POWER DEVICIS
F Z Y dollars(5500. OTENANT ❑FOOD SERVICE=Q O1,as owner of the propery.or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
Sy+FO wi11dothework.end themmcture is our intended mattered forale(Sec.704i,Business OOTHER
and Professions Code:The Convector's Litmnm Law docs not apply to an owner of OUTLET'S-SWITCHES-FIXTURES
property who builds or initiatives thereon,and who does such work himself or through -
his can employees,provided that.such impmvementa arc nm intended or offend for NEW RESIDENTIAL ELECTR FT.
sale.if,however,the building or impmremem is.sold within one year ofcompletion,the SQ.IT.rLOORAREA VSQ.FL
costar-builder will have the burden of proving that he did not build or improve for par-
pose of sale.). Al
1,as owncr of the property,am excI siv It'contracting with Licensed contractors to TOTAL: r Q'
va,arml he p j ct(Scc.7004 B a ad]'.if .Code)'rhe Caatmrta,I �T 2�
c me Law does notapply it) fpr pent'who builds or improves thereon and QTY. PLUMBINGPERMIT FEE
whocontractsf such ) t 'th tautrt)I sed pursuant to the Contractors �9gs
License law. tPERMIT ISSUANCE LG!•
O lamexemptnader Sec. _ ,B&PCforthismason CN�7 r
Owner Ume
ALTER-DRAIN&VENT-WATER TA) VALUATION
'
WORKERS COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
1 hemby affimt under penalty of perjury one of Ne following declaration,
Ihave and will maintain tCerifcam of Consent to,elf-insure for Workers Compcn- DRAINS-FLOOR:ROOF AREA.COND. STORIES TYPE CONSTRUCTION
stairs,as provided for by Section 37M of the Labor Calle,for the performance of the
work for which this)smut is issued. FIXTURES-PER'rRAP '
I have and will maintain W..an,Compensation Insurance,as aequited by Section
37W of Ne laMsrGen,ftperkmaroaccofthc work fw hieh this permit is is%ua. GAS-EA.SYSTEM-1 INC.4 OUTLMS
on InsurOCC.GROUP APN
My Workers Compensatiance artier end Policy number a2:
Cartier: 6Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION
(This scent.need not hecompleied if Nc permil is forme hundred dollar,(SiNd FEES
ur less.) - GREASETRAP PIANCHECK FEE
I certify Nat in the performance ofthe work for which this Permit is issued Ishall SEWER-SANITARY-STORM P.A.2W IT.
ort employ any person in any manner so as to become subject to the Workers Compeer- ENERGY FEE
Z. wins laws of Calif armic Dam WATER HEATER WNENT/ELECTR
7� O Applicant GRADING FEF.
q N NOTICE 10 APPLICANT If:after making this Cenilicme at Exemption,you should WATER SYS]'EM(I REAL ING
a 7 become subject to Lie Workers Compensation provisions of the Labor Code,you must SOILS FEE _
forthwith comply with such proOsionsor this Permit shall be deemed merked. WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
V y. Lherewhich thi tIADherc isa.iton lending agency for the performance of Date RemiptM
the wurk Tia which this lwnnh a issuad(Sc,ISv71197,Civ.C,)
ULender's Nume 'TOTAL:
Lenders Address 1
�• I certify that 1 have read this application and stat¢that the above information is BUILDING FEE
F racy correct.l agree to comply with all city and county ordinances and state laws renting to QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby authorize representatives ofthis city mender upon the SEISMIC FEE
abavementit vid p o,any lin Inspection puaposes' 1'17RMIT ISSUANCE
(We)agree m save,indemnify and keep harmless Ne City of Cupertino against ELECTRIC 171711
habilities,judgmeres:crsts and expenses which may in any way scenic against mid City ALTER OR ADDTO MECH. PLUMBING PEE
in consequence of the granting of this permit.
APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
S 'ER- ULATIONS� h1ECHANICA1.FEE
�. � .ser�-I Lit'f� NRIIA.1'OLING UNIT(OVEN ItI,IXIt1CFM) CONSTRUCUON'IAX
,ignamrc of ApplicanisContractor Date EXHAUST HOOD(W/DUCry HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building acceptor stare or handle hazardous material HEATING UNIT TO 100.000 BTU).
as defined by the Capcnino Municipal Cade,Chapter 9.12,and the Healtb and Salery
Cral Section 255I2(a)'f HEATING UNIT(OVER 100,000 13 IU)
F7 Yes 0 N VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt M "
emit bazaNrus air contaminants as defined by the Bay Area Air Quality Manugemcn, BOILER-COMP(3HP OR IW,000 BTU)
TOTAL:
DistneG BOILF,R-COMP(OVER 100.000BTU)
O Yes ON.
`
Ihave orad Ne haamdous materials uluitements under Chapter 695 of the Cali- - AIR CONDITIONER" ISSUANCE DATE
Ratio Health&Safety Cade,Sections 25505.8533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. -
Wilding docs and currently have a truant.that it is my responsibility to notify tits occuptnt
of the mquimmems which most Ire in primm issuance oft Carficade of Occupancy. �`-{'-(/ 1A`
Owner or oat cane d agent Dam TOTAL: ISSUED BY: v✓— - '5)
f OFFICE