28998 APPLIUANT TO FILL IN INFORMATION WITHIN RED LINES-.USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICALi PF.RMI'FNO, 2 a.a A A 8
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L CSJr JJ��,/J lYJ
BUILDING PROJECT'IDFNTIFICAFION
BUILDING ADDRESS: - - - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: C AC R'S MF/.: NO:
e e (� fQ� NIC CONTROLN
•ARCHITECTTSIGINEER: LIC NO. n sl ,S J loo vv-lo
oNl'nCf: PHONE: ' BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLIDDG/ELECT PLUMB MECH
' LICENSED CONTRACTORS DECLARATION QTY. F.LECTRICPERMIT FEE
I herahy afrtrm that I art,licensed order provisbms of concern 9(emoneruag JOB DESCRIPTION
1Qy0O wit Section700B]Iyyf Division Jofthe Business unJ fes'emsCo yliccmeis PERMIT ISSUANCE
F{y�, in full force anJ.lfre 1, FDWL ❑KITCHEN REMODEL
�FUzU Licen. Class LC!! Limp NCFS-RESIDV!T1AL ❑ADDITION El PLUMBING R&PIPE
W 6 Dm� ntracm
E.Dy ,ARCHITECTS DE gNLLS ❑MULTI-UNIT []STRUCTURAL
1 u thadand my plans sh ll be used os puhlic records MODICAI ION
oz g - 11PT02(NIAMPS 'DIMI'FIUOR IMNEYREPAIR
r tO„E'tB Licensed Profcs.ionul 201-I001IAMPS IMPROVEMENT
S 0 Z Oat I am exempt LDER
UIiCe Contractors
ON OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
LLy C' 1 hereby.(Sect that I S.S.eaempl from the feWa, License law for the
�(�LV 'Inelk ingreosoo.(arrol1 ]OJLmt, fares and Pe'deaons Code:An,city.,county SIGNS ELECTRICAL []OTHER
41aW which its isssapemst tocveuouct,lireitnprove,demolish,nr,a tir,nysouclure
(r�� pat he isscensed e.aborego the previsions oto fon Conarermiunicense aw(Chmmcut SPECIAL CIRCUIT/MISG
��}
that he itcinvsWpursuant 70th))provisionsof there Business
nssnti Proe Woo(Chapter
C� (commencing whhSmion]glll)of DivisionO of that Uusineas mAlknfcysloos Code)or TBMP.MUTER OR POLL'INST. COMMERCIAL,
NSA
c C that he is exempt therefrom and the basis for the alleged exemption.Any violmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
an,
Section 7031.5 byany applicant box the applicant to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SI?ItVICE
t more Nen live hondead dollars S500). -
FZ_Y - - IMPROVEMENT
60Lma othe work,the pmpeny.omyemployees with wages as their safe compensation, SWIMMING POOL ELECTRIC
will do me work,and the swctureisnm intended offervill does of apply In
Business ❑OTHER
and Peaks ions Code:The Contractor's License Law dews not apply In an owner of OUTLETS-SWI"fCHFS-FIXTFEES
pmpeny who builds or improves thereon,and who does such work himself or through '
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FI'.
sale.IL however,the building or improvement is sold within one year of completinn,fle SQ.FT.FLOOR AREA S/SQ.IT.
ousence-builder will have the burden of proving that he did not build or improve for pun-
false ofsale.). r -
01,as ownr of the property,um exclusively contracting with licensed contractors to TOTAL:
conswcl the project(See.70,I.Business and Professions Code)The Contractors Li-
cenwLaw does nal apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts forsuch projects wit a contractors)licensed pursuant m the Crmruce is
License law. PERMIT ISSUANCE
1 am exempt under See. B&P C fur this mason
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Owner Dam -
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE. /���
1 hereby affect,under penalty of perjury one of the following declarations:
❑I have and will maintain a Canifcam ofConscnnn self-inmrc for Workers Compen- DRAINS-C_OOR.ROOF,AREA.COND.
satin cur ed far Iry Seed i 3700 of me Lunda Gale,for the pctlinmmnce of the _ STORIES TYI'H CONSTRUCTION
ark hinh this pemdl is issued, IgXTUR[5-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
3]0DctJinnI�R'o/ly�' ohoyrJc�nde,�for Jthe yperformance of the work for whicghhtis peorntt/fs's d1`/, GAS-ISA.SYS TEM-I INC.4 OUTLETS OCC.GROUP APN
Carricr:`••� sat �r Pot[Y Nn.ticad Ya_ - �/ • r" GAS-EA.SYSTEM-OVER 4IRA) {
CERTII'ICATB GF BXIiMPOON FROM WORKERS' a
COMPENSATION INSURANCE GRFASMNDUSTRL WASTE INTERCEPTOR
BUDDING DIVISION PEES
(This section need no,M completed iOhe parole is fnrone hundred dollars(S 1110)
or two.) GREASH'I'RAI' I'LANCHECK PEE
I ccnifyema,in the performance of the work for which tis permit is issued,i shall SEWER-SANITARY-STORM CA.2W FT.
not employ any person in Say manner so as to become subject m the Workers'Cotnpen- ENERGY TEE -
,`{ cation laws.1 California Date WATER IIFATIiR WNF.NTIEhF.CfR
z 0 GRADING FEE
LZ.t Applicant NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMIFREAI ING
I-' become subject to the Workers Compensation provision.of me Labor Code,you must SOILS FEE
W,7 forthwith comply with such previsions or this pemrit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENUINGAOENCY NEW RESIDENT IAL NLMB. SQ.Ff. PAID
Q I here by e�thi mat them iso ed(yia,.30 lending agency for to peAomtanre of Data - RecciptN
kit the work for which this perm N Issued(Sec 3119],Civ.C.) -
F••s Lender's Name TOTAL:
LJ Lenders Address TOTAL:
f7e u' 1 eettify that l have read this application and stain that the uhovu infomimion i. BUILDING PEE
�-t y correct l agree to comply with all city and county ordinances and itate laws relating to QTY. MECHANICAL PERMIT FEE
U building conswctioti,and hereby authorize representatives of this city to enter upon the S13TSMIC FEE -
above-mentioned properly for impeginn putpou.. PIiRMI'1'ISSUANCE
(We).,mto save,indemnify and keep hermless the City of Cupertino against BLECIRIC FEE
Iiahilideejudgmenls,costs and expenses which may in any way ocemc ugairstwid City ALTER OR ADD TO MI;CH,
in con.segoence office granting of this permit PLUMBING FEE
APPLI INDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOU r NS. CONSTRUCTION
NeE
,�n�yr.j`.VJ AIR HANDLING UNIT(OVER IO,WO CPM) CONSTRUCTION TA%
Signamroof Appllca /Cont Dam EXIIAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HA OUS MATERIALS DISCLOSURE
Will to applicant or future building occupant store orhandlehaardousmatenal HEATING UNIT(TO IIXLIXq BTU)
as dented by the Cupenum Municipal Co e,Chapter 9.12'and the Health and Safe,, '
Cade,Section 25532(x)^ HEATING UNIT(OVER IOQOOO BTU)
C Yes VENTILATION PAN(SINGLE RESID) PAID g3 #
Will too applicant on future building em or Devices which D pt
pp goccupanI use Nuipm
limit hazardous in contumacious os d by the Bay Area Air Quality Management IXIO BTU) P;
District? def BOILER-COMP(JHP OR 100,01) TOTAL:
❑Yes No BOILER-COMP(OVER IM,0001111H
read the
I have, hazardous materials reuirements under Chapter 6.95 of the Coll- AIR CONDITIONER
q p ISSUANCE:DATE
forme Heap&Safety Code,Sections 25505.25533 and 25574.1 understand that if the NEW RESIDE IAL MECH. SQ.FT.
building Nes not currently have a tenant,that it is my respmsibility to notify the occupaut
of Ne requirements which must le tree prior to issuance of a Cenllleam of Occupancy.
Owner or authorimil u,nt Dam TOTAL: , 1
OFFICE