28775APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT,PEN ONLY
1.CJT,Y
OE,OOPERTJNO •- i.
0, -,, 'BUILDING -ELECTRICAL, s
PERMIT NO
'28775
BUILDING DIVISION • APPLICATION/PERMIT,
PLUMBING -MECHANICAL
q
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:^'
SANITARY NO. -
APPLICATION SUBMITTAL DATE
aao�r Px,bs,� L�el
5NIC
N
O NER'S NA1M1E:' c 1 PHONE, `'
1725
CO RACTOR'S/NAME: LIC NO: "
CONTROL H ., v
ARCHITECT/ENGINEER: LIC NO: .,
ADDRESS-
❑."
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/ryy"
CONTACT., PHONE:'
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BUILDING: PERMIT INFO
-'
❑ Consultant Fees Paid by Applicant (Initial)
" BLDG , ELECT 'PLUMB MECH
.
El ® ❑
•-
in LICENSED CONTRACTOR'S DECLARATION ^
QTY. ELECTRIC PERMIT FEE
s ns of Chapter? (comma°eas
1 hereby affirm Nat I ant licensed rude, provision,
JOB, DESCRIPTION
oaz
wish Secton 1000.1'D tithe Business dP f ami Code, and my license is
RESIDENTIAL
PERMIT
¢I W r,full
F -
1. p
force and effect
ISSUANCE
O SFDWL ITCHEN REMODEL
.�U
License Class Lick
' to Contractor
D
a
APPLIANCES -RESIDENTIAL
DADDITION MB RE -PIPE
•F". a y
, ARCHITECT'S DECLARATION .
PANELS,
❑ MULTLUNIT STRUCTURAL
Z8 5 zit
1 understand my plans shall he used as public n cams
-,' i
-
UPt'02fi0 AMPS
MODIFICATION
oz-^„
❑ INTERIOR. �CHIMNEY REPAIR.
Licensed Prof i
2014000AMPS
IMPROVEMENT ,
OWNER -BUILDER DECLARATION
OVER 1000 AMPS
❑B ATH REMODEUREPAIR' D DEMOLITION i
O y U
that I am exempt from the Contractors 1 e se Law forrho
1 hereby affirm m
following (Section 7031.5. Business and Professions Code Any city or county
SIGNS ELECTRICAL -
❑ OTHER
WO rFy�"
j
which req permit t c toner alter improve, demolish, or reed r invitation,
prior 0 its issuance, alsoq res the applicant fh permit tofile a signed statement
STECIACCIRCULVMISC.
m
p.
that he is I causedpursuant t the Provisions ofli Contractor's LLow (Chapter 9
..
0 �
(commencing with Section 70(eq or Dulkion 3 of the Business and Professions Cod ) or
TEMP. METER OR POLE INST.
COMMERCIAL: a
tY c a
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that he is exempt therefrom and the baste for the alleged exemption, Any violation of
'
❑ NEW BLDG/ADDITION ❑ DEMOLITION.,
Section 70315 by any applicantf perm[ subjects the applicant a i'Ip nahy of
POWER DEVICES :
'"
[]TENANT, El FOOD SERVICP.
%
[may d
t more than five hundred dollars ($5011)
fthepropetty theirole 'n,
SWIMMING POOL ELECTRIC i a
,
IMPROVEMENT
rya Q
01 eyemployees with wages as compensation,
willd Nework and that t not proffered forsale(S. 7044Bv.-ne.
[]OTHER
tai
and Prefts,iom. Code The Connectors Lmense Law does at apply to an owner of
, -
OUTLETS' -SWITCHES FIXTURESIj
�'
who bu Ids ar improves theregn, end who does such work h mself or through
- - '•
1
property
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL ELECTR - SQ FT
-
!'-
sale. If, however, the t is sold one afcom lettnn. the
building improvement Y P
SQ. FT. MOOR AREA,
$/SQ_IT.
owner builder ill have he burden f p' vmg t t he did not build prove for par
_
g^_ p -
pose f le) +
n
a'N
LLP•.
1 a, owner of the property, d rely a acting with I e sed retract ,1 t
ons[ ctthepoject(Sec 7044 Ensure, ro t Cod t t L
TOTAL:
S
,.
cerise Law de of apply tee roti builds
piyx inn area and
who ntme'af rsu r rchips)lit s d tut ontuatrra
QT'y. •< PLUMBING PERMIT FEE
i
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- v S79
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Lie°vsa Lew
❑ itoo_mpt ,ie ,B&PCfallbswavom
PERMIT ISSUANCE
Owne Data
T
ALTER- DRAIN &VEN- WATER (FA)'
- -
^ VALUATI Y
-
WO OM SATION DECLARATION
BACK FLOWPROTECT.DEVICE
I h troy -R- er penalty ° perjury one of the following declarations:
�I]Ihave
and will maintain a Certificate of Consent o se'lif-insure f' -Worker s Compere-
DRAINS -FLOOR, ROOF, AREA, CONTi
TYPECONSTRUCTION
sation, as provided for by Section 3J0H of the Labor Credo, for the antacids,
_
.STORIES
-
this permu cued. -
FURES- PER,TRAP
IXT
•
+
Ach
d will maintain Worker', Compensation tax umnce a roq°Imd by Suraima
_
-
3700 of the Labor Code, for the peiformance of the work for which this permit is issued.
'GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
APN
My Warm, Cpen ion losranee carrier and Policy°umber•
Carnot: �•us I ' PolicyNn: %��
GAS -BA. SYSTEM-OVER4(EA)
.•,
" .+ CERTIFICATE OF EXEMPTION FROM WORKERS',
COMPENSAGONINSURANCE ,-,
GREASE/INDUSTRL WASTE INTERCEPTOR..yq
.. w4.n e • BUIL"DING DIViSIQN
.
PCBSr-'
-
(Thnssectronaeedmt be completed if the permitis foram, hundred dollars($ 100)
or less) -
GREASE TRAP:. -
PLANCHECKFEE
I Imrtifythatiniheperformance of the work for which this permhls lssucd,ishell
'
not employ any person in any manner so as to become suhjed to the Workers'
SEWER -SANITARY -STORM EA'. 200 FT.
-
ENERGY FEE ,
Z
2WgTER
sation Laws of California. Date
Applicant - - ''
HEATER WNENT/ELECTR
GRADING PEE.
rq
NOTICE, TO APPLICANT:If, after making this Certificate of Exemption, you should
WgTERSYSTEMITREATING
-
F"
become subject to the Worker's Compensation provisions of the Labor Code, you must
SOILS FEE
Wforthwith
comply with such provisions or this permit shall be deemed revoked
WATER SERVICE
-
ao'
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLMB. SQ, FT.
PAID•
VQ
I.fb
I aconsw fun len ding agencyfor the performance of
Date Receipt is
this
the work for which th sp lsiswed (Stu. 3097, Civ. CJ
t farsprmit is
--.e
OE't
Lenders Name - -
-
T
r TOTAL,
•W
Lenders Address -
1 certify that 1 h d this appl at on and state that th hInformation is
_
BUILDING FEB
V)
coma l agree to comply with all city and county ordinances and state laws relatinglo
QTY. MECHANICAL PERMIT i FEE
'
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building construction, and heebyuthofze reprewimatves of this city to enter upon the
SEISMIC PEE
above-meneoned property for inspection purposes. -«
PERMIT ISSUANCE
BL9CTRICPE2
_
(We) agree m save, indemnify and keep humdess the City of Calami°o again,
liabilities,jodymaats, creta and asperse, which may i° any way accrue against said City
ALTER OR ADD TO MECH.
,
in consequence of the granting oftbis pcmtit.
PLUMBING FEE
'APPLICANT UNDERSTANDS AND . CO PLY,- WITH ALL NON -POINT
-
AIR HANDLING UNIT (TO 10.000 CFM)..
MECHANICAL FEE
SOURCERE(, rI015. s
_ -
-
d! •
AIR HANDLING UNIT( OVER 10,000 CFMy
CONSTRUCTION TAX '
-
Sign eo Applicant/CetameDone
EXHAUST HOOD(W/DUCf)
HOUSING MITIGATION FP.E-
-HAZARDOUS MATERIALS DISCLOSURE -
-
Will the applicant or future building occupant smreorhandle hazamous material
HEATING UNIT (TO 100,000 BTU)`
as defied by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety,
'
Code, Section 25532(a)P
HEATING UNIT (OVER lading) BTU)
-
•
❑Yca °' ❑N °
VENTILATION PAN (SINGLE RESID)
PAID
-f --
WIII the applicant or future bIlding mr.,am use eplipareal or devices which
-
Data Receipt#
th m contaminants retired by the Bay Area Air Quality Management,
BOILER -COMP (3HP OR 100,000 BTU) - -
,
•
District?
,< TOTAL
Yes ' ❑No �'a, e
,
BOILER- COMP (OVER 100,00013TID
- t
-1 have reed the hazardous materials requircmems under Chapter fi.95 of Ne Cnli-
Al R CONDITIONER
ISSUANCE DA
hands Health &'Safety C de Sell rte 25505 25533 and 25534 1 andermiLinfilen if the
-
NEW RESIDENTIAL MECH. SQ. IT.
building does not cenently e t m t y pons btllyt n ufyN ..apart
'• .
o
of here isw the n i.. ttnf f ie fOccuWny.
.0
Owner N dagent ,• Date
a TOTAL:
ISSUED BY
OFFICE