28452 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, 28452^ w
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL LCVJ L
BUILDING PROJECT IDENTIFICATION
BUIL R SANITARY NO. APPLICATIONSUBMI ALDATE
0WInNAMET
Vto ``J N/C COMROL N
AR ITE EE
LTC No. ADDRESS' ❑ '
ONTACT PHONE: BUILDING PERMIT INFO
♦/ / ,♦ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB H
AS (VAC ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION - QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Czp wilh5ection70W)of ivin 3 sf theBntrasand ofessions y 'cense is PERMIT ISSUANCE RESIDENTIAL,
�W�. in full force and<B I. D SFDWL D KITCHEN REMODEL
U Ldo LIC.# APPLIANCES—RESIDENTIAL
Dam Conitactnr ❑ADDITION [I PLUMBING RE-PIPE
CHITE A ❑MULTI-UNIT [I STRUCTURAL
yl) tun rstandn a..1 be wed public. o PANELS MODIFICATION
Oz.. r UP T02lH1AMPS ',
„'u/+v€F' Lic Profession D INTERIOR D CHIMNEY REPAIR
lip .OWNER- _ 201-1000AMPS IMPROVEMENT
a BUILDER DECLARATION OVER 1000AMPS El BATH RE3=4
IQtfjC682` M;LIT10
yTa�9 I hereby affirm that I
OWNER-BUILDER
from theRINConnotation's License 1.nw for 1M1e ll/, J`Y i/—
Sd 3 0.F following reason(Sedisn703L5.Business end Professions Cnde:Any oily or womY SIGNS ELECTRICAL D OTHER y � ,7 —yam
W O which requires a Permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires to applicant for such permit to file aslgroulnumment SPECIAL CIRCUIT/MISC,
y� that he is licensedpursuantthe....idunsof the Contractor's License Law(Chapter 9
00 (commencing wit Section 7000)af Division 3 of the Business and Professions Code)or TEMP METER OR POLE INST. COMMERCIAL:
0.q m C tut be is exempt therefrom and the basis for to alleged exemption.Any violation of ❑NEW BLDG/ADDITION D DEMOLITION
{iYC k. Section 7031.5 by any applicant for a permit subjects the applicant to o civil penalty of POWER DEVICES DTENANT 'DFOO)SERVICE
s. nut more than Ove hundred dollars($500). IMPROVEMENT
rap ❑I,es owner of theprnperty,of my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and thesmormre a not intended...ffered f.rsale(Sec 704,U Business D OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
p'a property who builds or improves thereon,and who does such work himself or trough
his own employees,provided[hal such improvement;ore not intended or offered for NEW RESIDENTIAL ELECTR SQ EF.
sale.If,however,to building or improvement is sold withinone year ofcampletion,the SQ.FT.FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for pur-
Pose of sale.).
El 1,as owner of the parody,am exclusively contracting with licensed contractors to TOTAL:
amount t the project(Sen.70,14,Business and Pafeetme,Co.,,,The Conmactor's Li- (�
cense Law does not apply to on owner of property whit builds or improves tereen,and QTY. PLUMBING TV PERMIT FEE At pp��N
who contracts for such projects with a contionatmod licensed pursuant o the Contractors
License Law. - PERMIT ISSUANCE
I atm exempt under Sea. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Date VATUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affren under penalty of perjury one ofthepdnowing declarations; Gil Y Vr UUrtHfINO
ave and will maintain aCertifcate of Consent to self-insure forWmker's Camper- DRAINS—FLOOR,ROOF,AREA,COND. STORIES NPE CONSTRDCTION
$l
as provided for by Section 37M of the Labor Code,for to performance of the -
w kfm aillwhthispermito,ormed. FIXTURES—PER TRAP
have and will maintain Worker's Compensation Insurance,as gtr'(ea M1y Section
7 ofthe LaborC , ortbe eofthewolkita t ' b GAS—FA.SYSTEM-I INC.40UTLETS OCC.GROUP APN
My Work i and Policy n he _L11
Carie. e .[icy No.: GAS—EA.SYSTEM OVER4(EA)
ER FICAT�O EXEMPTION FROM WORKERS'
COMPF,NSATION INSURANCE ��''++ GRE SEII llST WAST I RCEPTDR BUILDING DIVISION FEES
(This section need not he completed if the permit is for one hundred dsllatrf$I TNI) ,
sabers.) YY I G 56'
II _ PLANCHECK FEF.
lcenify tat in the perPormance of the work for which this permit is issue Ishall t SHW�RIS N A = ' R 200 FT.
mol employ any person in any manner an as m become subject m the Workers' impen` ENERGY FEE
,Z ration Lawsof California.Dam
•� Applicant W TIE ENT Fl%PR GRADING FEE
h NOTICE TO APPLICANT,If,afar making his Cerdreme of Exemptipn,you ah
a �^ become subject to to Worker's Compensation provisions of the Labor t�da�.v.0 must __ SOILS FEE
w ry forthwith comply wi[hsuch provisions or his permitshall be Jeemed revoked. WATER SERVICE
Q CONSTRUCTION LENDING LENDING AGENCY NEW RESIDENTIAL PLMEL SQ.FT. PAID
U z ays thereby affirm tel twtry
em is lending agency for e pe.founince of Data Receipt#
!bto work for which this permit is Issued(Sec 3097,Civ.C.)
Lender's Nome TOTAL:
WLender's Address TOTAL:
Ir-'-"i a I cenlfy that I have.cod this epplicatlon and state Thal the oMve infortrellon is BUILDING FEE
t.r N cortect.l agreemcomply with all city anJ county ore, and stem laws relating to QTY. MECHANICAL PERMIT FEE
V building constrvction.end hereby autnriu repres ativesoft u nnywomeruponlhe 'SEISMIC FEE
above-mentioned prnpedy for inspe<tinn puHnr s,
(We),ractsrnve,indardefyandke harmlesstbe ityof Cnpertiu.agelnst PERMIT ISSUANCE ELECTRICPEE
Exhilides,judgmen[s.examandex n swhi htuayinany yacemcnga,nnsaid City ALTER OR ADD TO MECH,
inourearuwceufte granting this 6E ami PLUMBING FEE
UNDr TAN A WI.L COMP. WITH A.L NO -POINT AIR HANDLING UNIT(TO 10,(100 CFM)
S URGE RE( LD '0'
�T) MECHANICAL FEE
Cy/'1 AIR HANDLING UNIT(OVER 10,000 CFMJ CONSTRUCTION TAX
4
Slg of Appl o�tor me EXHAUST HOOD(WNUC)
' HAZARDOUS MATERIALS DISCLOSURE! HOUSING MITIGATION FEE
Will the applicant or future building swcupant store or handle hazardous material HEATING UNIT(TO I WAGE BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and to Health and Safety -
Coda,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
You El No PAID
VENTILATION FAN(SINGLE RESID) Date Rereiplq
Will to applicant or future building occupant use equipment or devices which BOILER—COMP(31{p OR 100.000 BTU)
mit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District/
DYes E]No BOILER—COME(OVER 100,000 BTU)
teadthe . muteP�-1191i"Y'erC apter6.95 fte ali- AIR CONDITIONER ISSUANCE DAT
is Health afety ode.S ion53 .I on mus tut f the NEW RESIDENTIAL MECH. SQ.FT.
b ,ngdres not ore lyhave rens ' litymy,yyyeeeyyyfy am pa f re ww eM1 mal meCertificif�6( 1 v —
VV
Ow raat.rizedagen - Dam TOTAL: ISSUED BY:
OFFICE