28722 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.-
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 28722
BUILDING PROJECT IDENTIFICATION
e ES - SANITARY NO. APPLICATION SUBMITTAL GATE
E PHOQ— —a CSTOR' NIC CONTROL#
GINE R LIIIC,,1IIfNO:PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT , PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm[bat I am licensed undecprovisines of Chapter 9,(commencing JOB DESCRIPTION t
�0 with Section 7")of Division 3 ofthe Business a Pr cesium, e, d ylicensets PERMIT ISSUANCE RESIDENTIAL: t
F O ull force as t. /1,
U U License C s_ C- teT,l Lic.# ` [ISFDWL [I KITCHEN REMODEL
in f
�.�4W Date Convict APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DE ION - ❑MULTI-UNIT ❑STRUCTURAL
TF.. 1 mnderstand m la PANELS
y p P1'� y p ns shell Fs used at.public remNs MODIFICATION
OZ D UP TO AID AMPS - ❑INTERIOR C1 CHIMNEY REPAIR
�+ Licensed Professonal -fqi 201-1000AMPS IMPROVEMENT.
OWNER-BUILDERexempt
fr..
DECLARATION
1 hereby affirm e
that 1 am exempt from the Canvernr'a License Law for the OVER I WO AMPS (]BATH REMODEIJItEPAIR El DEMOLITION.
ip5, 4 U following renson.(Sermon]031 5, SIGNS[LECfRICAti
Business and Professions Cade:Any city or county - [30TH
ER
W it 0 I. which requires a permit to ems`truct,alter,improve,demolish,or repair any structure
h prior to as issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
<� that he is licensed pursuant to the provisions of the Contrivance's License Law(Chapter 9
COa (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
4 0 4 that he is exempt therefrom and the basis for the'alleged exemption.Any violation of _ ❑NEW BLDG/ADDITION ❑DEMOLITION
'^LL• Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of POWER DEVICES
[[F••... ,7N. not more than five hundred dollars($501). TENANT OF ODD SERVICE
6 O l,aso.wedrheproperty,way employees'with wages as themrsolecompema[ian, SWIMMING POOL ELECTRIC IMPROVEMENT
G will dote work,and the structure is not intended orweram for sale(See 7W4,Business ❑OTHER
and Professions Cade:The Contrarnr's License Lew does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
.. property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR •SQ ET.
sale.If,however the building or improvement is sold within oneyearafeampletion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have•the burden of proving that he did of build or improve for put-
, pose of sale.).
0 I,as owner of the property,am exclusively contracting with licensed conuacmrs to TOTAL:
consumer the pmjpr(Sec.7044,Business cad Professions Colon The Contractor's Lm- 0
cense Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a eontracmrp)licensed pammem to the Contractor's
License Law. PERMIT ISSUANCE
❑l am exempt under Sec. ,B&P C for this reason
Owner
ALTER—DRAIN&VENT—WATER(EA) VALUATION
— - Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herebyaffirm under penalty of perjury one ofthe following decision.am: I '
I haveand will maintain a Certificate of Consent to self-inmre for Worker's Compete DRAINS—FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
to, as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued FIXTURES—PER TRAP
0 1 have and will maintain Workees Compensation Insurance,as required by Section
37W of tb Labor Cod�y(me perf rmance ofthe work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS
MyW er' Co ` ' n neuron carrirend Policy v _ OCC.GROUP APN
Carrier Policy Nn.: GAS—EA.SYSTEM-OVER.4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
section need not be completed ifthe permit is foram hundred dollars ISIWO GREASE TRAP
ode's.)
I certify that in the performance of the work furwhich this permit is issued,I shall PLANCHECK FEE
not employ any person i any manner so as m u
become subject the Workers Compen- SEWER—SANITARY—STORM EA.200 FT. ENERGY FEF.
O ,� sermon Laws of Californiaa.Date i WATER HEATER W/VENTMLECTR
O Applicant - GRADING FEE
NOTICE TO APPLICANT,IL after making this Certificate of Exemption,you should
WATER SYSTLMITREATING a SOILS FEE�^ become subject to the Worker's Compensation provisions of the Labor Code,you must _
Cis forthwith comply with such provisions or this permit shall be deemed re WATER SERVICE
] z CONSTRUCTION LEND I GAGENCY l/'����/�J NEW RESIDENTIAL PLMB. SQ.FT t PAID -
U O Thereby affirm than there is aconsumctiun le agency f(;21e donamene of _ Date Receipt#
L4 H [he work for which[his permit is issued One.3097 J /// t.
O Lender's Name TOTAL: '
{U Lender's Address TOTAL:
M 1 certify that 1 have read this eppit lion to at a above tumor morn is BUILDING FEE
y correct.I agree m comply with all city an ry o s and state laws relating to QTY. MECHANICAL PERMIT FEE
U `7- building construction,and h y or e presents ofthis city to enter upon the SEISMIC FEE
above-mentioned property to sp pu ✓✓✓ -
PERMIT ISSUANCE
(We)agree m save,' and kaless the City of LLpertlnn against ELECTRIC PEE
liebiliries,judgmems,costs and ex es which many way wrote against said City ALTER OR ADD TO MECH.
mnconsequenceofthegrantingofth emit.
PLUMBING FEE
APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON,POTNT AIR HANDLING UNIT(TO 10.0(10 CFM)
SOURCE REGULATIONS. MECHANICAL ME
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX _
Signature ofApplicamu Contractor Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or firman building occupant smrem handle hiounchus material HEATING UNIT TO IW,OOn BTU) 1
as defined by the Cupenion Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(¢)7 HEATING UNIT(OVER IOEOOy BTU)
FI Yes Endo VENTILATION PAN(SINGLE RESID) PAID O_.LTLU
Date ReceiptI' #
Will me applicant or furore building occupant use equipment or devices which r
it hazardous it contaminates as demand by the Bay Area Air Quality Management BOILER.COMP(3HP OR 100.000 BTU)
TOTAL: 3�
tnctT BOILER IW,11n00TU)
oo
EYes Enda � ,
I ¢'read the aMnus ma[ermis re is under Chapter 6.95 of the Cali- AIR CONDITIONER
P ISSUANCE DATE
forma Safe, Cada Section 55 and 2553 dcrnand Nat if the NEW RESIDENTIAL MECH. SQ.PT.
Ed oes actc ndy haves it' y on[ify Ne occupant
requmreme which met mise norTfD p_ •' ✓,�as-�
rte authorized m I TOTAL: ISSUED BY:>; OP H/s+719/✓U�ei
OFFICE