S 0928 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. P FF NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL 0928
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - � SANITARY NO. APPLICATION SUBMITTAL DATE
osci f vu`� l (__LACAi7
IOW 'SN F.: H NE: CONT CTOR'S ME: LIC NO:
N/C CONTROL N
ARCHITEC'VENGINEER: LIC NO: ADDRESS: ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby alarm that 1 am licensed ander provisions of Chapter 9(commencing JOB DESCRIPTION
FWOmz with Section 7")of Division 3 of the Business and Professions Code,and my license isRESIDENTIAL
D full force, t PERMIT ISSUANCE.
�.. in � �n, I..,a.`b FDWL El KITCHEN RE-PIPE�UU License I LIc.M RW APPLIANCES-RESIDENTIAL - El ADDITION El PLUMBING RF.-PIPE
yLLl Dale Contractor_ ���
b.7H ARCHITECT'S DECLARATION PANELS 11 MULTI-UNIT ❑STRUCTURAL
ZO Z P1 O I understand ra plans shall be used i s public recoNs MODIFICATION
:1 UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r4�Ls.1l Licensed Professional 201-1"AMPS IMPROVEMENT []SWIMMING POOLS
G5 C •a] Oat I ma vUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION
1 hereby affirm that 11. exempt from the Contractor's License Law for the
Cyy,�6d O U following reason(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W'3 c F which requires a permit to cons mer.ante improve,demolish,or repair any structure
��
prior o its issuance,also requires Ne applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
yNat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9
w p0 (wmmcncingwlth Section 7Wn)of Division 3 oftbe Businessand Professions Code)or TEMP.METER OR POLE INET. COMMERCIAL,
d o K that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicam far a permit odoests the applicam to a.,,it penalty of POWER DEVICES
t more than five hundred call... El TENANT ❑FOODSERVICE'
7�Y IMPROVEMENT
< D 1.,she workfthe pmperty,or myemptended with wages Bred foaal.(Se 70,44,Bminun, SWIMMING POOL ELECTRIC
INN dmhe work,and theTactor Contractors
not intended numbered due,but apply ](N4,Business El OTHER
m end Pmfessinns Cede:The Contmcnsr's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXT'UkE
6'3..
property who builds or improves thereon,and who dues such work himself or through - _
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
.sale.If,however,the building or improvement is sold within one year of completion,the SQ.,FT.FLOOR R A $/SQ.PT.
owner-builderwill have the huNen of proving that he did not build or improve for par- Not/
of aaleoe
❑1,as meme,of the property,am exclusively command,with licensed contmemta m T67A1,1 //11
construct the project(Sea.7044,Business and Professions Cale:)The Contmemts Li- 01-'
cem a Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT � Y6/=UN
who contracts forsuch projects with a contraemr(s)licensed pursuant to the Contructtur's _ ` ly
License Law. PERMIT ISSUANCE Q
lamexemptunder Sec. ,B&PClmthmonton
Owner Date ALTER-DRAIN&VENT-WATER(EA) p VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE "1
I hereby affirm under penalty of pmjury one of the fallowing declarations:
❑I have and will numaimna Comments,of Consemmself-insarefor Worker's Compen- DRAINS-FLOOR,ROOF,AR EA,COND. STO S TYPE CONSTRUCUON
,ation,as provided for by Section 3700 of the Labor Code,for the pertornvnce of the
work far which this permit is isaued. FIXTURES-PER TRAP U�- 911
•�Ll have and will maintain Workers Compensation Insurance,as required by Section w
r.
3](Nl of the Lahnr Code.fmthe pertnrmance of the work for which lM1is permit is issue]. GAS-F.A.SYsFEM-I INC.4 OUTLETS
CyrWmIca"rrynpencelem Insurance carrier and Policy
olitwmhef-a :yQ\I GAS-EA.SYSTEM-OVER 4(EA) OC DPN
�a��o .
let �I 11 IICEERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section rad nm becompleted ifthe permit is forone hundred dollars($10(1)
or less.) GREASE TRAP PLANCHECK FEE
certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
nnm
not employ any person in any manner so as to beene sibbil to the Workers Compen- ENERGY FEE
O2 sauna Laws of C.Iirnmb Date WATER HEATER WNENT/ELECK GRADING FEF.
12 Applicant
r7 lin NOTICE TO APPLICANT.If,aftermaking Ili s Ceniticate of Exemption,you should WATER SYSTEMITREATING
abecame subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W forthwith comply with such provisions or this pernitshall he deemed revoked. WATER SERVICE
Q
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date Receipt N
1 hereby affirm that there is construction lending agency for the Performance of
L) the work for which this permit is issued
ue)(Sec.3057,Civ.CJ
L ,Name TOTAL:
C)
� V Lendermyk,'s AJdress - � TOTAL:
D+[ pf E.r 1 certify that 1 have read this application and Stam thin the above information le BUILDING FE
i..ih correct.l agree to comply with all city and county ordinances and slate lows minting to QTY. MECHANICAL PERMIT FEE
U building constmction,and hereby amhorire representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FE
ag
habit fics,judgmerm.costs and expenses which may in any way aecme against said City ALTER OR ADD TO MECH.
in m nparree of the granting of this permit PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14110E CFM)
S`-OyUtR�CE REGULATI.O/N.1 /I'f MECHANICAL FEE
/// 1 / /00 II JJ9 / AIR HANDLING UNIT 10,WO CFM) CONSTRUCTION AX
Signamreof pllean Contractor Dart EXHAUST HOOD(W/DUCT) HOUSING MIT TION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building owupamm
are or handle hicadom amimul HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CMe,Section 25532(x1? HEATING UNIT(OVER Id4(NN)BTU)
❑Yes yNo - VENT ILATION FAN(SINGLE RESID) PAID
1 Date Be iIn#
Will the applicaminor futare building byexcepand the
eea Air Quordevice,which BOILER-COMP(3HP OR 100,000 BTU)
' limit hseerdoos air contaminants vx def red by the Bay Area Air Quality Management TOTAL:
DislnbB
I
El Yes - �No BOILER-COME(OVER 100,000131H) _
Ihave read the haamdons marginals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
bu,ing does not cutrcmIy have a enant that it is my responsibility to notify the occupant
oI requirement whic4 u: h mm prior to lssuwee ofe Conificate of Oo panty. _
rf
Ow r agent ate TOTAL: ISSUED BY:
OFFICE