28959AFFLI(;ANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL -
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMITNO.
28959
BUILDING ADDRESS:
3 //r' er i
SANITARY NO,
APPLICATION SUBMITTAL DATE
1") --I 1-lS
O WE' HONE: ME:
CONT R'S AME: LIC NO:
NIC
❑
CONTROLN
%RCBJJECTPGIN= ' LIC NO:
13S
ADD S:
64seagler too -
CONTACT: PHONE:
per/ /i�el 7yS-/�
-
❑ Consultant Fees Paid by Applicant (initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I blomin 70 affirm that I nm licensed under ddPoprovisions.. ed Chapter 9 (commencing
with Seeti a unit e) of Division S of the Business and Professions Code, end my license is
in full (orae unit effect
License lass a
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
' RESIDENTIAL
D SFDWL D KITCHEN REMODEL.
❑ADDITION D PLUMBING REPIPE
El MULTI -UNIT "❑STRUCTURAL
MODIFICATION
❑IMPROINTERIOR
EMENT 0CHIMNEY REPAIR
D BATH REMODEUREPAIR D DEMOLITION
OOTHER
PERMITISSUANCE
Lic,
� D Course r
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
I understand my plans,hall he used as public reciml,
PANELS
UPT0200AMPS
c�] Lmenscd Pmfessmnel
3 OWNER -BUILDER DECLARATION
Ic 1 hereby affirm that I nm exempt from the Contractor's License Low for the
following renown. (Section 7031.5, Business and Transistors Cade: Any city our county
which requires a fiction or contract alter, improve, demolish, or repair any structure
poor to its issuance, also requires the applicant for such permit or rile a signed statement
£ that he is licensed pursuant to the provisions of the Contractor's License Low (Chapter9
D (commencing with Section 7000) of Division 3 of Ne Business and Professions Code)or
4 That he is exempt therefrom and the basis for the alleged exemption. Any violation of
n Section 7031.5 by any applicantfa a permit subjects the applicant to a civil penalty of
. net marc than five hundred dollars($50n. -
�1. as owner of Ne property, or my employees with wages on, their vale compensation,
will do the work. and the strucmrc is not intended oroffined for sale (See, 7744, Business
and Profession Cale: The Contractor's License Law does not upply to an owner of
property who builds err improves thcrcan, and who down such work himself or through
his own employees, provided that such improvements are not intended or offered for
vale. If. however the building or improvement is sold w Winona yloorit tmplotiov, the
owner -builder will have the burden of forcing that he did not build or improve for put.
posse wfsale.).
D 1, as owner of 0e property, am exclusively contracting with licensed contrecmrs to
colonel The project (Sec. 7014, Business and Professions Code:) The ConvectorI.I.
cense Law does not apply to an owner of pmpody who builds or improves thereon, said
whocarman forsuch projects with. coatilclur(x) licensed pursuant to Canmcmr's
License Law.
D 1 i m exempt under Sec. , B& p C for this taus,,
201-IOWAMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
I
-
TEMP. METER OR POLE INST. a
OMMFR IA .
❑NEW BLDG/ADDI770N ❑DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMEM'
DOTTER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FIXTURBS
NEW RESIDENTIAL ELECIR SQ FT.
SQ. FT. FLOOR AREA USQ. FT.
'
PAID Q pT
A's D
�^ ��
b
LUATION
r-(,urtHfIN(YA
TOTAL,
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE
Owner Dm
ALTER - BRAIN &VENT- WATER (CA) yNbr
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will mainmin a Certificate wfConwntto aelfinum for Workers Comped-
cation, as provided for by Section 3701 of the Labor Code, for Ne Performance of The
work for which This permit is issued.
D 1 have and will maintain Workers Compensation Insurance, as required by Section
37M ofthe Labor Cale, for the PeT(ormmnce ofthe work for which this permit is issued.
My Work mpensation as ca cr and Policy nu
Carrier: No,�'�de yrs I
CERTIFICATE FE FTION INN FRO 0 K R'
COMPENSATION INSURANCE
(This section rad not be completed Bihe permit is torose hundred dollars ($100)
or less.)
(certify Thrinthe anymannoro iliaass becomesuis bje this file Wisissued. 'Co sM1all
unionLaemploy any person in any mannerso asmbentme xuhjeutmthe Workeri Cnmpen-
cation Inwe of California. Data
Applicant'
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, C4152
, STORIES
OCC.GROUP
TYPE CONSTRUCTION
APN
FIXTURES - PER TRAP
GAS-EA.SYSTEM-IINC.401JTL
GAS - EA. SYSTEM -OVER 4TEAT
GREASF/INDUSTRL WASTE INTERCEPTOR
-
GREASE TRAP
BUILDING DIVISION FEES
.PLANCHECK .
SEWF - SAN[ "1'AHY-STORM FA. 200 FT,
MEFEE
ENERGY FEE
WATER HEATER WNENT/ELF.CTR '
GRADING FEE
NOTICE TO APPLICANT.IL after making this visnas of of Exemption. abodyoushould
become subject m the Worker's Compensation permit shat of 0e red Cale, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby offirthat there is a coperformancection lending agency for the performance of
Point
the work for which This pot is issued (Sec. 3097, Civ. CJ
Leader, Name
Lender's Address
I codify That 1 have read this application and state that The above information is
correct. I agree to comply with all city and county ordinances and shite laws relining in
building construction, and hereby authorise rcpresen atives of this city to enter upon the
aMve-mentioned property for inspection purposes.
(We)agrce to save, indemnify and keep harmless the City of Cupertino ogoinst
liabilities,judgmemscosuatbexpenses which may inny way,came apt.nstsaid City
in amsegne ,(the grunting of this Permit -
APPLIC T UNDERSTANDS AND WILL COMPLY WITH ALL NON -PO NT
SOU SRF ONS.
Signature of pplicaHAZARDO awe
HAZARDOUS MATERIALS DISCLOSURE
WillOeaMlicantorfumrebuildingacupantsmn: or handle hasammus material
as defined by the Canadian Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(x)1
Fly. 7 N
Will the applicant or future building occupant use equipment or devices which
(emit hvstdous ear contaminsms as defined by the Bay Area Air Quality Management
District?
❑Yes ON.
1 have read the to r makin s materials Onameaants ober Chapter 6.95 Of she Cali-
(aria Health at Safety Code, Sections 25505, 25533 and 25534, 1 understand dot if The
Wilding does not currently haves tenant what it is my resp risibility to notify The emotional
of Ne requimmenm which must be stet Poor to ietair. of o Certifinete Of 0mupancy.
WATER SYSTEM/IRGTING
SOILS FEE
WATER SERVICE
PAID
Data Reerftg "
NEW RESIDENT IAL TIME. SQ, FT.
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE "
PERMIT ISSUANCE
ELECTRIC FEE
PLUMBING FEE
ALTER OR ADD TO MF.CH.
AIR HANDLING UNIT TO 10.000 CFM)
- _
MECHANICAL FEE
AIR HANDLING UNIT (OVER 11,000 CFM)
CONSTRUCIDONTAX
EXHAUST HOOD(W/DUC) �
,
HOUSING MITIGATION FEE -
HEATING UNIT IM 100,000 BTU)
HEATING UNIT (OVER 101,001 BTU)
'
-
PAID
Date Receipt ot
VENTILATION FAN (SINGLE RESID)
BOILER- COMP THP OR 100,000 BTU)
-
- TOTAL:
BOILER- COMP (OVER 100,010 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL STICK SQ. FL -
Owner or authorized agent nam
TOTAL:
OFFICE