28714 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO a1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. 28
BUILDING PROJECT'IDENTIFICATION
BUILDINGADDRES : - SANITARY ND. APPLICATION SUBMITTAL DATE
l car ev- Ael.
OWN 'SN ME: ,IIONE:��� C RACroR' AME: - LIC NO:
''ll Fury NIC CONTROL
t ARCHITECT � [NEER: LIC NO: ADDR
ED
CONTACT. PHONE: - BUR.DING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG -ELECT PLUMB MECH
❑ ❑ ❑
uCPNSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I n 7 storm that 1 am licee under provisions of Chapter 9(commencing ]OB DESCRIPTION
�oZ with Sarioion]OOlq ofDivision JofthBusiness Business and Professions Code,and my license is RESIDENTIAL:
F in fullfomea.d eft PERMIT ISSUANCE
�Up Licens CI Lick OSFDWL ❑KITCHEN REMODEL
�<� Dme Comment, APPLIANCES-RESIDENTIAL ❑ADDITION D PLUMBING RE-P[M
F.7m ARCHITECTS DECLARATION []MULTI-UNIT -[]STRUCTURAL
PANELS
Zpv�XJ l.nderslnnd my plem shell be used es public mento, � MODIFICATION
OZ%-IQ / M02WAMPS [I INTERIOR ❑CHIMNEY REPAIR
I•,� 4�s Licensed Poor..ismal 201.1X00 AMPS IMPROVEMENT
Y , OWNER-BUILDER DECLARATION OVER IM AMPS D BATH REMODEUREPAIR ODEMOLITION
yyX a a 1 hereby orm tat hI ton exemptfrom the frothe Coalmnor s License Law for the
llowi
W 3 ffi
❑U fong reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
P40dr I" CS'NtuSe dX['1A
47 4 which requires a permit to construct,alter,improve,demolish,or repair any someone, �y} gy�pati,t�ryS
s1+t-y prior to its issmence,also requires the applicanlfor such permit to file a signed statement SPECIAL CIRCUIT/MISC.
y that he is licensed rommo0o the pmvisomsofthe,Combatme,License Law{Chapter 9
GC (commencing with Section 7Wg.fDivision J of the Business end Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
m =e' Chet he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
Y• Section 7031.5 by a nyapplicantfee.permit subjects the applicant to a civil penalty of POWER DEVICES
bo 04
[]TENANT UFOODSERVICE'
not more than Five hundeeddollars($500).O - IMPROVEMENT 01,as owner of the pmpeny.omy employees with wegex as their sole compensation, SWIMMING POOL ELECTRIC'
will do the work,and Ne structure is not intended oroffered fertile(Sec.7044,Business []OTHER
and Professions Cale:The Convector's License law does not apply m on owns of OUT LETS-SWITCHES-FIXTURES
Property who builds or improves thereon.and who does such work himself or through A n
his own employees,provided that.ouch improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FL A
rade.If,however,the building or improvement issold withinone yearofeumpletion,the - SQ.IT.FLOOR AREA $/SQ.IT,
poowner-builder will have the burden M proving that he did not build or improve far pun
ke of sojej. 1996
0 I,as owner of the p many ma exclusively contracting with licensed contractors m TOTAL: g 4 g
consumer the project(Sea 7044,Ra.einess and Professions Code:)The Contractor's Li- CRYLu
se Law does not apply m an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FE Uh
who commas far such pfoJtels with a contractions)h,enaed pursuant to the Contraflors �kk L INO
License Law.mPERMIT ISSUANCE
❑laekemptunder Sec. ,B&PCforthismason
Owner Dam ALTER-BRAIN&VENT-WATER ) VALUATION �''k
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE 5o O 0V
I hereby affirm under penalty of perjury one of the following rest...tions: '
l have atm will maintain a Certificate of Consent tovelf-firearm forWorker's Compact. DRAINS-FLOOR,ROOF,AREA.COND. ST RIES TYPE CONSTRUCTION
,alio.,as provided for by Section 37M of the Labor Cal,for the perf rmmnce of the
work for which this pemdt is issued. FIXTURES-PER TRAP '
I have and will maintain Worker's Compensation[nmwaae,as required by Section
J]W of the Labor Cale,for rhe perfnrmtince of the work for which this permit ix issued. GAS-EA.SYSTEM-1 INCAOUTLETS OCC.GROUP APN
My Wor sCompenwtion In.ce ca^^II rmhd Policy omhh areA030�, GAS-
FA,SYSTEM-OVER 4(EA).
Carrier AI "=,T,
)6L Policy No.:
CERTIFICATE OF E%EMPfION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES(This sectionradnot beoompleted ifflia mit is for one hundred dollars($1000 -
or les,.) GREASE TRAP PLANCHECK FEE
I cenify that intheperfonnanceofths work torwhich this permit is issued,[,bull SEWER-SANITARY-STORM EA.2W FT..
not employ any person in any manner so as to become subject the Workers'Coroner- ENERGY FEE ,
zZ cation Laws of California,Date WATER HEATER W/VENT/ELECTR
0 Applicant GRADING FEE
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM TREATING SOILS FEE
became iati to the Worker's CZatotiun provisions of the Lalmr Code,you most
[kr' forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW R6SIDEM'IAI.PLMB. - SQ.FT. PAID
VI hereby aRmh that there is u construction lending agency for the performanre of Dare 'Raeiptp
the work for which this permit is i...ed(Sce.3097,Ci,C.)
O U Circefs No TOTAL:
Til Lender's Address TOTAL:
I certify that 1 have read Nis epplicmion and stare thus ths above information is BUILDING FEE
VV) correm l agree to comply with all city ural county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V z buildinge...auction,and hereby authorize represenes tativofthis city to emerupoth
ne SEISMIC FEE
ti above mentioned property for inspalion purposes.
(We)agree to save,indemnify and keep hmmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue agalnstsaid City ALTER OR ADDTO MECH.
in consequence of the granting of this permit PLUMBING EEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFMI CONSTRUCTION TAX
Signmure of Applican ommetor I (Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantnrfrtnm buildingacupamsmra o locallehunrdous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? BEATING UNIT(OVER 100,000 BTU)
OYes 0No VENTILATION FAN(SINGLE RESID) PAID
Will thea licaat or fordre building t use equipment or devices which Date ReceiptharN
pp dby the
ea Air
y BOILER-COMP Of?OR 100,000 BTU)
•mtrict?edous air contaminants as definedb [he Ba Area Air Qualit Management
TOTAL:
District?
El Yes Otho BOILER-COMP(OVER 100."BTU)
I have mad the harallous macridsr, tdirsnrents under Chapter 6.95 of the GJi- AIR CONDITIONER ISSUANCE
hard.Health&Safety Code,Sections 25505,25537 and 25534.1 understand tam Fine NEW RESIDENTIAL MECH. Sq pT.
building dor net currently have a mount,that it is my responsihiliry to amity the occupant
of flue rtquimmen8 which must Ito met poor m issuance ora Certificate of Occupancy.
Owner m amhaorcd agcin Dam TOTAL: ISSUED BY:
OFFICE