28748APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE HALL PnINT PPN nNl v
CITY OF CUPERTINO, - 'BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
PERMIT NO.
28748
' BUILDING PROJECT EDENTIFICATION
BUILDING ADDRESS:, +
ERS Bo�� D�;vc
OWNERS NAM: - PHONC: -
� y _ sa 6
r
�f(.,o . Gq 9sory
CONT ACTOR'S N ME: LIC
(M C✓!rr Y 6 /
O
-
SANITARYNO.
APPLICATION SUBMITTAL DATE
t0.�� . S
. NIC CONTROL #
❑
BUILDING PERMIT INFO
CHITECI'/ENGINEER: LICNO:
CONTgCf: PHONE:
°
ADD ESS:
1, 1
-
❑ Consultant Fees Paid By Applicant (Initial)
BLDG ELECT PLUMB ECH
0 ❑ c ❑ '
Ihereby affirm that I em licensed under provisions of Chaprar 9 (commencing
Z with Scion.700B.&Division 3 equal Business and Profsssiam Cods,inl my license isJOB
.�. in full !once and t �/ ,QC
LICENSEDCONTRACTOR'SDECLARATION -=PT02WAMPS
QTY'ELECTRIC PERMIT FEE ,
DESCRIPTION
RESIDENTIAL
PERMIT ISSUANCE
License Class r,2 Lic,ir b l❑SFDWL
y Date LIZ,- 1-� t; /
❑ KITCHEN REMODEL
OADDITION ❑PLUMBING RE -PIPE
11 MULTI -UNIT ❑STRUCTURALS
MODIFICATION
O INTERIOR Ll CHIMNEY REPAIR
IMPROVEMENT
ES -RESIDENTIAL
PANELS.
MPS
Conuactor
y
a ARCHITF.CI"$ DECLARATION
Z 1 understand my plana shall Be used as public records
Gceneed Pmfesstonul
OWNER -BUILDER DECLARATIONI
PS
AMPS
hereby offnn that 1 am exempt fromthe Contmcmr'I License Law forthe
following reason. (Section 7031.5, Business end Professios Cale: Any city or county
which requires issuance, permit re construct, ghee improve, demolish, or repair any swment
Jd danhe its ensedna requires the
chat he is licensed pmrsuam to Ne provisions of the Commomr'e License Law (Chapter 9
unve,i applicant for such penni0LFile icense Law
(eommefeem, with Section 9000)ofDivision 3ofthe Basins. and Professions Code) a,
Y that he is exempt therefrom and the basis for the alleged exemption. Any violation of
nSection ]031.5 by any applicant for a permit subjects the applicanrto a civil unity of
not more Nan five hundred dollars ($5W).
❑ 1, ae owner of the pmpeny, or my employees with wages ea their Bole cnmpensatian.
will do the work, and the '"limit is not intended" Offered forsale (Sec. 7044, Business
and Professions ve
Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work himself or Nmngh
his own employees, provided that such improvements are not intended ov offered for
sale.If, however, the building or improvement is sold within Ane year ofeumpletion. the
owner -builder will have the burden of proving that he did not build or improve for par-
pose'ofaale.). -
❑ BATH REMODEUREPAIR El DEMOLITION
❑ OTHER
CTRICAL -
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INET.
-
C'OMMFRCIAL.
[I NEW BLDG/ADDITION [I DEMOLITION
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES ' FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
"
-
SQ. PI'. FLOOR AREA -'
$/SQ. FT.
S
muueet the project (Sec, 7044, Business and Pmfessiorts Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
I, ns owner of the property, am exclusively contracting with licensed contractors toMISSUANCE.
who conunns for such pmjrets with it embactuds) licensed pureuant le Ne Contractors
License Law.
❑ I nm exempt under Sec. , fl ffi P C fnr Nie reason
TOTAL:
y E�.
�,
QTY,UMBING PERMIT FEE
NCE
Owner Dare
&VENT -WATER (6A) -
/jVALUATIONWORKER'S
:3fIC rIhereby
COMPENSATION DECLARATION
affrm under penaltyof perjury one of the following declarations:_
and will maintain a Certificate of Consent to ulf-insure fur Workers Compen-
as Provided for by Section 3]W of the Labor Cade, for Ne performance oftheSTORM,Sf
work for whichNis permit is issued.
❑Ihave veil will maintain Workers Compensation Insurance, as na mired by Section
3700of the Latin, Code, for the performance of the work for which this permit is issued.
My Worker's rr99pp7r�eynn ranee carrier and Policy mamber re
striae �fl�{C... Jmsu Policy Na.: C1 127i4D
CERUFCACTEOF EXEMPTION FROM WORKERS'
, ROTECT.. DEVICE
-TJJve
OR, RODE, AREA, CGND.
(�cation,
1�IVTYPE
CONSTRUCTION
R q'RAP
GAS -EA. SYSTEM -1 INC. OUTLETS
-
GAS -EA. SYSTEM -OVER 4 (EA)
- OCCGROUP
APNI
GREASPIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section need not becompleend iRhe permit is forone hundred deltars($ 1 W)
or leas)
-
GREASE TRAP
PLANCHECK FEE.
I certify that in the perfammnce ofthe work forwhich this permiorker'Comer.
not employ any person is any manner so as to become subject m the Workers Compen-
Laws of California. Date
SANITARY-
SEWER- STORM EA. 2W FT.
ENERGY FEE -
WATER HEATER WNENTIELECTR
Application
Applicant
,NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
became subject to the Workers Comppnsmian p isions of the Labor Cade, you town
forthwith comply with suchmovisionso he hail he Deemed revoked.
WATER SYSTEMAREATING
GRADING PEE
SOILS FEE -
WATER SERVICE
PAID'
Data Receipt#
CONSTRU ON GAGENC��JJ'�,$' {{//.,��a
Ihereby affirm uhe s on le ndingigencyxj#r�ACpc[fomtance of
Newurkforwhie this c (Sec. 3095, C11C,) / t
NEW RESIDENTIAL PLMB. SQ. EL
_
lenders Name
LenderaAddress
1 certify that 1 hav a this p a nn and tate that the above information is
correct 1 agree to comply w ell citywunty ordinances and state Taws relatin6 to
building construction, and hereby amho 3e representatives of this city to enter upon the
property for inspection purposes.
(We)
(We) agree to save, indemnify end keep harmless the City of Cupertino against
liabilities,judgmerns,costs and expenses which may in anywayaccrue againstsoid City
m consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
SOURCE REGULATIONS.
-
TOTAL
-
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC
SEISMIC HE
ELECTRIC FEE
ALTER OR ADD TO MECH .
PLUMBING FEE
it
MECHANICAL FEE
AIR HANDLING UNIT 00 IQOOt)CFM)
AIR HANDLING UNIT (OVER 10,(100 CFM)
-
CONSTRUCTIONTAX
Signature of Apphca- Date
HAZARDOUS
HAZARDOO US MATERIALS DISCLOSURE .'
WIII Nb epplicnomrfutore bullNng occupant Hart or hanJla hazardous memdal
as defined by the CuPenina Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 2553I(a)?
❑Yes, El No
EXHAUST HOOD(WMUCT)
-
HOUSING MITIGATION FEE t'
HEATING UNIT(T0100,000 BTU)
HEATING UNIT (OVER 100.000 BTU)
n .
VENTILATION FAN (SINGLE RBSID)
PAID
Will the applicant or future building occupant use equipment or devices which
Date Receipt #
emit hazardous air contaminants as defined by. the Bay Area Air Quality Management
District?
C] Yes No
BOILER - COMP (3HP OR 100,IX00 BTU) t
-'
TOTAL:
BOILER- COMP (OVER 100.000BTU)
AIR CONDITIONER
�
I have mad the hazardous tionsmaterialsZ5 requirements under . 1 and 6.95 of the Gall-
that if to
fomie Health a Safety Cade, Sections 25505, 25533 and 25534, I u unity the
buildimg dos nor currently haveatea Nat itismy responsibiliryronodfy the occupant
ofthe imments hie bemix,e5zmoreenfa Cenif to of Oc.cupancy.
Owner or authori age Date
t
ISSUANCE DATE
'
'
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
- -
OFFICE