28948 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCOPERTINO .BUILDING-ELECTRICAL PERMIT NO. 289 p 8
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL L MMVV 4 VX
BUILDING PROJECT IDENTIFICATION
WAEDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
086.
SOC CJL1 e �r �0--14��lS
OW E 'S PHONE: CPIT CTOR'S NAME: /I LIC NO: N/CCONTROL#
ARCHTTEC UE GINEER: LIC NO:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDGELE PLU MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ri ❑
I hereby ti iren that I am imwaed ander pnov;amn%of chapmr 9(commencing JOB DESCRIPTION
with Section]IXIO)of Division Sof the Businseand Professions Code,and my license is RESIDENTIAL
F�.. in full Sarcastic[affect. PERMIT ISSUANCE
<UF' License Class Lic.# - - ❑SFDWL ❑KITCHEN REMODEL
rFa
DataContractor - APPLIANCES-RESIDENTIAL " ❑ADDITION El PLUMBING RE-PIPE
>>� ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
,x O m F] 1 understand my plops shell be o%ed M public records
OZ- - UPT02MAMPS - � - MODIFICATION.
Licensed Tonionnl - [I INTERIOR EICHTMNEYREPAIR
201-1000 AMPS' s ROVEMENT
� OWNER-BUILDER DECLARATION
y U, 1 hereby affirm that 1 am exempt from the Contractor's License Law for the - OVER I000ELECTRICAL
TRICMPS TH REMODEVREPAIR DEMOLITION
sd 3 M F following reason(Section 7031.5,Business and Professions Cade:Any city m county SIGNS ELECTRICAL - ER
47 O which requires a permit ni constmct,alcor,improve,demolish,or repair ony stmcture '
�y priortuiu issuance,also reyuiresthe applicant for such permit to filen signed mamment SPECIAL CIRCUIUMISC.
p. that leis licensed pursuant to the provisions of the Commcmrs License Law(Chapters
a£ (commencing with Section]O00)of Division 3 of the Business and Profession..,Code)or
TEMP.METER OR POLE INST. COMMERCIAL
F o rOa� that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 6 an applicant fare ermit subjects theapplicant o a civil ❑NEW BLDG/ADDITION '❑DEMOLITION
Y Y PP ppenalty of POWER DEVICES
Iq„ N not more than five hundred dollars(5500). [I TENANT ❑FOOD SERVICE .
ASO ❑1.as owner of the property,or myemployces with wages as their sale compensation, SWIMMING POOL ELECTRIC - IMPROVEMENT
aL I. wdl do the work,and the stmcum,is but intended or offered for sale(Sec.]0ki,Business ❑OTHER '
L5C and Professions Code:The Contmciors License Law does not apply to an owner ofOUTLETS-SWITCHES-FIXTURES r•
properly who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ n. t
sale.If,howeveq the building or improvement is sold within one year of completion,the - SQ.FT.FLOORAREA $/SQ.7..
owner-builder will have the burden of proving that he did not build or improve for par-
pose of sale.).
❑1,as owner of the property,am exclusively cdntraning with licensed con tors -construct the project(Sec 7044,Business and Professions Code:)The actors L
cease Law does not apply to an owner of property who builds or i as theieon,en ' QTY PLUMBING PERMIT FEE
who comrede for such projects with aconnecin )tiara. uemm the Cnnhadnr'
License Law. s I PERMIT ISSUANCE t
am exempt under Sec. B&P C for this reaso
Owner " Date ALTER-DRAIN&VENT-WATER(EA) It[VALUATION
WORKER'S MPENSATIONDECLARATION BACKFLOW PROTECT.DEVICE
I hereby affirm unde eaalty of pe jury one of the following declstatio99ss^^ V
•0'l have and will mime a Certificate of Consenu elf-insure for Worker's Qompe - DRAINS-FLOOR.ROOF,AREA,CONK
smion,es provided Tai Sermon 3]00 of eyabo c,fpr the pert Hwy of t r•�. ST TYPE CONSTRUCTION
work for which this rii5 issued r rJ FIXTURES-PERT AP t+�� ti �,
❑I have end w01 imein Workers Comps at, s n es requt b [i (/ -
3]fooftheLabor ode,fo he o vemilmrw�i�,/)L'spur aissued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.CR PP' APN
My Worker's Co ansa io ns Ce en of y rym1
Cartier. Po��mY GAS-EA.SYSTEM-OVER 4(EA)
ERTIM EXEMPTIOyF WOR RS' - t
CO P SATION IN RANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This se,tion need not he o pletedifthepermitie ranchundreddollmSition BUILDING DIVISION FEES
or less) GREASETRAP PLANCHECK FEE '
Icertif that in the performance of the wor or which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 PT.
not employ a person m mry nu as t e subject m the Workers'Compen- 7ENERGY FEE .
,Z arrive Laws I' min.
0 e n come WATER HEATER WIVENT/ELECTR GRADING FEE
�— NOTICE TO PLfCANT:If pensationsvisiosfficare dm Labor Code.you
WATER SYSTEKiTREATING
a becomesubject
comp racoon or
arnvisihal of thelabor Code,you mus[ SOILS FEE
W
forthwith comply with such previsions or Nis pemtit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH O SQ.FT. PAID
affirm I hereby thatthem is a construction lending agency forthe Performance of Data Receipt# ;
WH the•work for which this permit is issued(Sec.301 Civ.C.)
0 U Lender's Name TOTAL: .
W Lender's Address L} _I cenify that 1 have read this application and stem Out the above information is .BUILDING FEE
IA catnep.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT
U `& building construction,and hereby northern representatives of this city to enter upon the FEE SEISMIC FEE
above-mentioned property for inspection purposes.
DEC)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE -
liandities,judgments,costs and expenses which may in any way accrue against said City ,ALTER ORADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE-
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE EG ILATf NS' MECHANICAL FEE r
(/(/•�YMsC/(i/a� AIR HANDLING UNIT(OVER10,gIDCFM)
(/� O CONSTRUCTION TAX
Signature of ApplicartnContrarna Data EXHAUST HOOD(WMUCTj^ HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant soon,or handle hrardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Consist.Municipal Code,Chaptai 9.12,and the Health and Safety
Code,Section 25532m)] 1 HEATING UNIT(OVER I00,OgB BTI]) -
❑Yes 0 N s
VENTILATION CAN(SINGLE REMD) PAID '•
Will the applicant or future building occupant use equipment or devices which [. Data Receipt#
mu hazardnt
Interactions air coaminants as defined by the Buy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District? - TOTAL:
❑Yes " - ❑No BOILER-COMP(OVER 100,1100 BTU) -
I have read the hazmdous mammila requiremen¢under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornia does correctly
Code,Sections 25505,25533 and 23534.1 undersand thin if the NEW RESIDENTIAL.MECH. SQFT
buildingg does not outly heventwant,tha�It is my responsibihtymnrnw
notify me . . '
of the requirements which must od met priano i,.,suance of a Cmificnte of Occupancy. '
ISSUED BY:
Owneror authorized agent Data - TOTAL:
OFFICE