28711 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY '
CITY OF CUPE RTINO - BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 28711
BUILDING PRO]F.CT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATI
D2 CRo -Llb
OWN R'S NAME: PHONE LIC NO:
A CHITF.CT/ENG EER C23�� AD FSS: �� - ❑ s
CONTACT: PHONE: Lfa)qn6 sr - BUILDING PER ITINFO
❑ Consultant Fees Paid by Applicant(Initial) PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby eMr.that 1 am hoe roed under provisions of Chapter 9(commencing JOB DESCRIPTION -
OWZ wiMS et 7000)of Div" nIoOn Businessand Plofess'ons Code.ndmylicanxis RESIDENTIAL, „
Fo, full eeand ellen. l y PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�WdE License as Lica FseAPPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F�4 Date Crnh➢Cmr
fF Doe ARCHITECT'S DEC ARATI PANELS ❑MULTI-UNIT ❑STRUCTURAL
OZ! Z 1 understand my plans xhall M1e used asp lie re Ns MODIFICATION
:! UPTO200"PS ❑INTERIOR ❑CHIMNEY REPAIR
[-. Licensed Prefessional 201-100DAMPS IMPROVEMENT
LqCOWNER-BUILDER DECLARATION nnEUREPAIR ODEMOLII70N
6 1 heieby affirm that I am exempt from the.ConwOVER Ifg10AMPS ❑BATH REMOC
ctor's License Law for the
fiDyU following maim.(Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
uR71u4171 which requires v permit to construct,alter,improve,demolish,or repair any awcmre
LLLEy...y .J7 prior in its issuance.also requires the applicant for such permit to file a signed seemed, SPECIAL CIRCUI'DMISC.
that he is licensed pursuant Contracts o the provisions of the Contraor'a License Law(Chapter 9
YY66''11 a'0 (commencing what Seelion]hq)of Division Jnf the Bmincssund Professions CMe)or
TEMP. OR POLE 1NSf.� Cl1MMFoCldl
6pr
�o eG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
yyx, Y• Stenon 703 LS by any applicant far a point subjects he applicam to a civil penalty of POWER DEVICES ul�vr ❑TENANT ❑FOODSERVICE
3 y t more Nan five hundred dollars($500). IMPROVEMEN�!�J a�.Z:PYA
Q ❑I,as owner of the property,or my employees with wages es their sole compensation, SWIMMING POOL ELECTRIC ` ,T `S to ML
y will do the work.and Ne structure is not intended or for sale(Sea]044',Business �0OTHER •
R7 and Professions Code:The Contracmis License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through - -
his own employees,provided that such improvement are ru intended or offered fur NEW RESIDENTIAL ELECTR SQ FT. -
sele.ILhowever.the building or improvement is sold within one year of completion,the SQ.IT..FLUOR EA' S/SQ.ET.
wncolvailder will have the burden of proving that he did not build or improve far,.,-
pose
urpar-pose of ass.). '
❑Las owner of the property,am exclusively crane ins with licensed contractors Ed
ennsuuct the project fSec.70H ,Business and Professions Cede:)The Convector's Li-
cense Law does not apply to an owner of property who builds or improves themon,aid QTY, PLUMBING PERMIT FEE ei, �� 18 7,996
whocomcaets for such projects witha centractode license t pursuant tote Contractor's (Ih
License Law. PERMIT ISSUANCE LVrCl7/q
❑1 am exempt under Sec. ,B&P C for this reason �U
ALTER-DRAIN&VENT-WATER(FA) VALUATION
Owner Date
' WORKER'S COMPFWSAJ'ION DECLARATION BACK FLOW PROTECT.DEVICE
ti � I hereby affirm under penalty of perjury one a1 the following dedvcatinns: ���YYY •J
Ihave and will maintains Cenificvm of Consemmself-insure for Worker's Compete DRAINS-FLOOR,ROOF AREA,C D. STORIES TYPE CONSTRUCTION
sation,vs provided for by Section l]W of the labor Cale,for Ne performance of the
work ¢h Nia permit is issued. FI%TURES-PER TRAP
have and will ode,far he ,ma Compensation ark
shi h required by Section
3]00of Ne labor Cala for rhe perfonnanm of the work fa which Nis permit is iaseedGAS-EA.SYSTEM-1 INC. OUTLETS OCC GROUP APN
My WorhR'ifi�ftrs: r and Policy rsae.32 A�oGAS-EA.SYSTEMR4(EA)
Cvnier: i rz Policy le.,-.�7-I
CERTIFICATE,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEHNDUST WASTE INTERCEPTOR
BRAIDING DIV ION FEES
(This section need not he completed if Me permit is for one hundred dollars IS 100) GREASETRAP
or less.)(This
FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER-S ITARY-STORMEA.200FT.
not employ any person in any manner so as to become subject N the Wmk.'Compen- ENERGY FEE
sation Laws of Califndie.Data WAT12 EATER WNENT/ELECTR EI
Applicant GRADWGF
F7 wNs NOTICE'I'O APPLICANT:IL after making this Certificate of Exemption,you should WA ,R SYSTEMOREATING
become subject to the Wmkels Compenaahon provisions of the Labor Cade,you must SOILS FEE
[LITi] forthwith comply with such Provisions or this person shall be deemed revoked. ATER SERVICE
Cls Q
Z)z CONSTRUCTIONenisacLENDINGACENCY NEW RF.SIDENTIALPLMB. SQ.FT. PAID RmcitN ,
I hereby wh his
thin Nerc issnd(See,ion lending agency for the performance of p
V Le work for wM1ich this permit is issued(Sec.JW],Civ.C.) r
OLender's Name TOTAL:
Lender's Address TOTAL
1 ccnify Nat 1 hove rad Nis application and stain that Ne above infonnmion is BUILDING FE Ta
f0.q .1.I agreem comply with 01 city and county mdinaies and state laws relnting to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby amhonae representatives of this city so enter upon the SEISMIC FE
WU
alwve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ogre.m save,indemnify and tarp han ideas the City of Cupertino against ELECTRIC E
liabilities.judgments,costs and expenses which may in any way areme against said City ALTER OR ADDTO MECH. PLUMBIN FEE
in consequence of the scanning of this permit.
APPLICAANyT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO Ig000C ) MECHA CAL FEE
SOURCFEGU TIONS/ / -
(`//•�,( , '^ —�� AIR HANDWNG UNIT(O VERT , CPM) CONSTRUCTI AX
/_I/ y
Signe rre of ApplicuMConuacmr Dale E%HA UST HOOD(W/DU HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle broadens material HEATING UNIT(TO 1/"BTU)
us defined by the CuNrti no Municipal Code,Chapter 9.12,and the Health end Safety ,
Care,Section 25532(a)° HEATING UNIT( ER 100,1X4)BTU) Y�
❑Yes ON. VENTILATIO WNSINGIERESID) PAID Data
Will the applicam or fuwre building occupant use equipment or devices which BOILFiR- OMI'(3HP OR 1011.004)BTU) Ann
1 t hamdoux air conmminanrs as defined by the Bay Arca Air Quality Management T TAE:
rsvicR BOIL -COMP(OVER 100,000 BTU)
❑Yes 'pato CITII OF CUPERIm •
I have read the ha a dens mmenuls requiremnt eunder Chapter 6.95 of the Cali AI CONDITIONER �1IiI UdNCE
form.Health&Safety Code,Semens 25505,25533 and 25574.1 undersual Nat if Me F.W RESIDENTIAL MECH. SQ.FT.
building doe,Jysgl,pWpp •m have.aciam,M.it is my responsibility to runty But occupant
of Ne raptul\hons - must be or to issuance of a Cenifcate of Occupancy.
Owner or um�i/1cd agent Date' TOTAL: ISSUED BY.
OFFICE