28557 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL. PERMITNO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
28557-
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/ol 15 8 YRivF- AVC. �'
r OWNER'S NAME: PHONE: CONTRACfOR'SN LIC NO:
wr Iw NIC CONTROL#
ARCHITECT. 1 EER: 0X - LIC NO: ADDRESS:22.%2 n T a ❑ I�6 0
CONTAACT' PHONE: i RV BUILDIN`,G P`ERRMI�T INFO
CI") "Z —0/4>1 CansWtant Fres Paid by Applicant(Initial) _ QLDG LE ;F!!
D EC
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE env.1 hereby affirm Thal 1 sat licensed under provisions of Chepm (co
r 9 mmencing JOB DESCRIPTION
"Z with Section 7")of Division 3 of the Businessard Professions Code,xnd my license is
O O PERMIT ISSUANCE
WyI[ infallran force and attar. WI. ❑KITCHEN REMODEL
FVt' License Clau Lie. APPLIANCES-RESIDENTIAL []ADDITION CI PLUMBING RF.-PIPE
Fn<Z Y6� Date Contractor
I.DARCHITECTPANELS S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
.. 4 1 understand my plans shall he used m rc
public cmds MODIFICATION
UPT02MAMPS
C ❑INTERIOR El CHIMNEY REPAIR
[-I W Licensed Professional OVER00 AMPS IMPROVEMENT
06G `a{
OWNER-BUILDER DECLARATION Conte ON OV[R 1000 AMPS ❑BATH REMODEIJREPAIR [I DEMOLITION
1 hereby,affirm that 1 am exempt from the Contractors License Law for the T
00.V followingrveon.(Section 7031.5.Businessund Professions Cale:Any cityoeeouny SIGNS ELECTRICAL ❑OTHER
0.0 F- which requires a permit In construct,ahm,improve,demolish,or repair any structure I
prion.lts issuance,alns requires the applicant for.such Permit file a signed statement SPECIAL CIRCUIT/MISC.sr a
yIhu he is licensed,uimam mtheprockomofthe Contractor's License Law(Chapmr9 -
GC (commencing with Sado.7(100)of Divisinn 3oflhe Business and Prnfessians Cnde)or TEMP.METER OR POL T� 1yn
that he is exempt therefrom and the basis for the alleged exemption,Any violation of [I NEW BLDG/ADDITION F1EfION
^,hSection]031.5 byzayapphotimfor.permit subjects lheuii,hount to.civil penalty of POWER DEVICES ` ❑TENANTI'llY ❑FOODSERVICE:-
not more Nan Five hundred dollars($50IMPROVEMENT, VVI[
❑Las owner of the property,or my employees with wages as their sole compensation. SWIMMING EDGE.ELE IC '� K�INV
Fri ❑OTHER
willdothework,and the suucurc is oat intended oro(fered for sale(Sec.91E4,Business
C66$ and Professions Code:The Conwnofs Licensee Law dues not apply to an owner of OUTLETS-SWITCHES-FIXv RE'
property who builds or improves thereon,and who dcea such work himself or through his own employees:provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR
sale.If.however.the building or improvement is sold within one year of completion.the SQ.FF.FLOOR AREA $/SQ.FT.
caner builder will have the burden of proving that he did not build or improve far pur- L g
Asift
faasso. ,51 e�-'ECp ,03
1, nes of Ne property,am exclusively contracting with licensed contraztors to
n ct the project apply
o an Business and Professions Code:i The Conwaafs Li- ��
ens,Law does not cpplymts sitowner who Is or improves thereon,and QTY. PLUMBING PERMIT FEE
he contracts farauch projects with a contracmgs)licensed pursuenuo the Cmnvacmr's
License Law. PERMIT ISSUANCE
❑Iamexemptunders". ,B&PCforlhisrenwn
ALTER-DRAIN&VENT-WATER(EA) VALUATION
OwnerDme
WO ER'S COMPENSATIONDF.CLARATION BACK FLOW PROTECT,DEVICE -
I hereby alfimt under penally of perjury one of do,
��www following declarations:
I have and will maintain a Cenificam ofComent to self-insure for Workera Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIESTYPECONSTRUCTION
ration,as providal for by Section 37W of the Labor Code.for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Irsumnce,as required by Section -
3TWoftheLabor Code,for the Performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40VRETS OCC.GROUP APN
My Worker',Compensation Insurance carter and Policy number an:
Carrie. Policy No.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
BUILTqk13RIZ ION FEES
('this section nee.)oat hecnntplecd if the permit is(Drone hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE O
Loy any that int he Eamforany
of m)the incoork me
subject
the
I,issued, SEWER-SANITARY-STORM EA.2W ff.
is
not employ any,,exon in any manner nt as to become nuM1ject m the Workers'Compen- ENERGY FEE
s cion Laws of Cnlif rrin Data WATER HEATER WNENWELECTR
Applicant - GRADING F oa �
y NOTICE TO APPLICANT:If,after making this Cenifente of Exemption,you should WATER SYSTEMZBEATING
become subject to the Worker's Compensation pmvixinns of the Labor Cade,you must SOILS FEE
.W 0 forthwith comply with such previsions or this permit shall be deemed revoked. WATER SERVICE
UaCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB, SQ.Fr. PAID
p 1harmyaffrm thauhem is.,rowmNon limuingagency forth,per ostanceof Dare e k
the work for which this permit is issued(Sec.3097,Civ.C.) -
0 U Lenders Name, L:
Lenders Address
s� BUILDING FEE s�
1 certify that I have rcaJ this application and stem thus the above information is 1
.F.t V) correct.I agree to comply with all city and county otdinatims and state laws relating to QTY. MECHANICAL PERMIT FEE
LIZ building construction.and hereby authorire represenmtivesafthis cityuenterupon the SEISMIC FEE
above-mentioned property for inspection purposes. '
(Wo)same to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC EE
liabilities judgments,constant espenxs which may in any way accrue against said City ALTERORADDTOMECH. PLUMB]
Nkk
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CIT)I0d010 CFM) MECHA FEE
SOUR(.REGULATIONS.
V GyI/ AIR HANDLING UNIT(OVER 10.000 CIM) CONSTRUCITONT
Signiatilf of Applic NContmctor Dam EXHAUST HOOD(W/DUCq HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmardous material HEATING UNIT CEO I00J030 BTU)
is defined by the Cupertino Municipal Cale,Chapter 9.)2,and the Health and Safety
CWe,Section 25532(x)1 HEATING UNIT(OVER 100.000 BTU)
E]Yin, r7 No VENTILATION FAN(SINGLE RESIDE PAID
Date pt R
manWillthe applicant orfmure building tyAree equipment or devices which BOILER-COMP(HIP OR IW,000 BTU)
hazardous nes Dir comnminums JefineJ by by the
Bay AAir Quality Management, Al:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yea EJ No
- -
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE -
tomia Health&Safety Calc,Sections 25505,2.5533 cad 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT. '
building does not carnally have a tenant,that it is my responsibility to notify the occupant .
of the requirements which must M met prior to issuance of a Certificate of Occupancy.' '
. Owner or untharized agent Date !IOIVV% ISSUED BY:
OFFICE