28693 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
�t CITY OPCUPERTINO i BUILDING,ELECTRICALPERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
" 8 6 9
3
BUILDING PROJECT IDENTIFICATION 8 6 J 3
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O R'SN ME P ONE:_ CONTRACTORS- I •CONTME: LIC NO:
" NIC CONTROL M
• A TECT/ENGINEER: Us NO: DDDR sS�I S r❑•
J t
,TACT: PHONE • BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG
-L71-1 E
3 . LeCf PLUMB MUCH
LICENSED CONTRACTOREl ❑ El'S DECLARATION QTY. ELECTRIC PERMIT FEE - -
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOE DESCRIPTION
{O d'Z with Section TXO)of Div' 3ofNe Bust and Profusions Code,and my licensees RESIDENTIAL
FOO full force end effect PERMIT ISSUANCE'
�U� License Class Licp ❑SFDWL ❑KITCHEN REMODEL
7W
Data Contrmm APPLIANCES-RESIDENTIAL CADDITION - ❑PLUMBING RE-PIPE
y 'ARCHITECTS DECLARATION - 11 MULTI-UNIT ❑STRUCTURAL
w lundersmndm 1 PANELS MODIFICATION
ZOZ4� Ypane shallhused as public recoNs UPT02W AMPS
�=-0 LicensedPerfess]onel [_1 INTERIOR ❑CHIMNEY REPAIR
a3 OWNER-BUDERDE 201-faro AMPS IMPROVEMENT
fLDECLARATION OVER IM AMPS ❑BATH REMODEUREPAIR El DEMOLITION
1 hereby affirm that Pam exempe s an the Contractor's License Law for the
O y U following reason.(Section]031.5;Business and Professions Code:Any city or county SIGNS ELECTRICAL - []OTHER
I. which requires a permit to construct,alter,improve,demoli.uh,or repair any armature
pnor[o its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. " L�s �—
Cthm he Is]learned pursuanuo the provisions of the Contractor's License Law(Chapter 9 -
Q
(commencing with Section 7")of Division 3 of Ne Business snit Professions Code)or O TEMP.METER OR POLE]NST. COMMERCIAL
that he is exempt therefrom and the basis for the cts the exemption.An 'f
{cXl {c p Any of ❑NEW BLDG/ADDITION �DDEMOLITION
Secthot dan]03LSby any for a 050d,it subjects the applicnmmacivil penalty of POWER DEVICES
"y nn[mare Nan five hundred dollars y employees
e ❑TENANT T 1 C1 FOOD SERVICE
O ❑ Lo the work,the property,remyot amended with wagesamilf r theirsolecompen.ines,i SWIMMING POOL ELECTRIC IMPROVEMENT
anddo the work,and the shvcmre is not intended oro w do Inc sale(Sec.TW,Business []OTHER
and Professions Code:The Contractor's License Law does not apply oflf owner of OUTLETS-SWITCHES-FIXTIIR85
.. pilaw who builds or improves thereon.and who does such work himself of through
his awn employees,e provided that such improvements are not intended of offered for NEW RESIDENTIAL ELECTR SQ FT.
owneLuildar ill have
burden
of vementisat sold hedid non build or improve for
SQ.FT.FLOOR AREA $/SQ.FT.
owneo islder will have the burden of proving that he did not build or improve for put- ,
' Pose of sale.).
❑1,as owner of the prolan,an exclusively contracting with licensed contractors to TOTAL: - -
consumer the project(Sec.7044,Business and Professions Code)The Contractor's Li-
cense Low does not apply to an owner of property who builds or improves]hereon,and QTY. PLUMBING PF,RMIT FEE
who contracts for such projects with a awarectur(s)licensed pursuant[.the Conneaut's
License Law.- -
❑I am exempt under See. -,B&P C for this reason PERMIT ISSUANCE ,
ALTER-DRAIN&VENT-WATER(EA)'
Owner ' Dam VALUATION -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Cmnsenuo se• -itsure for Workers Compete DRAINS-FLOOR,ROOF,AREA,COND.sation,as provided for by Section 3]W of the Labor C ,for Ne performance of the STORIES TYPE CONSTRUCTION
work for which this pecmitisissued. FIXTURES-PERTRAP 1'
❑1 have and will maintain Workers Compere + ce,as requ' y Section
37Wof Ne Lads Code,for the performance of th n hich to r it is issued. GAS-G.SYSTEM-1INC.6OUTLETS OCC GROUP DPN, 1
My Worker's Compensation Insurance carte and 1 nu -
Carrier:- 11 o.: r GAS-EA:SYSTEM-OVER 4(EA) ..
CERTIFICA OFE E FRO W ERS - -
CO E TI N U%ANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thlssectionoeed-t emdlff itisforoaehundreddollars($I00) GREASE _
or lees.) PLANCHECK FEE
I ceniry'bar in Ne pert'o rebut Ne work for which this parrottisissued,IsM1all SEWER EA
no'employ any person in any man so as m - - 2W FT.became subject to the Workers'Camper- ENERGY PEE '
Z sation Lwsof Califomia.Dme
�O
Applicant WATER HEATER W/VENT/ELECTR
�T%) GRADING FEE
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTENITREATING'
f•' �" become subject to the Worker's Compensation provisions of the Labor Code,you must - SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked. - WgTER SERVICE
Q
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FIND. SQ.FT. PAID
I hereby affirm that there is a construction lending agency for the performance of Data Receipt#
the work for which this permit Is Issued(Sec.3097,Civ.C.) L - - J
O (~ lander'.Name - ,. - TOTAL: t
.y V Lenders Address TOTAL:
I cenify that I have read His application and state that the above information is BUILDING FEE
,r TA correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V 7- building construction,and hereby authorize representatives ofthis city to enter uponthe SEISMIC FEE, `
dove-mentioned proper,for inspection purposes. PERMIT ISSUANCE p�
(We)agree to save,indemnify and keep harmless the City of Cupertino against - &A 00 ELECTRIC FEE -
liabilities,judgments,costs and expenses which may in any way scene against acid City ALTER OR ADDTO MECH.
in consequence of the gran m,W Nis amen. - ruPLUMBING FEE
.APPLICANT NDERSTANDS WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10,0110 CFM)
SOURCE RF UL TION]. r - MECHANICAL FEE
.-/`S/— AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX" .
S,rati f pphwnt/Contracros I June EXHAUST HOOD(W/DULT) HOUSING MITIGATION PEE:.
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future buildingueempam store or handle hazardous material HEATING UNIT TO 100.000 BTU) P - 00
- t
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the HeaIN end Safety,
Code,Section 25532my? HEATING UNIT(OVER 100,00)BTU) -
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID</ �Dl
Will no applicant or future building comport use equipment or devices which are Receipt#
emit air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
0 Diane? u n TOTAL: 5?2a00
F7 yes 7N BOILER_COMP(OVER 100,000 BTU) - -
(have read Ne hurmdoos materials requirements under Chapter 6.95 of Ne Cali- AIR CONDITIONER 11$]g19$NCF'DATE
fomie Healthg does&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. NOVIYI V �.7.D
building uiremet iswhich
currently have a tenant,Nato is my,re.of.C ility to rata myth ips..,ant
o]f Ne requirements which must be met poor mis.uance MuCertificarc of Occupancy. CI1y Or 6U?LI+I INU
Owner or emhoriud agent DateTOTALIS tUrit ISSUED BY:��e-
0FFICE