28981 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO - - BUILDING-ELECTRICAL. PERMIT NO. I
BUILDING DIVISION '' APPLICATION/PERMIT PLUMBING-MECHANICAL. Q(] p q
ILDING PROJECT IDENTIFICATION O
BUILDING ADDRESS: BU9 v.1
J SANITARYNO. APPLICATION SUBMITTAL DATF
OWN• 'S NAME: � �{1 UHF: C RACTOR'S NAME: LIC NO: N/C CONTROL#
,11111011k gilL< sG6s3Ss
CHIGI MEER: LIC NO: ADDRESS: t -I I
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CONTACT. PHONE: ? I - BUILDING PERMIT INFO
it e L ❑ ;onsultant�es Paid 6y Applicant(Initial) BLD FLECf PLUMB MPiCy
Y LICENSED COME RACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm than I om licensed under pmvimns of Chapter 9(commencing -
40Owith Section TOW)ofpivision3of the Business and Profen.+inns Code,and mJOB DESCRIPTION,y licensees PERMIT ISSUANCE RESIDENTIAL:
n full force and effect F-p
U 'License Class Lic.M �J - ❑SFDWL ITCHEN REMODEL
Date Contractor APPLIANCES-RESIDENTIAL EEEE ❑ADDITION ❑PL MBING RE-PIPE
Dm ARCHITECT'S DECLARATION r PANELS ❑MULTI-UNIT ❑STRUCTURAL
7� 1 undersand my plans shall be used as public records- 11��,' MODIFICATION
UPT0200 AMPS ypNTERIOR [I CHIMNEY REPAIR
,E] Licensed Professional 20140A)AMP5 IMPROVEMENT
44c5c5�r11''
OWNER-BUILDERDECLARATIONCe Contr ON OVER IOOOAMPS ❑BATH REMODEUREPAIR El DEMOLITION
I hereby affirm that1 1 exempt From the Lessons c :Anne Law for the
d U following reason.(Section 7031.5, t,Business and Professions Code:Any city or county SIGNS ELECTRICAL - ❑OTHER
ya which requires a permit m construct,alcor,improve,demolish or repair any structure ', -
y11 priortoitsksuance,also requires the applicant for such permit o fileasigned statement SPECIAL CIRCUIT/MISC.
Q� that he is licensed pursuant m the provisions of the Contractor's License Law(Chapter 9 - -
Gb (commencing with Section 70tNp of Division 3 of the Business and Professions Code)or TEMP.METER OR P6LK4NsT. COMMERCIALy o a that he Is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
3 �W Section 7031.5 by any applicant for a permitsubjems the applicant to a civil penalty of POWER DEVICES ^+,,
Z p, na more man five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
❑I,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECfRIC IMPROVEMENT
2 m will do the work,inl the demand is not intended or offered for sale(Sec.7044,Business ❑OTHER
4 no and Professions Code:The Contractor's License Law does not apply to an owner of 29 OUTLETS-SWITCHES-FIXTURE9q-
" property who builds or improves thereon,and who docs such work himself or through
his own employees,provided Nat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLO#AREA $/SQ.PT.
ncomilder will have the burden of proving that he did not build or improve for pur- - p/ p S.`'
pmseofsolr.) - W �1
❑1,as owner of the propery,am exclusively contracting with liwnred eonnacmrs to
cmnstruet the project(Sec.7000.Business and Professions Code:)The Cora cods to DECease Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE ^ O4 �} n�
who contracts for such projects with a contractors)licensed pursuant to the Contractor's _ P'srY 11997
7 1 am exempt
PERMIT ISSUANCE Y��- U*EN
❑ Lem exempt under Sec. ,B'&PCfonhis reason L '
Owner Date _ ALTER-DRAIN&VENT-WATER(EA) VALUATION
_ WORKER'S COMPENSATION DECLARATION . BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing reelection:
❑I have and will maintain a Certificate or Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CON I,
action,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section -
37Wofthe LaborCore,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTLBTS ' y. OCC.GROUP APN
rkel Com nsmio 1 ranee a rand Policy pip
arrior: Ff!/VD R1C Policy No.:°T.r OZJ'9S GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' - -
' t/COMPENSATION INSURANCE - GREASFIINDUSTRL WASTE INTERCEPTOR
(Thee senlon nq=4nwbacomplamdiflhe permitiifinoiohundreddollars($1007 - B1111 DI SION FP.ES
or less I I .,J : GREASE TRAP pLANCHECK FEE
Iccnify thm in clrjxrfomance of the work far which thispenmit is issued,/shall SEWFR-SANITARY-STORM EA.200 Pf.
not employ any person in any mtry so as become subjeetto the Worsen" ENERGY FEE
z nation Laws of California.Data
WATER HEATER W/VENT/ELECfR - GRADING F
0 Applicant _
NOTICE bj APPLICANT:IL after making this Certificate of Exemption,you should WATER GRADING
ul
become subject y the Worker's.Compensation provisions of the Labor ,mad you must - SOILS
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forthwith comply with wch provisions or this permit shallMdeemed revoked. WgTER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. i' SQ.FT PAID -
1hereby affirmthat there isaconswctionlending agency for the performance of Dam Receipt#
O the work for which this permit is issued(Seo.3097,Civ.C.)
U Lender's Name
{Z1 Lender's Address TOTAL:
y (� I certify that I have read this application and state that the above information is BUILDING FE .,
w y come[,l agree to comply with all city and county ordinances and state laws relating toQTY. MECHANICAL PERMIT FEE
y building construction,and hereby apihnriee representatives of this city to enter upon the SEISMIC FEE
above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE 0� ELECTRIC
Iiabililiea,judgmcnts,costs and expenses which may in any way accrue against said City ALTER OR ADO TO MECH.
in asequence of the granting of this permit. PLUMBING E -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,OIXI CFM) . '
SOUR 'RED CATIONS. MECHANICA
,l AIR HANDLING UNIT 10,000 CFM) CONSTRUCTION TAX
Si at Of ApplicontlComractor to 'EXHAUST HOOD(W/DUCT) �� HOUSING MITIGATION FEE
HAZARDOUS MATERIAL DISCLOSURE
-Will the applicant Or future building occupant store or handle hazardous material HEATING UNIT TO 100,000 BTU)" - -
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)? HEATING UNIT(OVER 10111100 BTU)
❑Yes ❑No
VENTILATION FAN(SINGLE RESIDE - PAID
Will the applicant or future building occupant use equipment or devices which - Date Receipt#
unit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,000 BTU) ' '
District? T&A
❑Yes El No BOILER-COME?(OVER 10b,"BTU) ,. - i
I have read the hazmdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forme Health'&Safety Code,Sections 25505,25533and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my responsibility o notify the occupant
of the requirements which mus,he met poor to issuance of a Cenifeate of Occupancy. s
Owneror authonrW agent pate TA '
_ ISSUED BY:
h OFFICE
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