28610 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. AAI O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL LSV( 1
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
�c�z3 �sfi��+� •s-�-5 , ams
OWNER'S NAME: PItONC: CONT ACTOR'S AME: LIC NO:
.2 ,! —y77 o / - NIC CONTROL#
ARCHITECHENGIf R: _ LIC NO: -! AOD,RES �� ❑
CONTACT. ,PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy of ori thm I nm licensed made,pr..Nions of Chapter 9¢ommenemg JOB DESCRIPTION
GC with Section 7000)of Division 3 ofthe Business and Professions Cale,and my licenseis PERMIT ISSUANCE �RESIDENTIAL,
n full force and¢flat
UUP Licca acv Lim,al ❑SFDWL ❑K CHEN REMODEL
W De. om Contractor APPLIANCES-RESIDENTIAL ❑ADDITION MI R&PIPE
0 ARCHITECTS DECLARATION ❑MULTI-UNIT � ❑STRUCTURAL
F. PANELS
Z O'vJ Z 1 understand my plans shall be used as Public records MODIFICATION
OxYkJ.� UPT02N)AMPS C1 INTERIOR ❑CHIMNEY REPAIR
��IIs����..jjjj,, Licensed Professional 201-1000"I'S -'IMPROVEMENT tr
N
OWNER-BUILDER DECLARATION OVER I(M AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
pj0tY 1 hereby affirm on I am exempt foramina Cessions Co License Law for Ne
V following reason,(Section 7031.5.Business and Professions Code:Any city or countySIGNS ELECTRICAL []OTHERid 3[L which easpines a permit to conseuct titer.improve,demolish,or repair any structuretaw prior m its issuance,Mso requires the applicant forauch permind file aligned smmmem SPECIAL CIRCUITIMISC.
} that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapmr9
00 (commemmng with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE DIST. COMMERCIAL:
e e that he is exempt themfrom and the basis far Ne ailcged exemption.Any violation of 'Q NEW BLDG/ADDITION ❑DEMOLITION
ret Section 7031.5 by any applicant for n permit subjects the applicant to a civil penalty of POWER DEV ICES C1 TENANT ❑FOOD SERVICE
> not mom than five hundred dollars ON%
�CQ ❑I.as ownerof Ne property,or my employes with wages as their sole mompenasion, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended or offered formic(Sec.7614,Business ❑OTHER
and Professions a Cade:The Contactors License law does nos apply to an owner of OUTLETS-SWITCHES-FIXTURES Propriety who builds or improves thereon,and who does such work himself or through
his own employees,pnwided that such improvements art rat intended or offered far NEW RESIDENTIAL ELEM SQ FT.
sale If.however,Ne building or improvement is sold within one year ofcompletion,the SQ.A FLQOR AREA $/SQ,FT.
owner-builder will have the burden of proving that he did not build or improve for put.
arms
(�� gq
01,as owner of the property.am exclusively contracting with licensed contactors to TOTAL:
consents are Project(Sec.7094,Business and Professions Code:)The Contractor's Li-
cense Low does not apply to anowner of property who builds or improves themon,unit QTY, PLUMBING PERMIT FEE U
whocoadects loath projects with a contortions)licensed posmantodeContractor's _ 1•�f''/,h �99�
License law. PERMIT ISSUANCE V L(Jlw
❑l am exempt under Sm. ,B&P C for this reason
Owner Dae ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby u0irm under penalty of perjury one ofthe following decluations:
❑I have and will maintain eCenificate of Cotlsem to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE GDN$TRDMON
sation,as provided for by Section 3700 of the Lubor Code,for the Performance of the
work fm which this permit is issued. FIXTURES-PER TRAP
AP have and will maintain Worker's Compensation Insurance,us required by Satinet
37W of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40VI'LETS OCC.GROUP - APN
My Werka�sCp pen 'on lnsu and puImyJ '`{a�. -
Curner��(FdT' rz ¢Policy No:
�'a r's/'7�45 GAS-EA.SYSTEM-OVER4fEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(Thu section need nm be completed if the Permit is for one hundred dollars(SI W) BUILDING DIVISION FEES
or les.) GR�ASETRAP PLANCHECK FEE
I ceniythm insheperformance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner an ea to becomesubjecuo Ne Wmkcr%Compan- ENERGY FEE
z sation Laws of Califomia.Dam WATER HEATER WNENT/ELECIR
Q Applicant - GRADING FEE
y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING
became subject m the,Worker's Compensatin_n proviz ns of she labor Cale,you must SOILS FEE
{la Q forthwith comply with much provisionsnal spa IMdeemed000ked. WATER SERVICE
�s NSTRUC'TI LL AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Dole Receipt N
U 0U Ihereby"'for therm on lrnding tag c rth�pcd ce of P
W the work fm which thisi 's esu Sec.3
Q fi) I.endeis Nome TOTAL:
Lerldels Addreas TA .
A. I centfy that 1 have thin appl ican ands m that the above infmmmion is BUILDING FEE
VV) corset.I agree to comply wt all city and count'ordinances and store laws rtleting m QTy, MECHANICAL PERMIT FEE
V building convection,and herehyaothmiu representatives ofihis cityta snmrupon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to ave.indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way occas agelnstwid City ALTER OR ADD TO MECH.
in onuquace of the grow ri,afthispe yya. PLUMBING FEE
APPLICANT UNDff'RSTANDS pIL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IG.dXCFM)
SOURCEBR I t'I'IONS. FE
MECHANICAL E
Com/ g 91y AIR HANDLING UNIT(OVER 10,1010 CFM) CONSTRUCTIONTAX
Signature ofApplicanUOuselictor Data EXHAUST HOOD(WMUh HOUSING MITIGATION FEE
' HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant some or handle hsardous material HEATING UNIT ITO 100,000 BTU)
m defined by the Cupcnino Municipal Cede,Chapter 9.12,end the Health and Safety
Code,Section 25532007 HEATING UNIT(OVER 100,01(1 BTU)
L]Yea E]No
" VENTILATION PAN(SINGLE RESID) PAID '
Will the applicant m future buildin Dae Receipt d
pp g by the D y A ms Air eu or,device,Management
BOILER-COMP(311P OR 100.003 BTU)
emit District?
s air conlaminanls as defined by dm Bay Area Air Quality Managcmcnt TOTAL:
DisWnT
❑Yes INa BOILER-COMP(OVER 1110,000 BTU)
..
I have revels the haadim,materials da,mmments under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE D
Gonia Health At Safety Code,Sections 25505,25533 and 25534.I understood that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my respmsiblliry to notify the occupant _
of the requisemen¢which most be met pHotto issuanre of a Certificate of Occupancy.
Owner or auinuired agent Date TOTAL ISSUED BY:
OFFICE