28794 143 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - -
CITY OF CUPERTINU BUILDING-ELECTRICAL PERMR NO.
l� BUILDING DIVISION APPLICATION/PERMITPLUMBING.MECHANICAL.
Q BUILDING PROJECT IDENTIFICATION .28794
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
o ,9 fmA1.1
OW ER'S NAME: 11 �i PHONE: e C074: CTO ' AMEN. f/ry yT�,. 'LIC NO: - `
'S'r 1' T i 3-2— L✓ _ ^-ta(_ -t- -z'I ., N/C CONTROL#
ARCHITECGENGINMR: LIC NO: ADD S'. .k ❑
F Uye, �s �_�'f
CONTACT. - PHONE: t BUILDING PERMIT INFO
❑ Consultant Fees Paid by ApplicantBLDG( ELECT . PLUMB MECH
n (t '•I LI SED CONTRACTOR'S DECLARATION' ` QTY ELECTRIC PERMIT FEE ElED1 heP ❑
reby affirm mat 1 am licenud under provisions of Chapmr 9(commencing
00 with Searm,7( xE;fDi n3 ftheB my JOB DESCRIPTION
Business and Professions Code,and license is RF
{{dcl
in full force and IT a PERM]T ISSUANCE ID NTIA <
fQ�U� License ss IT �S�L' # / �'� �SFDWL
ry a
Data Co ❑ADDITION almm APPLIANCES RESIDENTIAL CHEN.REMODEL
MBING RE-PIPE
O tin ARCHITECTS DECLARATION " aef
OZ z-2 - I un island my plans shall be used as public records PANELS ❑MULTI-UNIT .[]STRUCTURAL
� UPT0 2W AMPS MODIFICATION
Incensed Professional ❑' INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
yy O,�"EE{{ 1 hereby affirm that 1 am exempt from the Contractor's License Law for me OVER IOOO AMPS ❑BATH REMODEI/REPAIR ❑D MOL1770N
k'a V following reason.(Section 7031.5,Business and Professions Cade:Any city or county - - '
which SIGNSELECIRICAL ❑OTHER
F O:} R permit t construct alta pr demolish,or repay any summit i '
H...77777 priors it ante Inrq es th ppl etf suchpe nm filen signed statement SPECIAL CIRCUIT/MISC. ` i
P+ Nat he islicensedpursuant tthe provisions fthC trees tis License Law(Chapter 9 _
Do (commencing with Sato 0000) fDivision 3 of the Business add Poomssions Code)or TEMP.METER OR POLE DIST. OMM R I.A
Mev that he is exempt therefrom and the basis far Ne alleged exemption.Any violation of
m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [I NEW BLDG/ADDITION DEMOLITION!
not more than five hundred dollars($5W). - ❑TENANT ❑FOOD SERVICE
❑1.as owner of the progeny,or my employes with wages ae theirsole compensation. SWIMMING POOL ELECTRIC dMPROVEMENT
,ry wtll do the work,and but swcture is oat immirdedocoffered trestle(See7014,Business []OTHERirE"1 M and Professions Code:The Conlrannr's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,end who does such work himself or through
his own employees.Provided that such improvements arc rias intended or offered for NEW RESIDENTIAL ELECER SQ FT.'
aide.If,however the building or improvement is sold within one yearofcumphaion,the - - SQ.FEFLOORAREA $SQ.IT.
owner-builder will have the burden of proving that he did not build of improve for par-
a-,.. ..pe.f'sele.), '. - ,. n
❑I,as owner of the pmpeny.am exclusively contracting with licensed comcacmrw to TOTAL: - y� { Y
cmwd me project(Sec.]044,Business and Professions Code)The Contractors Li- W
cense Law does not apply to an owner of property who builds or improves thereon,and
who vnidmctsforrueh projects with acontmdor(s)lieeased p QTY' PLUMBINGPERMIT '
License Law. - pursuanua me Contmcmrs
[I1 em exempt under Sec. ,B&P C for this contact, PERMIT ISSUANCE - r�` 11 -
Owner Dam ALTER-OWN&VENT-WATER(EA) s / VALUATIO '
-WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �urEM17y0
1 hereby elan under penalty of perjury,one of the following declarations V
I have and will maintain a Certificacrf Corwin In self-i...mArWorker's Compen- , DRAINS-FLOOR,ROOF.AREA,COND. _
sa0on;es provided for by Section 3]0(1 of rhe labor Code,for the perforttmnce of the STORIES TYPE CONSTRUCTION
work Jnr this permit is issued.- FIXTURES-PER TRAP
❑ e and will maintain Worker's Compensation Insurance,as required by Section
OR ofthe Labor Cade,for.the performance ofthe work for which this permit is issued GAS-EA.SYSTEMd INC.4 OUTLETS
My Workrr'^Campers. jot,Incur ce artier arta Policy number DEC.GROUP APN
Cartier: Policy No: x So x.z.Z.j GAS-EA.SYSTEM-OVER4(EAG -
ERTIFIC N FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This sectionneed not be completed fthe permit is feature handled dollars($100) _ BUILDING DIVISION FEES,
or less) GREASE TRAP
I certify that in the performance o as t work for which this PLANCHECK FEE
Permit is issued,i shall
net employofC.1iuvin any manner so aembecome suhjecuothe Workers Corruption- SEWER-SANITARY-STORM EA.20fl Ff. ENERGY FEE
� Z cation Luws of Calif.mia.Dale WA'T'ER HEATER WNENT/ELECTR
7 Applicwt - - 'GRADING FEE
G NOTICE bj APPLICANT.If,is after making this Certificate of Exempting ,you
WATER SYSTEMOREATING
a f� become subject to me Worker's Compensation provisions of the Labor Code,.you most SOILS FEE '
ry foMwim complywithsuch provisions or this permit shall be deemed revoked,
96 Q ,iy WATER SERVICE
CONSTRUCTION LENDING AGENCY NEWRESIDENq'IALPLMIL SQ.FT. PAID. - I
V Q I hereby affirm that there is a commdioh lending agency for the performance of Data Receipt!
Gks F the work far which this permit is issued(Sec.3097,Civ.C.) ,
0 Lenders Name - v - TOTAL: "
Lender Add TA .
y, 1 acidify that I have read this application and state that me above informdtron if - BUILDING FEE -
wr h correct.l agree t comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U building construction,and hereby awhorze representatives ofthis city to enter upon the SEISMIC FEE '
i b nvo-me t ed propeny for inspection purposes
(we)agaw ro save,indemnify and keepharmless the Cit f Car non against PERMIT ISSUANCE
a P< g ELECTRIC FEE
liabilities,judgmentsecosts and ofexpenses mit, may in anyway ecrneegaihst said City ALTER OR ADD TO MECH. ' i.
inconsequence of the granting S this permit. - PLUMBING FEE'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. 'MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,00)CPM) 1 CONSTRUCTION TAX
Signature of ApplicardContmctor - Date' EXHAUST HOOD(W/DUCf)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE,
Will the applicant or future building occupant store or handle hazardous materiel HEATING UNIT(TO I W.000 BTU) I
as defined by the Cupertino Municipal Cede,Chapter 9.12,and me Health and Safety. -
Code,S lmm 25532(x)7 HEATING UNIT(OVER IOg000 BTU)
❑Yes F]No
VENTILATION FAN(SINGLE RESID) PAID
WIII the applicant or(nture building occupant use equipment or devices which Oats, Receipt#
7z'
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR IOO,O(I(IBTU) -
Discictp' - TOTAL:
❑Yes ❑N. BOILER-COME(OVER 100,000 BTU)
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
iction Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the ISSUANCE DATEuildin¢.����,.s imntlyhegvcaten iTtisiny rtsponsibilitymnati me occupant NEW RESIDENTIAL MECH. SQ.FTIf the rim'6ts.avlzi ea irsuenq fn CeniEcu,e c .
weer. u . dg l/= 7 at - s'r TOTAL: ISSUED BY:
OFFICE