28777 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL-POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION'
28777
BGILDI GoADORESS, SANITARY NO. APPLICATION SUBMITTAL UATI
CL ST-
OW HONE: COW ACTOR'S NAME:
NYC CONTROL x
A0.CHR[LT/ENGINEER: LIC NO: ADORES ax'C� / ❑
CONTACT: PHONE: 6633 /{7 (w(J - BUILDING PERMIT INFO
1 ❑ Consultant Fees Paid by Applicant(Initial) B� ELECT PLUMB' ME❑CH .
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I heteby.M,.dial Tem liCcreed (c
under provisions of Chapter 9 .mmcncig nJOB DESCRIPTION
1'•'Z with Sectinn700fBof Uivieimm3ol the Business anJ PmfexsinnsCodc,and mylicense is RESIDENTIAL•
Gp in full force and cRc PERMITISSUANCE
4l[. C� S y''3(� ❑SFDWL ❑KITCHEN REMODEL
License CI ,ie.p
Contoxhi APPLIANCE'S-RESIDENTIAL C1 ADDITION C3 PLUMBING RE-PIPE
GG ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O mu,Zj I understand my piens shall be used eapublic records PANELS MODIFICATION
O Z UPTO 2W AMPS
[..O Lioeved Rofaxional ❑INTERIOR .CHIMNEY REPAIR
gg=C 201-1"AMPS PROVEMENT
KKKKYi :OWNER-BUILDER DECLARATION OVER IIIOO AMPS EREMO UREPAIR 0DEMOLITION
T hereby affirm that I am exempt from the Contractors License Law for Ne'
3 a U following return.(Section 7031.5•Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
F C which requires a permit to construct.alut,improve,demolish,or repair any somem.
prior to its issuance,also requires the applicant for such Permit file a signed interment SPECIAL CIRCUIT/MISC.
Ilppppp.... y that he is licensed pursuant to the provisions of the CunuactoYs License Law(Chapter 9
(commencing with Section 7000).(Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: J
d c eC End he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
-^,m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT E3 FOOD SERVICE
H Z Y not mote Non five hundred dollars(85110). IMPROVEMENT
gQ ❑ asowrterofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
GCGC
will,Oo Ne work.and b ray,
is not intended oroffered formic(Sec.7044,Business []OTHER
and Professions Code:The,Contmnors License Law does not apply m.n owner of OUTLETS-SWITCHES-FIXTURES
a property who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such improvemeats ere not int.ones!or offered foi. NEW RESIDENTIAL ELEC R SQ FT
sale.If,however,the building or improvement is said withinone year of completion,the SQ.FT.FLOOR AREA ESQ.FT,
owner-builder will have the burden of,mum,Nat he did not build or improve for pur.
pose of sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions CnJeJ Thu Cnntracuv's Li
-
onxLwdoesn.t.pply to an owneTnfpmpmy who builds or improvestheremn.and QTY PLUMBING PERMIT FEE
who contracts for such projects with.emanamn,)licensed parruantto the Comment's ,
License low. . PERMIT ISSUANCE
I am exempt under Sec: ,B&P C for this ,on
Owner Dote - ALTER-DRAIN&VENT-WATER BEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declamtioas:
❑Ilmocand will meintaina CertificmeofConsenttoselbutima for WorkeYs C.mpen- DRAINS-FLOOR,ROOF,AREA,COND. I STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this pemrA sissued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as acquired by Section
3700of the Labor C.dgfar the perfomanceof the work for which Nis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker' Com ensation ins Pence tamer and Policy num
Comer. Policy No.: 2MVIIGAS-EA.SYSTEM-OVER 4(EA)
EXEMPTION FRO OnFOks,
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
_ BUILDING DIVISION FEES
(Thissecaomnad not ba completed if the permit is faro.,hundred dollars(S I W) GREASETRAP
or less) PLANCHECK FEE
I certify that in the performance of the work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as m become subject m Ne Workers'Camper- ENERGY FEE '
OZ satioul.awaof Celifami.,Data WATER HEATER WNENT/ELECTR
Z O Applicant GRADING FEE -
r.1 c4 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you s 1d WATER SYSTENUTREATING
F^
become subject to Ne Workers Compensation prow;'ore ol'the Labor Codyyylll.sssx��''',,y(,/S„st SOILS FEE
Q forthwith comply with such provisions or this peri ]be deemed revoY�\ WATER SERVICE -
O CONSTRUCTION CP�NC 'e V , NEW RESIDENTIAL PLMB. SQ.FT. PAID Data RaeiPtp
I hereby off rte that Ner<isac.nstr o 1 Jinge n far eperfnrmunce of
I--m Ne work for which this par mi is issuer S Civ. J
healers Name TOTAL:
V Lenders Address TOTAL: '
tla 1 certify that 1 have mea pplicmion that the above information is BUILDING FEE
caA corrcct.l agree to comply wird el it nd county Nitlmlcex endnerelawssxlatingto QTY. MECHANICAL PERMIT FEE
U building constmntutor herebya h representatives of this city to enter upon the SEISMIC FEE
drove-mentioned properly far... l pmprams. PERMIT ISSUANCE '
(We)agree to save,indemnify and keep harmless the City of Cuper inn against ELECTRIC FEE
diebboaa,judgments.cans mal cxpxmwx which may in any way accmeag.awn said City ALTERORADDTOMECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0001 CFM) MECHANICALFER
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,tIW CFM) CONSTRUCTIONTAX
Signature of Applicam/Contracmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building occupant score or handle htandous material HEATING UNIT(TO 100.000 BTU)
os defined by the C Wino Municipal Cnde.Chapter 9.12,and the Health end Safety
Code.5e<a (a)7 �s HEATING UNIT(OV tR 101,001!1 BTU)
,
N\u VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which - r;,DoH �'Receipt x
emit hazardous air contaminants as defined by the Boy Ata Air Quality Management BOILER-COME(3HP OR 100.000 BTU) 1+ TOTAL:
DamcR BOILER-COME(OVER 100,000 BTU),
Yes
AIR CONDITIONER
SEP Z13
I have Bred Na hazardous materials requirements oiler Chapter 695 of dime Culi- ISSUANCE!)ATE
foods Health&Safety Cade.Sections 25505.LS533 and 25531.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. !s I I Y V F V Uf Cf1I INTI./
building does not conically have a tan t it is my responsibility to unify Ne azul4nt V
of the icp .t killer PAcrui issuanceof a Ccnifirin of '
Owner tar amhnde agateata TOTAL ISSUEDBY:
OFFICE