28559APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION
APPLICATION/PERMIT
BUILDING -ELECTRICAL
PLUMBING - MECHANICAL'
BUILDING PROJECT IDENTIFICATION
PERMIT NO,
9
N V
8
11VV IIIIVVpp�-
. BUI`DIONQA13i S$, C
JOB DESCIRiPTION
RESIDENTIAL'
0 SFDWL 0 KITCHEN REMODEL
CADDITION CPLUMBING RE -PIPE
O MULTI -UNIT O STRUCTURAL
MODIFICATION
❑INTERIOR 0CHIMNEY REPAIR
IMPROVEMENT
O BATH REMOOaDEI_JREPAIR ODEMOLITION
0OTHER
a•�{/
-
SANITARY NO.
APPLICATION SUBMITTALDATE
OWNE NAME:/ JPHONE:
y
OVER 1000AMPS
SIGNS ELECTRICAL-
CONTRA R'S N t^/�, LIC O:
�- NIC
F-1
CONTROL#
RCH CDENGINE 1 NO:
ADDRESS: / _ s - g �p
0
I hereby M. that I am licenses) ander provisions of Chapter 9
N Section ]000)of Division] of Ne Bumucsarb PiakasCado. vn
full force
s, and ny
to Zpp� 1 understand my plans shall be used as public records {
rJ {aI Licensed Professional
LES •aj OWNER -BUILDER DECLARATION
I hereby .(firm that 11. exempt from the Caston Cod License Law for she
4 V following mason permit to"Io mm Business and Professions Code: Any city or county
0. which inquires a permit to comment. he eller, improve, demolish, orerepairsi. any aabructurm
mmorm
:y that hor eslicen mcpursalso requireproviisiappons o far mchpermina Nese Law(summem
ysc
that it pursuant N) of Division 3 theeBusinessnd ProflawsCoullrr
�00 (°ommencing with Senion]f100)ofDiviaionlofthe Business and Professions Code) or
EC that be is exempt therefrom and the basis far the alleged exemption. Any violation of
ry Section ]031.5 by any applicant for o fermis subjects the eppl ic.nt to. civil penalty of
_ mm
t othan five hundred dollar: ($500).
Z Q C)1, as owner of the property. m my employees with wages as their sole compensation,
will do the work, and she stmetum is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply m an owner of
terc
property who builds or improves don, and who does such work himself or through
his own employees, provided that such improvements we not intended nr offered for
We. If, however, the building or improvement is sold within one year of completion, she
asamobuilder will have Ne burden of proving Net he did not build or improve for pur-
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct she project (Sm. 7044, Business and Professions Code:) The Contractors Li-
cense Law does and apply to an owner of propeny who builds or improves thereon, and QTY,
who contracts for such projects with a conractods) licensed pursuant o she Contmcsurs
License law.
I am exempt antler Sec. ,B& P C for mutation.
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self --insure for Worker's Compeu
Wiwi, us provided for by See]inn 3000 of Ne Labor Code, for the performance of the
work for which this permit is timed.
O 1 have and will maintain Workds Compensation Insurance, as required by Section
JWo win, Labor Cale, for the performance of the work for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number are: .
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP SATION INSURANCE
This section nerd at be planed ifthe permit is fur one hundred did lars($1 W)
or It
I certify Not' th perfo cnfine work far wM1ich this permit is issded,lshall
not employ any an in
vny m &.a 1, h �nme sub' c]dthe Workers' Compen-
,� ration Law G 7
70 (2 Applimnt
G y NOTICE*P Aa ing this Cenificam of Exemption, you should
a 5 become subject to the Worker's Coupe ntim provisionsof the labor CWe, you must
W
forthwith comply with such provisions or 's permit shall he deemed invoked.
Q
z CONSTRUCTION LENDINGAGENCY
V 0 Thor which
than there tseco (Sec. 3W7,
agency for me performvnce of
V. f•+ me work for which Nis permit is issued (Sec. 709], Civ, 0)
O Landers Name _
Lenders Address
fy.� 1 certify Nat 1 have with
thirty and county un and state tees me above information is
building I agree m comply with ell ad andrepotdirunces and case laws relating a QTY.
L: .1having construction, and hereby 6umnriu reprcsenmtives of this city to enter upon the
above-mentioned propene (i`nr1 .conn puFCOMPLY
s.(We) agree to rove, indemnifyand karmless theCity ofa. re Wit C ss
liabilities,jutl ts, costs and expenseaway in any wayseem..#statsmidCityyuc f NDERSTANDS ANI/'SWITH ALL NON -POINT
Will me upplicmmr fumrc builJing octtsfham store or handle hazardous maredal
ss defined by the Cupertino Municipal Code, Chapter 9.12, and Ne Health and Safety
Code, Section 2 532(.D
I-] Y.,0
Will Ne applicant a future building oecupmt use cquipmcm or devices which
t hazardous air conic I s defined by the Bay Area Air Quality Management
istrict'!
❑ Yea
I have read rhe bawd s materials restatements under Chapter 6.95 of the Cali -
forma Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand and if Ne
building does not currently have a mnam. shut it is in, responsibility to notify Ne occupant
of the requireroenss which moa he roes prior so issuance of a Certificate of Occupancy.
Owner or mthodud agent Date
PLUMBING PERMIT I FEE
'
❑ ❑,❑
ALTER- DRAIN & VENT- WATER (EA)
ELECTRIC PERMIT
FEE
JOB DESCIRiPTION
RESIDENTIAL'
0 SFDWL 0 KITCHEN REMODEL
CADDITION CPLUMBING RE -PIPE
O MULTI -UNIT O STRUCTURAL
MODIFICATION
❑INTERIOR 0CHIMNEY REPAIR
IMPROVEMENT
O BATH REMOOaDEI_JREPAIR ODEMOLITION
0OTHER
a•�{/
PERMIT ISSUANCE.
APPLIANCES -RESIDENTIAL
PANELS
UPT02WAMPS
201-If100AMPS
OVER 1000AMPS
SIGNS ELECTRICAL-
SPECIAL CIRCUGUMISC.
GREASE NDUSTRL WASTE INTERCEPTOR
-.
GREASETRAP
TEMP. METER OR POLE INST.
SEWER -SANITARY -STORM EA. 200 FT.
COMMERCIAL,,
O NEW BLDG/ADDITION
0TENANT -
IMPROVEMENT
OOTHER
CDEMOLITION
OFWD SERVICE
"
POWERDEVICIS
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
WATER SERVICE
PAID
Date Receipt#
NEW RESIDENTIAL PLMR SQ. PL
NEW RESIDENTIAL ELECTR SQ FT.
TOTAL:
SQ.FT.FLOORAREA
&SQ.FT.
PLUMBING PERMIT I FEE
'
PERMITISSUANCE
ALTER- DRAIN & VENT- WATER (EA)
VALUATION
,
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF AREA, COND.
STORIES
TYPE
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
- ,OCC. GROUP
'
GAS - EA. SYSTEM -OVER 4 (EA)
GREASE NDUSTRL WASTE INTERCEPTOR
BUILDING DIVISfON FF
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGYFEE
WATER'HEATER W/VENT/ELEC R S`
GRADING FEE
WATER SYSTEMITREATING
SOILS FEE
WATER SERVICE
PAID
Date Receipt#
NEW RESIDENTIAL PLMR SQ. PL
TOTAL:
MECHANICAL PERMIT
BUILDING FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
PLUMBING FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT C"X.030 CFM)
ICAL FEE
AIR HANDLING U (OVER 10.000 CFM)
UCIIONTAX
NHOUS
GMITI
EXHAUSTH D(W/DUCT)
HEATING NIT (TO [(to" BTU)
HEATING NIT (OVER IW,g10 BTU)
`
PAID '-
Date
VENTILAT NPao(SINGL FSI
1OO,Of#)
NEW RESIDENTIAL
OFFICE Nl—/
ISSUED