28841 APP.LICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMITNO. A
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 2QQ41
BUILDING PROJECT IDENTIFICATION V�J 1
BUILDINGADDRESS: 1 SANITARY NO. APPLICATION SUBMITTAL DATE
1 D la CA Q 1 L /o 101f C
OytpER'S1AMEo� �- ., PHONE: CONTRACTOR'SN ME: C\U L Vo/O NIC CONTROL#
90
ARCC�_KK• (ENGINEER: LIC NO: ADDRESS: 1!,
CONTACT: PHONE: BUILDING PERMIT INFO
/d
?,3( /a.Q/ ❑ Consultant Fees Paid by Applicant(Initial) B ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
I hereby affirm that 1 atm IicensN under pmvisi.nx of Chapter 9(commencing JOB DESCRIPTION
000 with section 0(g111pefDivisionJpfnM Badness and Prnfeasiom Code,and my license is RESIDENTIAL'
C O i PERMIT ISSUANCE
toll force end effect. Q � � ❑SFDWL �� ❑KITCHEN REMODEL
UZ License Class Lie.x
<
Date CT Canwaor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
�� ARCHITECTS DECLARATION ❑MULTIUNIT ❑STRUCTURAL
O Z Z 1 urdc y n m plans sh I +I f'rccnrds PANELS �"' MODIFICATION
[� UP TO 200 AMPS Qo4p1'fERIOR ❑CHIMNEY REPAIR
F rvl f+; Licensed Pro essmnel 201.10041AMPS - IMPROVEMENT
kr L^y�^��6^�l6 Ott -BUILDER DECe Con ON OVER WIMAMPS ❑BATH REMODEUREPAIR El DEMOLITION
y CC I hereby affirm Nat m exempt from Ne Cnmrncmr's License Low far the
x 3 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
til - which requires o permit in consumer,Aron trotrounceimprove,demolish,or repair any scm
FSO primo lu issuance.also requires Ne applicant for such Permian file a signedstatement SPECIAL CIRCUIT/MISC.
y Nathvislicrosed pursua tto the powisiamo( mnnr
the Com 's License law(Chapter 9
p0 (commencing with Section 7")of Division 3 of the Businceavnd Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefrom media hvsis for the.Ilegcd exemption.Any viobnion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5 by any applicant for a permit subjects the applicant to a civil pmally'd POWER DEVICES
❑TENANT ❑FOOD SERVICE
but more Nen Can hundred dollars($500). IMPROVEMENT
��< (]1,mowner of the property,or my employces with wages os their sole compenmtion, SWIMMING POOL ELECTRIC
and da thewonal and theswcmreisnmimeaded Law
apply
an Business ❑OTHER
�,�� and Professional Code:The Convacmr's License Law dines not apply m an owner of - OUTLETS-SWITCHES-FIXTURES
property who builds or imp r..a,thereon,vad who dues such work himself or through
his own employees,provided than such improvements are nut intended or offered for NEW RESIDENTIAL ELECTR SQ IT.. Fro -
W.,If.however.the building or improvement is sold within ane yearof completion,the SQ.Fv F'1'AOR71R8Au $/SQ.PT.
owner-builder will have the burden of proving that he did rot build or improve for pur- o
tom of sale.). cr - 2
1,as owner of the property,am exclusively contracting with licensed contract. 1995
c.nslmn Ne pmjttt IStt.7044,Business and Ihofessions Code)The Convect a Li, T�a� • 1 V
cedae Lew does not apPlYman owner of pr.peny who builds or improves th on,ane QTY. PLUMBING PERMIT FEE CITY(Jf Lu
who contracts for such projects with a contrnctor(s)licensed pursuant m the amrucror's LUrLnI��^„`
License Lou. P RMIT ISSUANCE X11 11'(J
❑1 em exempt under Sm. ,B& for this reason
wder m A ER-GRAIN&VENT—WATER IEA) ////��I VALUATION
ffinWORKER'S COMPENSATION DECL ATIte BA K FLOW PROTECT DEVICE T( S v a G
I hercbyanunder penalty of perjury mm.df following dedamtione:
❑I have and will unit aCCmfc I fCoru elf surefnrwi,ders Cy(�e [)RAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
svton,as provided for by Section 3]00 of uhpr Code fnr the Peifnrmvnc�MSN
work for whichthis permit is its, — `I FIXTURES-PER TRAP
1 have end will moi orker's Compensauby Sectio
3/00of NeludanCod.for pert. the fur wLic ate iuixiss GAS-EA.SYSTEM-(INC 4 OUTLET OCC.GROUP APN
My Worker's Camped tion) a Poulibmaamrr2���
Cartier. cu 'Poli GAS-EA.SYSTEM-OVER 4IRA)
CER t ATE EXEMPTION ORKERS'
COM SATION INS[) ANCIi GRF.ASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thisscetinn rte not bac nplmed it the permit is for one nun ddallws($IUp _
or less) GREASETRAP PLANCHECK FEE
(certify NatinN perf rromeeofncwork fnr which 111 um it is iisbW,lshdl SEWER-SANITARY-STORM EA.200 FT.
not employ any person i any manner m as to bcco7e� e 'rkaa'Cnmpen- ENERGY FEE
O2 sai.nlswa.fC 'o Date WATER HEATER W/VENT/ELECiR GRADING F£6
Z�+ O Applicata
�(((///��� NOTICE TO APPLICA .IL ft making Nis snit ate of Exemption.you ahauld WATER SYSTEM/TREATING
[^ become suhject w the Wor t mammon rovisinns of the Labor Cnde,you muss SOILS FEE
foMwiN comply with such p s inns us permit shall he deemed revoked. WATER SERVICE
�1. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.14. PAID
'r ,'� Date Receipt X
V 0 I for which
this
thou it i is a construction lending agency for the perfomwnce of
Li work for which Nis permit is issued(Sec.3097,Civ.C)
w f't Lender's Nome TOTAL:
V Lender's Address TOTAL:
IYS 00.1 BUILDING FEB
I vanity Not 1 have read this application and stale that the above information is
coned.l agree to comply win all city and county ordinances and spite laws relating to QTY. MECHANICAL PERMIT FEE
construction,building consction,and hereby authorim representatives of this city m enter upon the SEISMIC FEE
above-memioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Caperton against ELECTRIC FEE
rml
liabilities,judgments.costs and expedms which may in any way revive against said City ALTT:R OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPL ANT UNOERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOL' C REGIn A N
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sig ammo(Applicant=1R.c' Dv EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARD �1ATERIALS DISCLOS E
Wlltheapplicanmrfm uAdingnccu...I store ctrl andle ha.mdous material HEATING UNTT GO Mufflio BTU) /
m d red by the Cupertino Mn mipul Code.Chapter 9.12,and the Health unit Safety
Code, celmn 25532(x)? HEATING UNIT(OVER 100600)BTU) Is Wi
❑Ycs - ❑Nn PAID
VENTILATION FAN(SINGLE RESID) Data Receipt#
Will Ne applicant or future building eventual use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emir humorous air conpiminanus as defined by the Bay Area Air Quality Management TOTAL:
District?
(]Yes El BOILER-COMP(OVER 100,000 BTU)
' � ,
(have read the hazardous m.¢oWs requiremcnu under Chapter 6.95 of the Csli AIR CONDITIONER ISSUANCE DATE
Nmis Health&Safety Cade,See ions 25505,M533 and 25534.1 understand But if Ne NEW RESIDENTIAL MECH. SQ.PT.
huilding dom rson e...fly have.tewnt,that it is my responsibility to rodfy the occupant
of the,requimmems which most be met poor m issuance of a Certificate of Occupancy.
Owner or emorriaed agent Dam - TOTAL: ISSUED BY:
OFFICE