28593 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - t
CITY OF CUPERTINO, . . BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - n O C(J
BUILDING PRJETI
OCPIDENFICATION G o J J
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DATE
Ile
7OWN SHAME: HON CONTRACTOR'S NAME: / LI NO:
MT- AI_S L�o-n� a�- S Y2 vrP rv� /U M y4 66 N/C: CONTROL#
ARCHITECT/ENGINme fEER: LIC NO: ADDRES �0.t/t[Wh Q� ❑
CONTACT11. ' PHONE: j BUILDING PERMIT INFO
.v 1 1 Cr �,Q r�'Q(VL �-� I /6 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT . PLUM MECH
LICENSED CONTRACTOR'S DECLARATION
ED
herebQTY. ELECTRIC PERMIT FEE
1 y affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO lith Secdon]ll)(F- Dilisiom3 ofNallsinessand 1114simea Code,andanylice se is
F
"'E
'n full force and effey. ( PERMIT ISSUANCE RESIDENTIAL
�Uj Licence Class `�3� •Lie.# 6a ❑SFDWL ❑ ITCHEN REMODEL
WM
Data j6—(Ze � Commctm APPLIANCES-RESIDENTIAL ❑ADDITION _04_ NT RE-PIPE
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O Z PJ 7� I understand my plana sh311 h used as public records
J MODIFICATION
UPTD 200 AMPS
r 4IQi1 Lmensed Profeestonel .. ❑INTERIOR .❑CHIMNEY REPAIR
kkk777 •1 OWNER-BUILDER DECLARATION 201-1000 AMPS 'IMPROVEMENT
.4 OVER[MOAMPS El BATH REMODEUREPAIR [I DEMOLITION
6 I hereby affirm hat I nm exempt from the Contmcturs License Law for the
6 U following reason.(Sectiton 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F which requires a permit to construct,alter.improve,demolish: re or repair any structu
VF'
pdintritsi.so...c:also requires the applicant for such pe.it o Ne cosigned a.ammen( SPECIAL CIRCUIT/MISC.
0Cthat he is licensed pursuant to the provisions of the Comtmctors License Law(Chapter 9
(commencing with Section]OLY)1of Division 3 of the Business and Profession,Code)or TE MP.METER OR POLE INST. COMMERCIAL I
.(but he is exempt therefrom and the basis for the allegW,exemgion.Any violation of ❑NEW BLDG/ADDITION ❑
DEMOLITION
taN. Section 7031.5 by any applicant for a permit mbjectn the applisma n,a civil penalty of POWER DEVICES ❑ [ITENANT FOOD SERVICE
y n more Nan five hundred dollar($500).
G ❑ Las owner of the property,or my employees with wages ane their sole compensa(inn, SWIMMING POOL ELECTRIC IMPROVEMENT
th
will do e work and the structure is ma intendedoroRered farsale(Sea 7044,Business El OTHER
a " and Profesntracicenseaw dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
sions Code:The Cotors LL
Property who builds on improves thereon,end who does such work himself or through
his awn employees,provide)that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT. '-
.]a.If,however,ma,building or improvemem is sold withinone yearofcompletion.the SQ.FT FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pun- t 1Na
❑ 4
pose of sale.). /® '
I,as owner of the properly,em exclusively contracting with licensed contractors to TO L: w�
construct the project(Sec.7044,Business and Professions Cade:)T'he Comment's Li-
cense Law does not apply toanon of propeny who builds or improves thereon,and QTY. PLUMBING PB 41T FEPyry
who contracts for such projects with asummations)licensed pursuant to the Comactofs
License Lawexempt
PERMIT ISSUANCE �F�. 1995
❑I am exempt under Sec. B&P C for(his reason -
Owner Data ALTER-DRAT VENT-WATER(EA) >, VALUATION
WORKER'S COMPENSATION DECLARATION BAC WPROTECT.DEVICE
V
I hereby affirm under penalty of perjury one of the following declarations: .
❑I have and will maintain a Certificate of Comen(mself-income for Worker's Crimper. DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 37W of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP •t "
❑1 have and will maintain Wmker's Compensation Insurance,as required by Section
3709ofthe Labor Code,for the performance ofthe workforechich this permit is issued: GAS-EA.SYSTENL INC.40I1T OCC GROUP APN
My Worker's Compensation I.s.mnce carrier and Policy number are: ,
Cattier. Policy No.: GAS-EA.SYSTEM- VER A)L,
CERTIFICATE OF EXEMPTION FROM WORKERS' .
COMPENSATION INSURANCE Cut ASPM U T I NR PTOR
(This section need not be am,11t ed If Nepermit is faronehundmildollms(SIM) _ BUILDING DNISION FEES
or less.) GREAS PLANCHCCK FEE
Icenifytha(inthepe ormance of the work Por whicti this permit is issued,Ishell
ma employ any person i y manneraise;to pepQma ,,nit m t Compen- ER SA r R STO EA.2W FT. ENERGY FEE
7i smtion Laws Ca thin to /V"-st 4— 'F J rs
Applicant ER HEAT R NE /FLECPR
tiGRADING PEH
NOTICE subject
APPLICANT Lafter ma mgthis visionsof of Exemption,you should W RSYSTEM? 'ATING
a becomes rxanpio.he Worker's Coons or this parovisirns of the Labor Code,you most SOILS PBB
W0. Qforthwith comply with such provisions or this permit shall be deemed revoked.
WATER SERVI ..
CONSTRUCTION LENDING AGENCY
U z NEW R ENTIALPLMB. SQ.FT. PAID
U k ereby forwheh thisat pmthere isaco Sac,i3nlending agency for the performance of Data Rectint#
than work for which this permit is issued(Sec 309],Civ.CJ t
B" F+ Lenders Nate
UTOTAL:
W Lender's Address
y p„ I certify that I have read this application and state that the above begainumn is BUILDING PEE
rq correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U building construction,and hereby authorize apreswmtives of this city to enter upon the SEISMIC HE
above-mentioned)property for inspection purposes.
(We)a to save,indemnify p y o p g PERMIT ISSUANCE -
gree yes which
harmless way
fCu Cupertino aunt ELECTRIC FEE
inconses,judgmentsof e costs and expenses which may in any way accrue against said City ALTERORADDTOMECIL
consequence N SthisD WILL
PLUMBING FEHy Li
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(TO 111,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I thus)CFM) CONSTRUCTION TAX f
Signature of ApphwnUContracmr Date EXHAUST HOLD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(M 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25572(a)^. / _ HEATING UNIT(OVER 100,000 BTU)
❑Yes �[
VENTILATION FAN(SINGLE REBID) PAID
Will the applicant or future building occup$nt use equipment or devices which Date Receipt#
.it houndousair contaminants as defined by the Bey Area Air Quality Management' BOILER-COMP(3HP OR I DO."BTU)
District? —/ T
Ely. BOILER-COMP(OVER I0,00(1 BTU) g
I have read rhe hazmdous materials requircmems under Chapter 6.95 of the Cii- AIR CONDITIONER - ISSUANCE DATE '
fomia Health&5 sty Cade,Sections 25505,25533 and 25534.I understand that o the NEW RESIpENTIAL MECH. .
b ildingdce no tly havea¢na that it is mymsponsibility mortify the coca.... SQFT.
-
oflherinu's (tsson
ustl -(o issuance of a Cenlftwta of0aup
Owner or authaii S]agent Date - -, - TOTAL:
ISSUED BY:
OFFICE