28955 CITI'OF CUPERTINO BUD131NG-ELF.CfRICAL ^ IR�S f�
BUILDING DIVISION APPLICATION/1'ERh11T PLUMPING-MECHANICAL L XV lJ.f `Vl
BUILDING PRO16CT fOBNTIFICATION ".
SANITARY NO. AI'1'LICATIDN SUtlMITTALOA TE
BUILDINGADDRFSS:
�
OW 'SNAME: 2 / PHONE: COhTRACfOR'SNAME: LIC NO: Ll NIC CONTROL
AtIK
•AR HITS /ENGO.T.ER: LICN ADDRESS: C
CONTACT: PHUNE: 3 BUILDING PERMIT INFO
❑ Consultant Fees Paid by,Applicant(Initial) ELEC; UMB %C/
LICENSED CONTRACTOR'S DECLARATION QTY '- ELECTRIC PERMIT FEE JOB DESCRIPTION
I hcaby efTum Nat 1 am licensed under provisions of Chepair 9lcrmeamemp RFCIDFNTIAI
11=Z with S.mn]00010 BnO,mr3of Ne BusNessand Professions Codr.md my license is PERMIT ISSUANCE
-I - infull forte want effect. ),' 5.23 0 ❑SFDWL CHEN REMODEL
V(;-j Llause Class cis T-7 APPLIANCES-RESIDENTIAL ADDITION
h10ING RE-PIPE
�<yDote Co.ntractor!V ' !p^'G3IL ❑MULTLUNIT ❑STRUCTURAL
-=y A CHITECTDECLARATIONPANELS MODIFICATION
t2 Z I understand my plans shell he used at public records UpTp 300 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
?F'IOa] Licensed Professional 101-I(IOI)AMPS MOVEMENT
4�.4 OWNER-BUILDER DECLARATION OVER I000AMPS ATH REMODEIIREPAIR [I DEMOLITION
i < I hereby a fum that I am exempt from Ne Conuucmr s License Law for the ❑OTHER
d U fo0owirg reamn.ISedan]031.5,Business and Profaxi«s Cde:Any city or county SIGNS ELECTRICAL i
which requires a permit in answcL alter,improve.demolish.«aper any immune
g priamiu issuance.dso aquines Ne applicant for such prompt to Rle resigned suamem SPECIAL CIRCUIT C.
Cjy it.,he is licensed pusoed to Ne pmvincrsofthe Comrecmrs License law lCheptat9 COMMERCIAL.
YOC (commencing with Suvon7")of Dlvisi°n 3 o(the Business and pretentious Code)or TEMP.METER ❑NEWBLDGIADDMON ❑DEMOLITION
r� Nm ix u exempt dxrtfrom end Nc basis fm the alleged exemption.Any vioh,ion of wi
S n Section 7031.5 by any applicant for a permit subjects the applicant to a civil penahy of POWER DEVICES []TENANT [I FOOD SERVICE
_Z y not roma dun five hundred dollars(55001. IMPROVEMENT
-�< I.uowver of the pmpmy,a my employees with wagesu Ncir role compemanion. SWIMMWG POOL ELECf3e1C �''z ❑OTHER
will do the ao kand the swmurc is not intended 01 mficrd for role Sec.]Oak.Bure,of UTL�S-gWITCHFS-Fl%Tl1RPS
3 ad Prafesiom Calc:The Canvecbrs Littnse Law d«z not apply m an rarer of "r
Property who bu0ds m imarme.th mum.and who clues such wool,himself m through NEW,RESIDENTIAL ELECIR SQ FT.
his own employees provided Net such improvements am not intended or offered for SQ.FT.FLOOR AREA VSQ.FT.
sale.If.however,the building°,improvement is sold wWun a n,ind.f comphro.n.the �}
nmr.,odder will have the huden of paving that he did eat build in improve for put-
PoR ctf see.).
❑1.as owner of the property an,exclusively connecting with licensed corneeror to _.- DEG 1
connect the projeca(Sax.7045,Business and Professions Cede:)The C°nm rice"U. - ` . _ 199
amu law does m aPp1Y to an°weer o(Propmy wo builds m improves Nerzon,end QT'y. -' ^F PLUMBING PERMIT - +' FEE' C
whownvecm fors«h projects withaconvacmrlsl licensed purtuanuo the C°nwaofs - I^, �l
Licevse Law. PERMIT ISSUANCE .s w- '1.•. �^ Jt U .. ,:
❑I an exempt ander Ste. .B&P C for dtis rerun '� Gr•( -
� ALTER-DRAIN&VENT-WATER(EA) VALUATION
0. Data
W'ORKER'S COMPENSATION DECLARATION BACK FLAW PRO'TECT.DEVICE b
I hereby akar under pemlty of perjury one of the following declarations:
IWveandwillmainuina CedficatarfCoesennoself-insurz(m WurWs Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
adom ss provided fee by Section 3700 of the labor Code,for the Perfomunce of One
weh for which this permi,is issued. FlXTUBES-PER TRAP
❑I have end will maintain Workers Compensation Insurance,u squired by Section
3900 oftheLabor Cede.fa Ne Nrfamunceof de work for which this perms,is issued. GAS-EX.SYSTEM-1 INC.4 OUTLETS LIr (>CC.GROUP APN
My W'mkef rope au an' surance carrier end Policy nu �j�s�/ GAS-EA.SYSTEM-OVER 4IEA)
Cartier.-� 1�P°Icy No.: r}7 F�d-�
CA 'OF EXFMMON FROM WORKERSGREASFANDUSTRL WASTE INfERCEPfOR -
aCOMPENSATION INSURANCE '_;6,: • :BUILDING DIVISION FEES'
Missecit.mad net M completed ifthe permit is furore hundreddollex Cila) GREASE TRAP PLANCHECK FEE
or I..)
Loy my Nnindrc any Performance to bar(m which this thePermitWisissud,lshel SEWER-SANITARY-STORM EA.200 FT ENERGY FEE
no,employ any person in any manse,so as m become subject m the Workers'Compen-
0 Z armor laws of Califa°ia.Data WATER HEATER W IVENTELECTR GRADING FEE
.Z 0 Applicant
0— NOTICE TO APPLICANT:If,after making this Cmificete of Exemption,you should WATER SYSTEMRREATING SOILS FEE
Z 7 become subject to the Workers Compensation provisions of the labor Code,you man
fmNwith comPly with such provisions or this Peanut shall he deemed revoked. WATER SERVICE
S
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
Z Date x
J 0 week
ichum Nat there lsacmusec.3nledNB agency for the performance of
S dx work(or which Nis peanut is issued ISec.309],Civ.C) TOTAL:
0 F' Lenders Name TOTAL:
;a.U Li tier's Address BUILDING FEE a Ix
A. I anify Nn I have sad this application sodium,that the move information is
n comet.I agree to comply with all city and county ordinances and inch,laws caning m QTY, 1 MECHANICAL PERMIT FEE SEISMIC M �!
J Z building construction.and berebymuthonee apasentedies of Nis city to ental upon me
wove-mentioned Property f°rinspecuon purposes. ` PERMIT ISSUANCE F1.ECTRIC E
(We)agnee m save,mdemefy and kap harmless Ne City of Cupertino against
it , 'udgmenu.costs and expenses which may in any wnyaccacitru et said City ALTER OR ADD TO MECH. PLUMBING FEE
in eomequ mf the granung of th' Pe
APP ICA UNDERSTANDS A ' WI L COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,"CFM) MECHANICAL FEE
SO CE GUL INNS. 'j���-fI D AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION T
gnamrzof ApplicatCon I Date EXHAUST HOOD(WIDUC) HOUSING MITIGA 'E
HAT JUS MATERIALS DISCLOSURE I�
Will NeappIwan r um building occupant store or handle harmdous material HEKDNGUNf r=MI00,001IBTU1
to defined by the Cope in Municipal Code.Chapter 9.1'_.and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Cade.Smion'_5S31u1 /a
❑Yes ON. PAID FAN(SINGLE RESID) PAID Dam Receip
Will the applicant of future building occupant use equipment or devices which BOILER-COMP OHP OR Hat"BTU)
eat haxadaus au ronumieants as dermd by Nc Be.,
Area Air Quality Management TAL.
DismcR BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
I have rax bomtdms dommuls mqulmmenm under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE ATE
ead
fomite Hand&Safes Code,Sectio,n505,25533 and 25535.1 understand Nm if the NEW RESIDENTIAL MECH. SQ.Fn
building it.not svrerdy bace a Road.Nat it is my asl rmibility to notify the occupant
of the imme mems which man he nen prior W issuance of a Cmificam of Occupancy.
Ownerm euNonud agent
Data ISSUED BY:
OFFICE