28657 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU
BUILDING-ELECTRICAL PERMITTING.
BUILDING DIVISION APPIACATION/PERMIT PhUMBING-MECIfANICAI. /,X t� "17
BUILDING PROJECTIDENTIFICATION L V VVV V
BUILDING ADDRES�, Cu.�.XJ1'14o 1 - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERS N/AU(�(kY PHONE: CO ACTOR'S NAME: LIC NO:
5*4 sg V1 IZ t r -� �'y� N/C CONTROL
ARCHITFa1 /ENGI EER: . LICNO: ADDRESS: - ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
hereby motion,that I am licensed under provisions of Cbapmr 9(commencing JOB DESCRIPTION
"Z with Section 700a)of Division 3ofRa Bushels and Purfirmons Code.ond my hreme is
y OO PERMIT ISSUANCE RFCIDFNTIAI
F ad" in full force and effect.
UT' License Clms Lie.M ❑SFDWL [I KITCHEN REMODEL
L.Z W Dam Contractor APPLIANCES—RESIDENTIAL ❑ADiETION O PLUMBING REPIPE
�yg..• y ARCHITECTS DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL
z ovJ p 1 understand my plans shall he used as yuhhe recorde MODIFICATION
O z=f UlIT02MAMPS - [I INTERIOR - El CHIMNEY REPAIR
Licensedl Pmfeadonal - - 201-11X0 AMPS- IMPROVEMENT
Qom+ OWNER-BUILDER en Ce Contract.,,
ON OVER 1000AMPS ❑BATH REMODEL/REPAIR El DEMOLITION:
yayX�C 1 hereby efftmt that 1 I exempt from the Comecmh Liceme Lew for the
pd 3 p,U which falubins reosan(Sent 1 to3 trust,site impr Prove.demob Cale:Any city .county. SIGNS ELECTRICAL ❑OTHER
which requires a permit to construct,alms improve,demolish,or repair any swcwrc
pdormimissunnce,ileo requircathe applicant for such permiuofileusignW smmmem SPECIALCIRCUDMISC.
that he is licensed pursuant to the provisions of the Common's License Low(Chapterf)
eC (commencing with Sec0on7000)of Diviaion3of Ne Business and Professions CodO or TEMP.METER OR POLE INST. COMMERCIAL:
oq Net he is exempt therefrom and the oasis for the alleged eaempuon.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
u• Section 0031.5 by any applicant for a permit subjects the applicantto a civil penalty of POWER DEVICES
❑TENANT 'El SERVICE
5. t mare the five hundred dollen(8300)' IMPROVEMENT
G Gl,es owns of the property,or my employees with wages us their tole cnmpemotinn, SWIMMING POOL ELECTRIC
6• will do the work.and Neswmure is not intended oraRered Include(Sm.701 Business ❑OTHER
cal and Professions Cale:The Connector's Liana Law does not apply to an owner of UTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such wink himeelf or through
his own employees,provided that such improvements ata not funded or offered for NEW RESIDENTIAL ELECTR SQ Fr..
sale.If,however Ne buildingarimprov...t k uddwithinoneyeomfclontak on.the SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build nr improve for Aur
pose of sale.).,
O 1,ax owner of the properly am exclusively contracting with licensed contractors to T
onsruct the project(Sec 7044,Business and Pmfessium Co.,I Comwcmrs
cense Law does not apply to an owner of property,who builds or improves thereon,and QT'Y. PLUMBING PERMIT FEE
who co moscna for such Projects with a coauactorts)licensed pursuant to the Commmorx
License Us. PERMIT ISSUANCE
f am exempt under Sm. B&P C for this meson
Owner Date ALTER—DRAT 'NT—WATER(PAT „ VALUATION
WORKER'S COMPENSATION DECLARATION VICE P y O hAys�
I hereby is BACK FLO E
firm under penalty of perjury one of the following declarations: �C V V•(�
e and will maintains Ccmifrrm of Cunsem to self-mmu,for Workers Co.,.. DRAINS—FLOOR,ROOEA .COND.
aiduoq es provided for by Section 37M of the Labor Code,for Ne finfomunce of the STORIES TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES—PER TRAP
O I have and will maintain Workers Compensation Imumuce,as required by Section
37M mfmm labor Cada for the performance of the work for which Nix permit is issued. GAS—EA.SYSTEM-]IN .4 L OCC.GROUP APN
My Worker's Compensation Imurami,carrier and Policy numlmr arc:
Carrier: _ Policy No.: GAS—EA.SYSTEM-OVER4 A7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE INT R
BUILDING DIVISION EYES
(Thissection iced notbe completed if the permit isfmonehundreddollars(5100] GREASE TRAP
as less.) PLANCHECK FEE
Toy any Nan int he performance the work for which t to permit isi.ssuC,lshall SEWER—SANITARY—STORM EA.200 Fr. r
amt employ any person in any manner so as m beasm<subj<n m the Workers'Compen- �� ENERGY FEE '
Z •Z satian laws of Celifomia.Dam WATER HEATER WNENTIELECTR
0 Applicant - GRADING FEE
y NOTICE TO APPLICANT.Jr.after making this Certificate of Exemption,you should WATER SYSTEM?BEATING A�,
�^ become subject to the Workers Compensation provisions of the labor Code.you must SOILS FEE W
GQ forthwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE -
�' CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB.' SQ.Fr. PAID
UO I hereby affum thin them is a construction lending agency b.
So the performance of n. ZIP
ReceipnM
W {-+ the work which this permit is issued(Sec.3097,Civ.CJ
F' Lender,Name F e OTAL
U lenders Address TOTAL: c�
W 1 cmify that 1 have read this application and state that the above ird..ti an is BUILDING FEE 'sloe
N correct l agree to comply withal]city and county ordinances and state laws retailing no QTY. MECHANICAL PERMIT FEEry (1
U 4 building construction,and hereby authorize representatives ofthis city no enter upon the SEISMIC FEE r U 0
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep haeiless the City of Cupenlno against
liabilities,judgments,costa and expenses which may in any way accrue against said City ALTERORADDTOMECH.
in conseplere,ofthc grontin this permit. PLUMBING FEE
APPLICANT D EST . DSAND WILL COMPLY WITH ALL NON-POINT A]R HANDLING ON IT ITO 10,(MM CFM)
SOURC 10 MECHANICAL FEE
AIR HANDLING UNIT(OVER o%0MCFM) CONSTRUCTION TAX
sureof ApplinU .tractor Dam EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
till HAZARDOUS MATERIALS DISCLOSURE
'Ith pplicann or future building occupant store or handle hazam a rnamnal HEATING UNITf10100,000 BTU) ,
as defined the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
1 Code,Scotian 2553200? HEATING UNIT(OVER 100,000 BTU)
' [IYes FIN. VENTILATION PAN(SINGLE RESID) PAID'
sWill the applicant or future building accupam use quipment or devices which Dane Receipt ia
Ulf harardous air contaminants as defined by the Bay Amo Air Quality Management BOILER—COMP(3HP OR 100,001)BTU) ttlTp
District? BOILER—COMP(OVER IM."BTU)
Cl yes ON. `
I have cad the hazadous materials requirements under Chapter 6.95 of she Cali- AIRCONDITIONER, ISSUANCETOAATTEEE
Boost Health&Safety Code,Sections 25505,25533 and 25530.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. F/
building does all currently have a tenant,that it is my respomihiliny no notify the occupant
of the requirements which must be met prior to issuance of a Cerlificam of Occupancy. '
Owner or authorized agent Dune TOTAL ISSUED BY:
OFFICE