28851 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL. O C
BUILDING PROJECT'IDENTIFICATION o J
BUILDG ADORS . SANITARY NO. APPLICATION SUBMIT FpALL�DATE
111111 N(N(NN \V KJ
OWNER'SME,,EN PHONE: CONTRACTORS NAME: LIC RO'.
1 D-b
�+ NIC CONTROI,p
•ARCHITEC"UENGI EER: LIC NO: ADDRESS: ❑
FCOM*A�. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
arum Inas 1 am licensed under p,mi iff,of clamor,v(commencing JOB DESCRIPTION
o�zW)m'Dmiamu3atnr❑rim nondrrufanaonnade,amdm hnenseinfrOO y PERMIT ISSUANCE. RESIDENTIAL:
effect.=zULiex DSFDWL ❑KITCHEN REMODEL
yQaCartmcmr APPLIANCES—RESIDEM'IAL ❑ADDITION ❑PLUMBING RE,PIPE
ARCHITECTSDECLARATION El MULTI-UNIT ❑STRUCTURAL
Z p h PANELS�2� I tmJersmnJ u.y mL ro shall be nnrJ us public record. MODIFICATION
OZ-1 UPTO 200 AMPS C1 INTERIOR ❑CHIMNEY REPAIR
1=�E'u1 Licensed Pmficannd 201-1000AMPS IMPROVEMENT
%"� OWNER-BUILDER DECLARATION OVER 1000 AMPS D BATH REMODEIIREPAIR [IDEMOLITION
6 I hereby aMo.that 1 am exempt from the Cammorrs License Law forma FIMm
U following reason.(Section 9031.5,Business and Pmfcsions Code:Any city or County SIGNS ELEC'IBICAL D OTHER
3 1, which requires a permit in cnmtrvcl,alter,improve,demolish or repair any structure
poor to its issuance,also motion,the applicant for such permit m file a signed statement SPECIAL CIRCU TOM ISC.
f }
Not he is licensed pursuantto the provisions of the Comrecmes License law(Chapter 9
W L'�0 (commencing with Section 7")of Division 3 of me Business and Professions Code)or TEMP.METER OR POLE(NST. COMMERCIAL-
2T
OMMERCIAL
6 p,o T that he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
4X1 4' Section?031.5 by any upplirnntfair pi xobject,the f,p icantm pen
a civil aER lty al' POWDEVICES
or
not more than Five hundred Jolters(SSgO. DTENANT DFOOD SERVICE
FZQI,as owner of@e propcny,or my employees with wages as theirwle cnmpcnsaion, IMPROVEMENT SWIMMING POOL ELECTRIC
f�C will dathe work,and thenrvcture is not intended oroffered forsalc(Sec.709,Business DOTHER
Wm and Professions Cm1e:The Contractor's License Law does nm apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thcm'n,and who dcrs such work Limself or though
his own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however Ne building or improvement is sold within one year d completion.the SQ.IT.FLOOR AREA s/SQ.FT.
er-guilder will have the burden of paving that he did not build or improve for put-
note of sole.).
D I,as owner of the property,um enclosively connoting with licensed contracmn to TOTAL:
construct the project(Sec,9(94,Business and Professions Code:)The Contractor's Li-
came,Law does not apply to an owner of property who builds or improves themon,and QTY. PLUMBING PERMIT FEE
who eomrxets for such projects with a etec reendeas)licensed pursuant.me Contractor,
License Law. PERMIT ISSUANCE .
D 1 am exempt under Sec. ,B&P C for thio rwson
ALTER—DRAIN&VENT—WAT'ER(EA)
Owner Date VALUAT'IUN
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following dcclarstions:
❑I have and will maintain a Cenifcate ofCommann selLlnsure for Worker's Compete DRAINS—MOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
smion,as provided for by Section 3701 of the Labor Cade,for the Isarforreanec of the
work for which this permit is issued. FIXTURES—PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as acquired by Section
37W of the Labor Cede.for the perfmmance of Ne work for which this Frush is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS
M Workers Com motion Insurance carrier and Polis OCC.GROUP APN
Y pe Policy are
Cartier: Policy No: GAS—EA.SYSTEM-LIVER 4(1iA)
CERfIPICATE OF COMPENSATION INN FROM WORKERS'
COMPENSATION INSURANCE GRF.ASFIINDUSTRL WASTE INTERCEPTOR
(This cation tined not be<nmpleted if the memoir is T'r'ue hundmd dollars(Slq)) BUILDING DIVISION FEES
or last(sonify that in the erfo
GREASETRAP PLANCHECK FEE
prmanendthe work for which this permit is issued,Isnall SEWER—SANITARY—STORM EA.200 FT
not entpiny any person in any maturer.'as to beemne.subjectte '
o thrkcrx'Cnmprta. ENERGY FEE
.z smion laws of California.Data
Z O Applicant WATER HEATER W/VENT/ELT;CI'R
PP If GRADING FEF.
h
NOTICE TO APPLICANT.If,a per making this Certificate ,xemptionr you null WATER SYSTEM/fREATINC
abecome subject m the Warkeh Compensation pros cions the LaAa Cede,you list L SOILS FEE
forthwith comply with such pmvisinns'obis permit n he deemedruvnked. WATER SERVICE
a �?
7z CONSTRUCUONLE �IAIENCY NEWRESIDEM'IALPLMB. SQ.FT PAID
V O l hereby affirm thin there is a ran. on leading, cy for the perform ce f Dae Receipt#
Fthe work for which this permit is iss Sec.3197, 'v.C.)
Q Lender's Name TOTAL'
Lender's Address X UJI A - TOTAL:
y 1 certify that I has read this application a m at the aM f inion BUILDING FEE
IA correcrl ogmetccomply ithelleitya sou .r a JsWWt la remti QTy, MECHANICAL PERMIT FEF,
V z building mnswnion.and ereby ambo' r se rive fityt emcru urge SEISMIC FEE
above-meminned prnpea rinsme by s \ PERMIT ISSUANCE.
(We)agree m'co it demo ify ant , rhamfla,tr y nr Cup mo against ELECTRIC PEE
liabilities,judgments.costs a dexpcnses wh If ayinany ayxccaue sinstsaid City AI,TERORADDTOMECH.
rscqucnceofthcgramin offlaspermit. PLUMBINGFEE
APPLICANT UNDERSTAN SAND WILL COMPLY WIT ALLNON-POINT
AIR HANDLING UNIT(TO I O,qp CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNI'P(OVER 10.000 CFM) CONSTRUCTION TAX
Signamm of ApplicanuConuacmr Data EXHAUST HOODUVMUCI') HOUSING MITIGATION FEE
HA]ARDOUS Is((��TERIA ISCLOSURE
Will the applicant orfutumbi,Id L pain,store or handle hanoNous material HEATING UNIT TIO 100,000 BTU)
as defined by the Cupertino Municipal CwxxxxxXX,Chapter 9.12,and the Health and Safety
Cade,Scrota 25532(,)'/ HEATING UNIT(OVER 100,000 BTU)
E3 Ye, 0N
VENTILATION FAN(SINGLE RESID) PAID s
Will the applicant or future building occupant use equipment or devices which (Dam V ��Re !➢t p
.mit hazardous air contaminnna as defined by the Bay Arca An Quality Mamagomcm BUILER—COMP(3HP OR 100.000 BTU) s,
p11,1119 -- 'IOTA(_
C3 yes ❑No BOILER—COMP(OVER 100,0001tTU)
I have mad the hamNous mactials - AIR CONDITIONER ISSUANCE DATE
regm 533 had
under Chapter r ea of the if the
[forms HeaIN&Safety Cnwk,Sections 25505,25533 am1255J4.1 undcmm�d shut if the NF.W RESIDENTIAL MECH. SO.FT.lling due,not curealy have a mnum,that it kmyrespmibility,,allythe oceupun
the requirements which must be met priorm issuanceofa Certtficamof Ocummy,wner lir outhomed agent Dam TOTAL: ISSUED BY IPV N/T�
OFFICE