28539 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 28539
BUILDING PROJECT]DEN'FIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
106/1 FAST 65r,&7FS DR, S 'S
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: '
/. CY26q NIC ONTROL#
-6 RSr SS Sfe'N oar [OlJ ❑
ARCHITECT/ENGINEER: LICNO ADDRESS:
N Y170 Sd,a 0"""' iso/t< R fila 2s ill
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG E PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEF.
I hereby affirm that I am licensed under and
Professions
of shaper 9(commencing JOB DESCRIPTION
�,r with Section 70(y)of Division 3onne Business and Profes.inna cone,and illy license is RESIDENTIAL
~UU Infall eforce Cla and dYect. 6eVLlV 1'CRh11T ISSUANCE ❑SFDWL O KITCHEN REMODEL
I-U C.) License Class - Lic.#
'baa Dam Contractor 2 � _ APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING REPIPE
ARCHITECTS DECLARATION Osc K PANELS ❑MULTI-UNIT ❑STRUCTURAL
y p
Z O=? 1 understand my the useas public¢cor
d blids
t�i MODIFICATION
O Z— UP TO 200 AMPS
14�P Licensed Prido ionul ❑INTERIOR El CHIMNEY REPAIR
x(1l-IIX10pMPS IMPROVEMENT
�s( ,....II OWNER-BUILDER DECLARATION C.."ON OVER]"AMPS '
yp,��6 I hereby affirm that 1 um exempt from the Convamor's License Law bathe [3 BATH REMODEVREPAIR L1 DEMOLITION
x 3 6 V following mawm(Sai 7031.5,Business and ProlmW...Code:Any city mc....Y SIGNS ELECTRICAL ❑OTHER
LL Oa which require a permit to constroa,alter,improve.demolish,w repair any shvcture
F�mJ Frim to its issuance,also requires the applicant for such Permit o rile a signed statement SPECIAL CIRCUIT/MISCO
04 Q that he is licensed pursuant to the provisions of Ne Contractor's License Law(Chapter 9
(commencing with Section 40(Xy of Division]ofthe Business and Pmfiessiun,Gde)m 'HSP.METER OR POLE INST. COMMERCIAL
0. c that he is exmnpl therefrom and the basis for the alleged exemption.Any violation of
aI
See,...]031.5 by any applicant ler v permit subjects the applicant m v civil penalty of POWER DEVICES El NEW BLDG/ADDITION ❑DEMOLITION
F Z> ❑TF7JANT ❑FOOD SERVICE
not more Not five hundred dollars($500).
�0 ❑Las owner of the pmpeny,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
OG F'e will do the weak,and the saucme is ern intended aruffcred for sale(Set.7004,Business ❑OTHER
a3 and Professions Code:The Contractors License Law does not apply ,,an owner of OUTLETS-SWITCHES-FIXTURES
propmty,who builds or improve.thereon,and who docs such work himself or through
his own empleycc,,provided that such improvemems are not intended or offered fill NEW RESIDENTIAL ELECTR SQ FT.
sale,If.however,the buildingnaimprovementis sold within one yearofcompldion.the SQ.FT FLOOR AREA $/SQ.FT
owner-huilder will have me burden of proving that he did net build or improve for pur-
pose of sales.
❑h aseactcense
r of the p,., y.am exclusively contracting with lid cevtmcton to
oatmet tbeprv)at(Sea 7044,Business and Pmiro.ol s,Code:)The Contractors L,
cents,Law does not apply to an ewnerofpaopeny who builds or improves thcrcon,and QTY. PLUMBING PERMIT FEE
who commas for such projects with a contractions)licensed pursuant m the Cmu¢lass
License Low. PERMIT ISSUANCE
El I am exempt under Sec. ,B&P C fm this nnawn
ALTER-DRAIN&VENT-WATER(CA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE _
I herchy afrinn under penalty of perjury,one of the following declarations:
❑IhavcunJ will mainmina Cenilicam ofCunsenne sell-insurcfor Werkcr's Compen- DRAINS-FLOOR,ROOF,ARS .COND, TYPECONSTRUCTIOI
sation,as provided for by Section 370 of the Labor Code,to the perfommnce of the STORIES
work for which this permit is issued, FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700o1fthe labor Code,fmthe pefirromnceofthe work for which this permit is issued. GAS-E6.SYSTEM-IINC.4OUT1 S OCC.GROUP APN
My Worker's npc tion In a carrier and Policy number are:
Cmriu: _ /,r L(nc Policy No.: 1`2SS(a Z 3�iF' GAS-EA.SYSTFNFOV A)
CERTIFICATE OF EXEMPTION FROM WORKERS' n
COMPENSATION INSURANCEINDUSTRLW STE RCHMR
(This section nee]not be completed if the Fiction is furore hundred dollars(Sla) GREASE RAP
BUILDING DIVISION FEES
or less.) PLANC I( E
(certify that in the perfommntt ofthe work Terwhichmil permit i.1mud,hall SEWER A STORM 1
not employ any person in any manner se as to become subject m the Workeri Copen-mENERGY FE
Z small Laessef Califomla.Dam tt 799g.
7�O Applicant AT ER HE 1R WNE T/ L e GRAUIIJG FEE
G M NOTICE TO APPLICANT:If.after looking do,Cenilieme of Exemption,you should TER SYS 'M/I'REATIN
becomsubject to me Workers Compensation provisions of the Labor Cold,you must SOILS FEE Ifo
w forthwith comply with such provisions w this Fern shall he dmari revoked. WA R SERVICE
d
U Z CONSTRUCTION LENDINGAGENCY NEW ESIDENTIAL PLMB, SQ.FT. PAID
V Q I I,,,, affirm his
thaum,iis.c dation lending agency fonhe perfonnonce of Date Receipt#
0U
the link fmwhich this permit is issuedlSec.3trJ],Civ.C.)
Lenders Name
F
TOTAL:
V )¢odors Address �b I TO L: %
Fy Vemlify that I have read this application and state that the above information is BUILDING FEE
!n correct.1 agrm to comply with ell city and county ordinances and sus laws elating to QTY. ME CAL PERMIT FEE
V wZ-r building construction.andlumobyauthorixe ropla,nmtives ofthis city coemer upon the SEISMIC FEE
above-mentioned propeny for inspection purpose,
(We)agree to save,indemnify and keep hanale,the City of Cupeni no against PI!RM1T ISSUANCE ELECTRIC FEE
liabilities,judgmmau.costs and expenses which may i n any way accrue against said City ALTER OR ADD TO MF.CH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOU(pCE RE�GyLAT10X5 AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
/Ia_R/l �s AIR HANDLING UNIT(OVER 10,000CF M) CONSTRUCTION TAX
Stgnumroof ApplicvnVComracmr Elate EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or fmure building oce.famatere or handlehauudousmamdal HEATING UNIT(TO I00,0101)BTU)
as,defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cod,Semion 25532(.)? HEATING UNIT(OVER 100000 BTU)
E]yes E]No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future huilding accupunt uses equipment ar devices which Date Rucipt# '
emit hazardous air contaminants.,defined by the Boy Arca Air Quality Management BOILER-COMP LIFE OR 100,000 BTU)
Ld.xala
TOTAL:
s ❑No BOILER-COME(OVER 100.000 BTU)
read the hardous materials rcpmencuentx under Chapter 6.95 of the Cali- AIRC0NDITIONER ISSUANCE,DA
FarFJ
m &Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RF.SIDENTIAI.MLCH. SQ.FT.
not canendy havea mount,mat it is my re,plaWbilitym notify the nwcupamments which must be met poor to issuance ol'a Certificate of Occupancy.honxd agent Date
ISSUED BY:
OFFICE