28491 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUIL 11 10 APPLICATION/PERMIT PLUMBING-MECHANICAL ' 28491
BUILDING PROJF,CI'IDENTIFICATION
BUILDI AD SANITARY NO. APPLICATION SUBMITTAL DATE
NE off• 6ii6&s
OWNER'$NAME: �/� PHONE: • CONTRACTOR'S NAM LIC NO'.
E� e-� a NIC CONTROLM
'�'ARCHTfHCI'/ENGINEER: LIC NO'. ADDRESS: V
� lie N yE ❑
CONTACT: PHONE: BUILDIN P RMITINFO
n A,"nom /D'��C�L� ❑ Consultant Fees Paid by Applicant(Initial) BLDG E PLUMB MBCH
�i (i(.000tGG ✓ ,J ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
��Z with rasp ofoivisionlal76e Busineaaand pmloss igFx� dmy kcensn is RESIDENTIAL-
its .
O wt (U/ //C/7 \ PERMIT ISSUANCE
full forte and ecl.
QUV License Class�Ll0.n _ ❑SFDWL ❑KITCHEN REMODEL
y<iDla? APPLIANCES—RESIDENTIAL
OADDITION ❑PLUMBING RF-PIPE
A — S� RCIITCp-ptn DECLARATION PANELS MULTI-UNIT
O$TRDCfDRAL
Z O n Z 1 understand my plans shall be used as public records MODIFICATION
O Z— UP TO 200 AMPS
W Licensed Profeseh.nal [IINTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 2061000 AMPS IMPROVEMENT
yp,C w Q I hereby affirm tom I am exempt from the Contractor's License Law for the OVER IOW AMPS ❑BATH REMODEUREPAIR O DEMOLITION
x 3 a OF following reason.(Section 7031.5,Business and Professions Cale:Any city or county /� SIGNS ELECTRICAL OOTHER
uull u.y which requires it permit 10 omomim eller,improve,demolish,or repair ,any some,
prior m its is'em's,tio,rcglires theopplicunt fmsuch peril to fileasitneimatemenl SPECIAL CIRCUIT/MISC.
2 y that he is licensed pursuant o the provisions of the Contractor's License Law(Chapmr 9
ac5�7 (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.MITER OR POLE INST. COMMERCIAL.
d noG that he is exempt therefrom and the basis far the alleged exemption.Any violation of
,gym Section?031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ONEW BLDG/ADDITION ODEMOLITION
ul
not more than five hundred dollars 18510). —1 TENANT OFDDD SERVICE.
E] It,as ownerofthe progeny.or my employeeswith wages as lM1eir Solt,compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
^o will do Nc work.and the structure is not intended or offered for safe(See A044,Business ❑OTHER
W 3 m and Profcaions Code:The Cmnmemrs License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements:rte not intended or offered for NEW RESIDENTIAL 1?LECTR SQ EL
sale.IL however.the building or improvement is sold within one year ofcompktim,the SQ.FT.FLUOR AREA $/SQ.FT
posorbuilder will have the burden of Rtovi g al he did not build or improve for pu-
tofsola..
❑1,as owner of the proftedY.am exd ming x I commemrs ns T L:
construct the Project(u.](149,Bu`es a n)essions )yTrhts9ry�Clonuemo"Li�
se Law does not ap man peny bristi lsor -pfvesthenam.nd QTY. PLUMBING PERMIT FEE
whoconwa for su p lh r d 11 pursuant to the Contractors
License Law.
❑Ism exempt under Sesa ,B&PCfonhis reason PERMIT ISSUANCE ,
ALTER—DRAIN&VENT—WATER(EA)
Owner Date VALUATION '
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
I hereby affirm under penally of pc ytry one of the following declarations:
❑I have and will maintain a Cenificau of Comenuo self-insure for Worker sCompen- DRAINS—FLUOR,ROOF,AREA,COND.
satitm,as provided for by Section 3700 of the Labor Gyle,for the performance of the STORIES TYPE CONSTRUCTION
for and this parmir is issued FIXTURES—PER TRAP
C
1 have and will maintain Worker's Compensation work
hi h required by Section
M rfthe Labor Code,for the pet torccofthcolic lirr which this permit is loved GAS—EA.SYSTEM-I INC4(IUTLEfS OCC.GROUP APN
M Worke' tion 1.art carter and Policy,
Policy NoY a NT GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION LBO WORKERS' �a
COMPENSATION INSURANCE C(p,dq- �'L GREASMNDUSTRL WASTE INTERCEPTOR
TITk sccrion nerd not he complelad niche peril is for undY�iJJnndroJ dollars($I XB BUILDING DIVISION FEES
or less] GREASE TRAP
I certify that in the performance nfthe wort farwhich this petit is issued.Lsball
not employ any person in any manner so as to beamte subject the Workers'Compen- SEWER—SANITARY—S9ORM BA.21X1 FT. PLANCHF,CK FEE
ENERGY PEE
sattaws of California.Date
Z O Applicant
cant WATER HEATER WNENT/ELECI'R GRADING FEE
Fy NOTICE. bj APPLICAN F.teWork If,apermaking this visiosoficate of Exemption.you should WATER SYSTEM/IREATING
's
; became subject y the Workers Compensation provisions of the Labor Cale,you man SOI
0. Q fonhwithmmplywith such provisions nrthis permil shall Mdecmed revoked. WATER SERVICE
�DZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM). SQ.PI'. PptD
U O I hereby affirm Nat there is a construction lending agency lir the perforance of ^ D c Receipts
W P the work for which this peri,is issued(Sec.309],Civ.C.)
C) Loaders Name
U Lender's TOTAL:
AddI TOTAL
>i0, 1 rectify that I have read nau
this application and hire that the hove information is
h cooed.I agree m cmnply with all city and county ordinances and nate laws relatin to - BUILDING FE
U Z buildingtaction,and hereby g QTY MECHANICAL PERMIT
oons yauthonprposes noes of mi..city to rhe FEE SEISMIC FEE
abovementioned
are propene for inspection purposes, PERMIT ISSUANCE
(We)agrees.cove,indemnify and keep harmless the City of Cupertino s against ELECTRIC FEE
tocemescierac enca,emis and expenses m,. may in any way accrue against said City ALTER OR ADD TO MECII.
onscquencc of rhe gmming of this peril. PLUMBING FEE
APPLICANTUNDE TANDS AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQWIICFM)
SOU C EGO r ) S. MECHANICAL FEE
AIR HANDLING UNIT(EVER 10.000 CFM) CONSTRUCTION TAX
gnamer of ppiica otrncmr Ua¢ EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant noum
or handle hordouma
s mdal HEATING UNIT(10 I co,a51 BTU)
us defined by the Cupertino Municipal Code,Chapter cc.12.and the Health and Safely
Cade,Section 25532(x)) HEA'T'ING UNIT(OVER 100U001 BTU)
[3 Yes
VENTILATION FAN SINGLE RESID) PAID
Will the applicant orf tare building occupant use equipment or do ices which Date Receipt g
emit h:aardous air contaminants as defined by the Bay Arca Air Quality Management BOILER—COMP(3HP OR 100,0)0 BTU)
L
TOL, ,
No BUTLER—COMP(OVER (b,aW BTU)dte haurdous mmeuels rcquhcmcros under Chater fi95of me Cali- AIR CONDITIONER
fety Code.Sections 25505.25533 and]5534.I understand mat if the ISSUANCE DATE
u tly eo mnam,Uel it ism tesponsibiliry usnaiftheattuanr NEW RESIDENTIAL MECH. SQ.PC
INaEv he 1 e ofa Cenificau ofOcl.,unc,,
d agen TOTAL:
ISSUEDB .
OFFICE