28638 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 28638
BUILDING PROJECT IDENTIFICATION
BUILDINGADDJgI>SSO� SANITARY NO. APPLICATION SUBMITTAL DAI
pp//l1VV�``\\ g�2� q LQj
OW a NAME.: CONTR OR:SNAMIi: LIC NO.Tlilh� NIC CONTROLM
ARCHITECDENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ED E-] A E:1LICENSED CONTRAC'TOR'S DECLARATION
��'z QTY. ELECTRIC PERMIT FEE
1 hereby affimn t that 1 am licensed under provisions of Chapter 9(commencing
with section]BW)of Division 3afthe Baab,cas and Plefe:.ion code..,d my nnenaeia JOB DESCRIPTION
L License
Classdeffect PERMIT ISSUANCE ❑SFDDWI_ ❑KITCHEN REMODEL
FUZ U License Class Lin,X -
NQW Dam Contractor API'LIANCFS—RESIDENTIAL []ADDITION ❑PLUMBING RF.-PIPE
�' ARCHITECTS DECLARATION PANELS
El MULTI-UNIT ❑STRUCTURAL
Z O 4 Z 1 understand my plans shall be used m public record,O Z�G UI"r0 200 AMPS MODIFICATION
F 14�W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
y�Y j OWNER BUILDER DECLARATION 2111-IMIUAMPS IMPROVEMENT
6 I hereby affirm that I am exempt from the Contractors License Law for the OVER 1000 AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
3 a F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
.F,
o y which quires a permit to consume,altar,improve,demolish,or repair any suurnam W+ i
t
i
i
pror t,Is ssuance,also quires the applicant for such Penn,to file a.si signed m� 0nc SPECIAL CIRCUIT/MISE.} that he is licensed pursuant the provisions of the Comrudor's License Law
ay LOO (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
ac6 M� that he is exempt therefrom and the basis for the alleged exemption.Any violation of
X � Section]1131.5h at a Iitenl for a permit subjects the applicant m a civil [-I NEW BLDGIADDITION [I DEMOLITION
W I more Nan five hundred dollit,(S50T. ) penalty of POWER DEVIC135 ❑TENANT ❑FOODSERVICE
E=C ❑ I,as owner ofthe property,m my employees with wages as their sole compensation, SWIMMINGPWLELECTRIC d' ass IMPROVEMENT
pFo will du Ne work and the structure is not intended or offered for sale(Sec.7O 'Business ❑OTHER
e.,3 m and Professions Code:The Contuaordoes s License Law ds not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who docs such work himsell'ar through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,hevesca,me buildngar improvement issold within one yeanfcompletion,the SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par
pose of sole.).
1,as owner of he pmpeny,am exclusivelyd contrasting with l TheeCc,nactors i. TOTAL:
construct the project(Sec.7034,Business and Professions Codcq The Contractors Li.
cause Law does not apply to an ownerrof property who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
who contmets for such projects with a contracror(x)licensed pursoanuo the Contmemes
License Law, PERMIT ISSUANCE 1
❑I am exempt under Sen. ,B&P C lin this reason
OwnerALTER—DRAIN&VENT—WATER(EA)
Dae VALUATION
Wm penally of
of COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 Ihercby affirunder peperjury one of the following dedamtions:
❑Ihave andwill mvintuina Ccnificutc afConsem to Welt-insurefor Worker's Compete DRAINS—FLOOR,ROOK AREA,COND.
autian,as Elevated for by Section 37W of the Labor Code,for the Performance of the STORIES TYPE CONST RUCTIO;
work fm which this pemtit is i.valet, FIXTURES—PER TRAP
ED I have and will maintain Workers Compensation Insurance,as required by Section
370K)of the Labor Code,for the pedormanmof the work for which this permit is issued. L GAS—EA.SYS'IFM-IINC4OUTLETS13CC.GROUP
My Worker's Compcnmtion In.sumace center and Policy number are: ANN
Cartier: Policy No.: GAS—EA.SYSTEM-OVER 4(PA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASP/INDUSTRL WASTE INTERCEPTOR
or lea.)
(This veetlunrued not be en.nplemd it ho permit is Gaon,hundredGREASETRAP dal later($I lot BUILDING DIVISION FEES
I ramify that in the Performance ofthe work for whicM1 this pemtit is iauedPLANCHECK FEE,lshall SEWERSANITARY
not employ any Flown in any manner m — —
as v,become subject to the Weaken'Contact. STORM EA.2W FT. ENERGY FEE
sz vain,laws ofcelilinnia.Date
O Applicant WATER HEATER WNENTMLECfR
re, NOTICE TO APPLICANT:If. GRADING FEE
after making this Certificate of Exemption,you should LONER SYSTHh1/fREATING
? become subject m the Workers Camss
penunn provisions of the Labor Code,you most SOILS FEE
W Q forthwith comply withsuch provisions or this permit shall deemed revoked. WA'T'ER SERVICE
0e.
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN SQ.IT. PAID
L)Q thereby affirm that iso construction lenhintriency fur the perfomance of Date Receipt#
U. I—' the work for which this Komar is issued(Sec.301 civ.C.)-
Q Lenders Name
L unity TOTAL:
LU Erecters nitys
11t I cNa 1 have read this application and sure that the above information is BUILDING FEE
(n Comet.1 agree to comply with all city and county ordinances and stare lows relating to QTY, MECHANICAL PERMIT FEE
V Z buildingconwaim.and herebyindwrim,nepoescnuuvesefdr,city to enter upon the SEISMIC FEE
above mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupcnino against ELECTRIC PEE
liabilities.judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
in consequence of the gaming of this pnntit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1100 CFM)
SOURCE RE ,,ATIONS. p MECHANICAL FEE
B a 9�Q AIR HANDLING UNIT(OVER il),"CFM) CONSTRUCTIONTAX
Sigtat ofgppb 'mumanr ate EXHAUST HOOD(W/DUCT)
AZARDOUS MATERIALS DISCLOSURE - - HOUSING MITIGATION ME
Will the applicant or future building occupant atom or handle haaadous material HEATING UNIT(TO I W,W)BT U)
redefined by the Captain.Maaiapal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? HEATING UNIT(OVER IM."BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or furore building occupant use cquipinent lir devices which Y Date Receipt#
-lothr� us air commonanis as defined by the Bay Area Air Quality Management BOILER—COME CHP OR 10iff"BTU) s � a (
❑ �
forest
/ ❑Yes BOILER—COME(OVER 100,000 BTU) TOTAL:
I have .it the hmardova materials qui rcmcac under Chapter 6.95 o1'the Cali- AIR CONDITIONER ^)
famia Health&Safety Code,Sections 25505.25533 and 25534.1 understand Na if the — ISSUANCE DATE
building does nuourrendy have a tenant,first it ismy nesponsibilitymnotify the mountain
NEW RESIDENTIAL MECH. SQ.IT, r Lf p,L•
of the requirements which must M met prim to issuance offs Certificate of Occupancy. •r f f�;/',
Owner or author¢cd agent Dau TOTAL ISSUED BY: LJfY� 1
OFFICE