28909 APPLICANT TO FILL ININFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO! BUILDING-ELECTRICAL. - - - PERMIT NO. O�-
BUILDING DIVISION APPLICATIONIPERMIT . PLUMBING-MECHANICAL '
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY IS APPLICATION SUBMITTAL DATE
42
OW ER'S NA E: PHONE: C TRACTOR' E: LIC NO: 16,
N/C CONTROL#
rz ITECT GINEER: LIC NO ADD .S: - 4 ❑
CONTACT PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
LICENSED CONTFMCTOIVS IsECLARATION. QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(emnmenciag JOB DESCRIPTION
u�{R00 USection]000)of DlvIdon3 orae Businassand Professions Code,and my licensers
F�� in fullfumeandeffect,/��� y PERMITISSUANCE ,-RESIDENTIAL 1.
aU� Licens —L--�Lic.W _ ��SFOWL DSPRKNI REMODEL
Z APPLIANCES-RESIDENTIAL
and Dut .-_q- .Cuntmdor ❑ADDITION
'S LUMBING RE-PIPE
'Myin RCHITECTS DECLA A EIMULTI-UNIT �El STRUCTURAL -
O Z M Z.e [understand my plans shall be rain es blic records PANELS
Pu MODIFICATION
UP TO 200 AMPS ❑INTERIOR Ll CHIMNEY REPAIR
F� I Licensed Professional - 201-1fKK1AMPS IMPROVEMENT
OWNER.BNLDER DECLARATION
WW W.W I hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS [1 BATH REMODEUREPAIR [I DEMOLITION `
pea G Ufollowing reason.(Section 9031.5,Business and Professions Code:Any city oSIGNS ELECTRIC
f county C OTHER
I.
4417 , following
requires a permit to cconstruct,slier,improve,eemolish,'to repair any structure AL
¢ priortoitsissum e,also requires the applicant for Inch Ito Ile 4li dsatemen,'
permit gne SPECIAL CIRCUIT/MISC.
y thatim sliverisedpucsuani to the provisions of the Contractor's License Low(Chapt,9
p0 (commencing with Section 9000)of Division 3of Ne Business and Professions Code)., TEMP.MITER OR POLE INST. QMMER IA . '
6 e that he is exempt therefrom and the basis for the alleged exemption.Any violation of
I y Section]031.5 by any applicant fora permit subjects Ne applicaul to a civil Penalty of POWER DEVICES ElNE❑TE BLDG/ADDITION El DEMOLITION
NANT El FOOD SERVICE
>> not mare Nan five hundred dollsa%($50d.
F yqQ ❑I,as owner of Ne property,.,my elnployces wit wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
[.. will do the work,and the stmcmreis nnl intend ed if ad fareale(See, Business ❑OTHER
and Pr f. t ns Cade:The Con ori L L dce. not apply to vn owner of OUTLETS-SWITCHES-FIXTURES 1'
property who builds r improves t o e d such work himself or through his oemployees,provided b p i not intended been for NEW RESIDENTIAL ELECTS SQ FT. '
sale If.h N b Ing r tp t t' one ye #(npletion,the _ SQ.FT.FLOOR AREA $/SQ,PT.
err btolder 'll th b of proving Nal he Nd not bu(A�rnyoJ( pr a for par -
poseofsa .).
❑ Lase property,am exclusi ply cum dean ed contractors to TOTAL: ,
construct me pro (Sec.]044,Hosing{Yspd fes�siode:)The Contramor's Li-
cease Lawdoes'n pplYtoanowner dA,r1},Cnywho boild.orimpmvestercon,and Q7y. PLUMBING PERMIT FEE ®CT25,'1995
whoeommetsfors nh pmjects withacon ags)lici:nsed pursuant to the Contractors 1
License Lew. PERMIT ISSUANCE (A '
❑ 1 alto exempt under see. B&P C far this..,an Ur GUhER f Af
Owner Dare
ALTER-DRAIN&VENT-WATER(EA) VALUATION
s WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
hereby atrirm under penalty of perjury one of the following declarations
�. have and will maintain a Certificate of Consent to self-insure for Worker's Copper. DRAINS-FLOOR.ROOF,AREA,CONE) .,
tion,as provided for b Section 37M of the Labor Code,for the STORIES TYPE CONSTRUCTION
P y performance of the
workfar
ve.andh Nis permit is issued. IXTURES-PER TRAP
' ❑I have end w1lPmalmain Worker's Compensation Insurance,as raqulred by Section
3700 of me Labor Cade,for the performance of the work for which this permit is issued. GAS-EA'.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Woryl��p�s airier and Policy
Currier( //ifs Policy No, GAS-FA.SYSTEM-OVER 4(EA)
-
_ CCRTIFICATE EXEMPTION FROAT WORKERS' "
COMPENSATION INSURANCE GREASETSDUSTRL WASTE INTERCEPTOR' t BUILDING DIVISION FP-ES
(This section need not beeampleted if me permit is fortune hundred dollars($[ad) GRBA$6 TRAP
or less.) PLANCHECK FEE
Icerify that in the performance of the work for which this permit is issued,i shall - - -
not employ any permY pen-person manner so as to become subject to the Workers'Com SEWER-SANITARY-STORM EA.200 FT,
ENERGY FEE
Oz plt-ews of California.Data
Apicant WATER HEATER W/VENDELECUI
z O Appl - - GRADING FEE
E✓'� NOTICE TO APPLICANT:If.after making this Certificate of Exemption,,you should WATER SYSTEIGREATING
become subject to me Worker's Compensation provisions of the Labor Code,you mustSOILS FEE
[aS1� forthwith cornni
mply with such provisions or this pinhm
all he deemed revoked. WATER SERVICE t.
0. Q .
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL Pi-Mg. SQ.ET. PAID
U Q Thereby affirm thavhen-is a construction lending agency Por the performance of A Data Receipt# '
i--� the work for which this permit is issued(Sec 309],Civ.C.)
c F" Lenders Name' '1 TOTAL:
a Lenders Address ^
1 certify Nat 1 have read this application and state that the above information is BUILDING FEE
F..1 U) correct.I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V' building construction, it herehy authorize representatives of this city to enter upon the SEISMIC FEE'
above-mentionul paha for inspection purposes..
(We)agree to save,indemnify and keep harmless the City of Cupertino again PERMIT ISSUANCE BLECTRICFBE' -
Iiabilities,judgments;costs and expenses which may in any way accrue against said City ALTER OR ADO TO MECH. . PLUMBING FEB
in consequence of the gmming of this permit
Af ICANTOND ,P ANDS ANLL WILL COMPLY WITH ALL NON-POINT- AIR HANDLING UNIT(TO 10,000 CFM)
A'! 1•7 /� _L 4 MECHANICAL FEE
n �N �L�l � /� AIR HANDLING UNIT 10.000 CFM) - r
CONSTRUCTION TAX
re 6 f P cam7ccaffc, Dare EXHAUST HOOD(W/DUCT)• HOUSING MITIGATION FEE,
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicantor future building wcupam score or handleheznrduus material HEATING UNIT(TO 100,00 BTI)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)] HEATING UNIT(OVER 100,000 BTU)
❑Yes El No - - PAID
VENTILATION FAN(SINGLE RESID) Data, Receipt It -
to
Willthe applicant orfuturentsa bulling occupantuse equipmentAiror maces nagement
BOILER-COMP 13HP OR 100,000 BTU)
emir hazardmns air contaminants as_defined by theday Arca Air Quality Managem<m T L:
District' - BOILER-COME(OVER If(SEORTU)
❑Yes ❑N-
I lows'nm the hazardous crisis requirements under Chapter6.95ofine Cali- AIR CONDITIONER' ISSUANCE DATE
Radio Health&Safely Cede,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. "
building does not currently have a levant,that it is my responsibility to notify the occupam� - 1
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent -
Data TOTAL: IBSUEDBY:
OFFICE