28583 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY -
CITYOFCUPERTINO - - I .',BUILDING-ELECTRICAL. - PERMIT NO,,
BUILDING DIVISION APPLICATION/PFRMITPLUMBING-MECHANICAL 8 5
BUILDING PROJECTIDENTIFICATION 8 V$ K
V J
v BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
07YNi11'S NAME: - PHONE: ORAACfOR',NAME AIC NO: "
12 N/C C OL g
CHITECI'2 GINCIL LiUNO:. , -5' 67 ADDRESS,
CONTACT: PHONE _�, Z� - - _ BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ r ❑
LICENSED CONTRACTOR'S DECLARA N QTY ELECTRIC PERMIT FEE
I hereby affirm that l sin licensed under provisions of Chapter 9 commencing JOB DESCRIPTION
O=IZ with Section 70DEdf Division Sof the B.Imea teal Professions Code,andm license is `
�00 PERMIT ISSUANCE RESIDENTIAL:
in full fore and e ❑SFDWL ❑KITCHEN REMODEL
�UV Us s m.g APPLIANCES-RESIDENTIAL ❑ADDITION ' PLUMBING R&PIPE,.,
F
'Dun Data Contractoris" ,
'Dun - ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
y O�� I uMerstand my plain shall be used as public records MODIFICATION
OZ (ppb UPT0200AMPS [:1 INTERIOR El CHIMNEY REPAIR
F N., � Liutued Pmfessioand 201-1100DAMPti- IMPROVEMENT
Fp OWNER-BUILDERCON -
1 hereby effrm Nat 1
OWNER-BUILDER
fromm thee Contractor's License Law for the OVER P"AMPS El BATH REMODEVREPAIR ❑DEMOLITION
p(36F following reason.(Section 703 L5,Business and Professions Cada:Any city or county SIGNS ELECRICAL [)OTHER
LLLL1l Y.y which requires a permit to consumer.alter,improve,demolish,or repair any structure
F,trS,Oe prior to its issuance,also requires theapplicant for such permit to Blue signed statmem SPECIAL CIRCUIT/MISC.
�ya so••1 that he is licensed pursuant to Ne previsions of the Contractors License low(Chapter 9 bbb
W GAOa (commencing we
n 7")of Division 3o a Business mW Professions Code)or TEMP.METER OR POLE INST. � COMMERCIAL:
6 6
.0
LL tin he is exemm and the basis for th Ileged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
•-,y Sestion7031.5 plicant for pe 't . is to applicant to y,Civil penalty of POWER DEVICES �TENpNT ❑FOODSERVICE
=Z} not more tan fidollars ). / - IMPROVEMENT
�=C ❑Lasownerproperty, a til swot wages. it I omperuetion, SWIMMING POOL ELECTRIC
y� wrlldo the wohno ended ggfRf�Krtdf I .7044,Business ❑OTHER
W and Professioncol Liu` 6✓ s not ply to an owner of OUTLETS-SWITCHES-FIXTURES
6'3 propertyw bproves e dy' �ch work himselfor through s
his own amp ided Nn �c m��^^ve ma aR not imcnded or oRcred for NEW R[SIDENTIAL F.LECTR SQ FT. - -
sala.i(.howeveing or'in IIs sold withinoneyem ofcompletian,to SQ.PC FLOOR AREA LSQ.FT.
onsw r-builder e burden proving thm he did not build or improve for par-pose of sale.). - - - ,
I,ss owner of the property.am exclusively contracting with licensed contractors I. TOTAL:
contains the pmjmt(Sec.]DW,Business and Professions Cade:)The Contractors Li.
ve Law does not apply in an ownr-of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a conmctorts)licensed purseenua the Convenors
Lt..law. _ PERMIT ISSUANCE
❑l am exemptder Sec. ,B&P COf for Nis reason
n..•...• _ ,D ALTER-GRAIN&VENT-WATER IEA) V
VALUA'W e
ORI R'SC 1PENSATION DECLARATION �1
Ihereb nm uMalxnelty of perjury one of Ne fallowing dalentions: BACK FLOW PROTECT.DEVICE q
•❑l have and will maintain a CeuiGcate of Consent to self-iruum for Wmkelc Counter. DRAINS-FLOOR,ROOK AREA,COND. 'STORIES TYPECONSTRUCFION
anion,its province for by Section 37M of the labor Code,for the part..tsre of the
work for which da patent is issued. FIXTURES-PER TRAP
1:11 have and maintain Workers Compensation Insurance,as require)by Section
3700ofte ejordieperformanceaf ewod which tispconit isissued. GAS-EA.SYSTEM-IINC.4OUTLETS
OCC.GROUP APN
My Wotke o r s f Insu c er a ombcraR:
Cmri GAS-EA.SYSTEM-0VER 4IEA) ,
CERG AT OF EXEMPTION FROM WORKERS' GREASPIINDUSTRL WASTEIMERCEPTOR
COMPENSATION INSURANCE„ BUILDING DIVISION FEES
This section need nee W completedifteperautisfor mwhundreedollars(5100) GREASETRAP
or less.) _ - PLANCHECK FEE
leenirytatinthe neeofthewarkfor hichtispermii is isaued.ishell SEWER-SANITARY-STORM EA.200 FT.
notemployanypers .nee onin s to been a object'. �o Rer%Compen- ENERGY FEE
,Z suron Lawsof Calif aWATER HEATER WNENT/ELECI'R
00 Applicant s � GRADING FEE
y NOTICE TO APDL wa���.(,eftermaking t ris Certificate of Exemption,you r Id WATER SYSTEM/IREATTNG
�^ became subject to the Ma s Compensation provisions of the labor Code,you m st SOILS FEE
{t1 G fonhwiNcomply wird provisidns or this permit shall6e Deemed revoked. WATER SERVICE' _
Q
CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PCMB. SQ.PT. PAID
Ll0 I hereby affrrn construction them is a consction lending agency for the performance of Dine Receiptp
the work for which NNorm m is issued(Sec.3097.Civ CJ -
0 U Lenders Name TOTAL:
Leaders Address' TOTAL:
1 certify Net 1 have read Nia application and xmte that Ne.bovc information is BUILDING FEE
Fr Intl cooed.l agree m comply with all city and county ordinances and Stam laws relating to QTY. MECHANICAL PERMIT FEE
boildingeina'auctiomandhereby authorize rapmsenmtivesoftiscitym concretion the SEISMIC FEE -
above-mentioned pmticny for inspection purpous. PERMIT ISSUANCE
.. (We)agree to save,indemnify and keep harmless the City of Capsular,against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MCCH. ,PLUMBING FEE
I.consequence of the granting of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL:NON-POINT AIR i HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. t - MECHANICAL FEE i
AIR HANDLING UNIT(OVER 10,00(1 CFM) CONSTRUCTION TAX
Signature of ApplicamConuactor r ,Data EXHAUST HODD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
s Will the applicant or future building occupant store or bundle hazardous material HEATING UNIT( U)]Bit,"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
CWeSection25532m)? HEATING UNIT(OVER 100,(X10 BTU)
_ -
FI Yes [:]Nos ., PAID' I.
- VENTILATION FAN(SINGLE RESID) DatetlJ („gaRaeiptp
Will the applicant or future building occupant use equipmcm or devices which❑No BOILER-COMP QHP OR IIXI,oq)BTU)
emit harardous at contaminants as defined by the Bay Arca Air Quality Management .IYyyAL:
[3y.s
District? BOILER-COMP(OVER 100.000 BTU)
AIR CONDITIONER
Ihlth iCo7e us materials requirements under Chapter 6.95 hf the Culi 1 ~ fs•ry ISSUANC At
forma Health CWe roan 25505,25533 and 25534.1 understand tat if the NEW RESIDENTIAL MECIL SQ.Nib - CIT Uf VV~� r
buildingdces r,0 ave sten hmitismyrospon'midt'r.;ifyteucupatit
of to who niusibe or to isa'm Ce if ar 0.cupancy.
O ugem ' Dem TOTAL: ISSUED BY:
OFFICE'