28617 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PCRMIT NO, w
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING-MECHANICAL I6
17
BUILDING PROJECT IDENTIFICATION
BUILUINGADDRFSS: SANITARY NO. APPLICATION SUBMI'11 .DATE
O 16-0 114 /0
O WR'SNAME: PHONE: CONTRO e oA r0 'S NAME:' LIC N :
y/ a, N/C CONTROL
RCHITECTBiNGINEER: LICNO: ADDRESS:
•L ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid Ey Applicant(Initial) BLDG ELECT vLU MliCx
G - ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Q0Z with Section]ULG)of Division 3ofthe Business and Professions Code,and my license is RESIDENTIAL
�u00 wn PERMIT ISSUANCE,
CUU mfull force and / //j/a,��� ❑SFDWI. ❑KITCHEN RBMODFiI.
QUU License Class 6-i LieN �S/y P g-r� APPLIANCPS-RESIDENTIAL (3ADDITION [I PLUMBING RC-PIPE
F a W Date Con[ra<tnr
[t[-�-.. OL.y ARCIJITECT'S DIiC1ARA'1'ION PANELS [IMULTEUNIT El STRUCTURAL
Z O y Z 1 understand my Plans shall be used as public records MODIFICATION
oz-, UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�F. neared enced Pntlessional 2014000AMPS IMPROVEMENT
Q
i O.T- OWNER-BUILDER DECLARATION OVER IIKKIAMPS C3BATH REMODELREPAIR [I DEMOLITION
C a 1 hereby affirm that 1 am exempt front the Contractor,License Law for the
iPy U following reemn.(Section 7031.5,Business and Profcssiams Codr:Any city or county SIGNS ELECTRICAL. ❑OTHER
as 3 n.y whi<M1 rtquimx o pcwi[[o mnsw<t,alter,improve.Jcmolish,nr repair any swctum
gPriormits issuuneq also requlres the applicant for such pewina filcasigneJ eutememt SPECIAL CIRCUIT/MISC.
} Nal he ix licensed pursuammthe Pnwisnv of the Camracuv's licensela, Clmptar9 -
GS (commencing with Section 7000)ofDivision 3 ofthe Business and Prascii.na Code)or TEMP.METER OR POLE INST.
p O that he is exempt therefrom and the basis for the alleged extent tion.An violation al
yo� p p civil
❑NEW
NANIP ADDITION El DEMOLITION
Section]031.5 by any applicant for Traits 'tors the apPlicwtJye civil pcnahy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F.z6not mom than five hundred dollars TO pI IMPROVEMENT
❑ I,aaowme afmu,pntperty,mmy et In wages�le camltsnxmimi SWIMMING POOL ELECTRIC
TFC will do the work.and theswnurc is nm in oroffereJ for Ie c.'lDiq Business ❑OTHEk
13 m and Professions Code:no Cont m 's cense La J t a IY to an owner of OUTLETS-SWITCHES-FIXTURES
property who Imilds or impn c. J who J ^In work hinnsdf nr though
his own employeqildi
m ucM1 m immnJed or offered for NEW RFSIU1iNTIAL ELECTR SQ FT.
Sale.Ir, owevea lmprtw nL`d"d within one year ofecarru mr,he Sp.FT.FLOOR AREA LSQ.owner-builderwicn e1 p e t tat he did not build or improve forputsposeofsale.).Q 1,as owner ofexclusively contmming with licensed contractors to TOTAL:
construct She project(Sec.T".Business and Professions CMC:)The Contractor's Li-
cerise Law doanet apply toanowner of property who builds or improves mereon.and QTY PLUMBINGPERMIT FEE
who amwet,for Such nrojecu,with a usntrecmm(s)I mnecd porsaamno the commerce,
License Law. PERMIT ISSUANCE
m
l aexemr.p[uWett. &YC for this.,on
Owner _ lyarc ALTER-DRAINA VENT-WATER(EA) VALUATEDrv,C
O ER's COMPENSATION DECLARATION BACK FLOW PROTIiCC DEVICE Q
I III affirm under penalty of perjury one of the following declarations: Q
❑I have end will nesinaina Certifie leof Consenttoself-insumfor Worker's Compo- DRAINS-FLOOR,ROOF,AREA,COND.
STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this Permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workee,Compensation Insurance,as required by Section
31(X)mflhe Las LRcde,for the performance ut the nkfor which this permit is issued. GAS-EA.SYSTEM-1 INC.i OUTLETS OCC.GROUP APN
My Worker's mp flxallxT um c c'-..!'I'. n posy p pother are:
Cartier.— I Ne.:/,/C7.f.C//, rA/Yf GAS-
EA.SYSTEM.OVERJ(EA)
CERTIF A'IHOFEXEMPIONFResM WORKERS' GRIiA$FJINDUSTRL WAS[H IN'i'fikCEPI OR
COMPENSATION INSURANCE / BUILDING DIVISION FEES
(HoSSiction Tosca not be complaedif the permit is foronc hunJmd dmllam(510111 GREASE TRAP
art ties 1 PLANCHECK FEE
I certify Nat in theperfatmtrumoflcwork farwhich thispermit isissucd,lxhall SEWER-SANITARY-STORM PA.200 FT.
not employ any person in any manner So as in become subject o the Worker'Camper- ENERGY FEE
O2 suborn Laws of Callforrim Dam WATER H ENTER WNENT/ELEC'TR GRADING FEE
Z 2 Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
E' become Subject m the Worker's Compennariun provisions of the Whin Cntle,you must
foMwith comply with such provixionsunhis permit shall be amused rcvaked. WATER SERVICE
Q
p'
CONSTRUCTam,I,a'IONLtion]cGAGENCY NEW RESIUENI'IAI.PLMB. SQ.Ff. PAID
L)Qkhereby whafffwNemit i iSactt(Seeon]coding agency for the perfowartee of Date Receipt Of
the work for which this pcnnil is isweA(Sm.3(19].Civ.C) n
Lenders Name la's TOTAL:
U
y� Lendees Address TOTAL:
( . a I molly that 1 have anal this applicutlan andshe that the clave information is BUILDING FEE
OC 1 19 95
[^ to cornet.l agree to comply with all city and county oNinaaces and sate lres,ocmlng ro QTY. MECHANICAL PERMIT FEE
UsZ building comwctiun,and hereby authorize leprecrumier u
ves of this city to entpon Ne SEISMIC
PEE
aboveamemioned property lin inspect!on purposes. PERMIT ISSUANCE m rave. ELECTRIC FEE
(We)agtto indemnify and keep harmless the City of Cupertino against ex TY
liabilities,judgments,casts and eapxnxex which may in any way accuse against said City ALTER OR ADD TO MEC[. PLUMBING PEP x �
in asequence of the granting of this famint.
APPLICANT UNDERSTANDS AND WILL COMPLY WIT"ALL NON,POINT AIR HANDLING"NIT GO)10,000 CFM) MECHANICAL FEE
SOURCE REG TIONS.
/ � q /' AIR HANDLING UNIT(OVER 10,00C,CFM) CONSTRUCTION TAX
Signmu of A cant/Contractor J Date L EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF:
IIAZ RDOUS MATERIALS DISCLOSURE
Will the appli,taumfware building camonal,omor hadlehmardous material HEATING UNIT TO 100J000 BTU)
as dctiond by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Sofmy
Code,Section 25532f of "EATING UNIT(LIVER 100.00(1131 U)
C]Yes No VENTILATION FAN(SINGLE RCSID) PAID
Will the applicant or future building t use t or devices which Date Receipt N
pp d by then co Air Quality
BOILER-COMP DHP OR 100.0(10 BTU)
/ main hezarJrnis air titianu as acOneJ by the Buy Arta Air Quality Munagcmem TOTAL: �d
I Disbic@ BOILER-COMP(OVER I010.000 BTU)
Dyes [I No
I have read the hauudoos materials requirements under Chapter 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE,
forma Health&Safe,,Code,Sections 25505.25533 and 255th.1 ualcrstaml that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingJmx n,)[c1a merely have alonan6 thin it is my rcspanxihllhy ematify the occupant
of We rtq a (which rest temet prior, t of a Cerificme of Decorah".
Owner r 5o' eJagent D a TOTAL: ISSUED
OFFICE