28954 ,APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPDi RTINO " - BUILDING•ELECTRICAL PERMIT NO. ^ ^ 9 54
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL Llyl(��/J
HUILWNGPROJE IDENTIFICATION
BUILDING ADDRESS: / SANITARY NO. " APPLICATION SUBMITTAL DATE
O NER'S NAM@ PHONE: C-ONTRACf -S NAME. 5 LIC NO:
G NIC CONTROL g
R GT/ENGINEER: LIC (: ADORE 6 SS Z , ❑ ��
CONTACT. PHONE: Ave BUILDING PERMIT INFO
[��I, T p 8, 0 Consultant Fees Poi by Apt sant(Initial) BL ELF PLUMB MECH
5 r, . (/�
LICENSED CONTRACTOR'S D:CLARAt'ION" QTY. ELECTRIC PERMIT FEE
1 hereby affirm Thal I am licensed under provisiunx of Chnpmr 9(rommencing- ` JOB DESCRIPTION
�Z with Section]fAMI)of Division3of the Business and Profess'ianxCode.and mylicenso ix I� -
O unfall eforce Class it affect. PERMIT ISSUANCE' WL ❑KITCHEN REMODEL
�U License Class Lica APPLIANCES-RESIDENTIAL. ❑ADDITION C3 PLUMBING R&PIPE
Date Cmmlrum.r
Z8py AR CHITECTS DECLARATION ❑MULThUNIT ❑STRUCTURAL
sv� PANELS
O Z:d'� I understand my plans shall be used ss public records MODIFICATION
J pppp UP70200AMPS ❑INTERIOR El CHIMNEY REPAIR
I:y Licensed Professional 201-1000AMPS IMPROVEMENT
Y OWNER-BUILDER DECLARATION OVER IIXp AMPS
y a a I hereby affirm that 1 am exempt from the Convacmis License Law for Nc - O BATH REMODELIREPAIR O DEMOLITION
x 3 M U following reason"(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OOTHER
ID Q which requires a permit to construct,alter,improve,demolish,or repair any structure
poor to isw.nce,also"aims the applicant for such Permian file.signed statement SPECIAL CIRCUIT/MISC. ; ^
Nro
6 at he licensed pursuant to the pvisionsof Ne Convacme.License Law(Chapter 9 _ d. 4'
P� �O (commencing with Section 70fam.f Division Sof Ne Rusinessand Pamessi...CW,)., TEMP. OR POLE INST. COMMERCIAL'
tL q M that he is exempt therefrom and ubw basis for the alleged exemption.Any viblatinn of O NEW BLDOAOJ�T� 1 D O I ION
WX y Sedinn 7(171.3 by any npplicem forapennit snbjeds Ne npplicnnn...Al penalty of POWERDEVICES A a177���L
e, 6 LL 1 Nun fvc hundred doIla.(S5W). - ❑TENANT L-}F RVICE
O has owner of the Property,or my empinytte with wages as their sole comsenxetion, SWIMMING POOL ELECTRIC IMPROVEMENT
wIll do he work,and dinumcNre isnotintended mofferW formle(Sec.7074,Business ❑OTHER A�' `r Ws set �f11 H'I
and Professions Code:The Conmanors License law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
.G .. propeny who
Professions
as improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL RLEC R SQ PT.
sole.If,however.the building or improvement is sold within one yearofmmpinion,the SQ.FT.FLOOR AREA NSQ.FE
i der lwill have the burden of proving Net he did not build or improve for Pur-
posa
p.0 of Basale.). ILS
❑has owner of the S..704,,B exclusively contracting Platinum,with:)The C c uncemm to
seem La theprojectiplyto on BusinessandrtywbCash:)Thees thereen.Li-
who c Law Jas not apply m ts owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEF.
who contracts for such projects with a connections)licensed Pbrsuam to the Conuanors
License exempt
PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for reason
Owner - Dae ALTER-DRAIN&Vk-W ER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION - BACK FLOW PROTECT ICE ^ �
,/Q� I
Ihereby affirm under Penalty of perjury one of the following declarations: J�,..i C
I have anti will muintaina Certifidamof Conscatm self-insure for Worker's Compen- DRAINS-FLOOR,EOGEAR. • ND. STORIES TYPE CONS'TRUC'TION
scion,us provided fur by Section 3700 of use Labor Crude.far the performance of.the
work for which this Permit is issued. - FIXTURES-PERTRAP - 1
t O 1 have and will maintain Workers Compensation Insurance,as required by Section
37M ofum Labor Code,for the Performance move work for which this permit is issued. GAS-EA.SY C4 #ETS OCC.GROUP APN
My Wor r" \cation 1p,5y it Policy '1 O GAS-FA.SYSTE )
C.rrier (/ L/V(ecA0ePahcy N..�y( ��
(/ CER'TIFICATEOPE.XENUMONFROMWORKERS'
COMPENSATION INSURANCE GREASFANDU TRL WA._Q1TERCEPTOR
Olds section need not beconameted Bum Permit is forouehundred dollars(5100) BUILDING DIVISI FEFS
or less.)
Of
TRAP' ` PIANCHECK FEE
I many that in the performance of Ne work for which this Permit is issued,i shall SEWER-SANITA FA.2110 FT. �V..T
not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FEE
Z ration Law,of C.1if s ia.Date
Q O Applicant - WATER HEATER LNT GRADING FEE
F7 fn NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTE EAT
a Ce
become subject to the Workers Compensation provisions of the Lahor Code,you must _ SOILS FEE
W forthwith comply with such provisions or this permit shall be deemed invoked. WATER SER
Q
CONSTRUCTION LENDING AGENCY NEW RESIDEN' L .Ff. PAID
0 Thereby nffirm Not rheic is aconaruainn lending agency fnnhu perfennance of eceipt#
{T+ L� the work for which this Permit is issued(Sec.3097,Civ.C.)
O L) Lender's None TOTAL:
Lenders Address
0. I cenify that I have read this application and state that the above infatuation is LDIN
y corrcah lagrec mcomply with dl city end county ordinanc<a and arum laws reletingm QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby autharixe represenmtives ofthis city to enter upon the SEISMIC V `
above mentioned poison,for mspectual Wmoves. PERMIT ISSUANCE
(We)rgrtt and to save,indemnify keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilities,jwlgmama.,cru and expenses which may in my way acerae against mid City PETER OR ADD TO MECH.
in consequence oInsinuating ofthis permit. PLUMBING FEE Q 7k
APPLICA T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE f:GULATIONS. CONSTRMCCHAUCTION N
FE4 '3
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION
Si uta pplicantlConmador - Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATIO E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store.,handle haoarcmus material HEATING UNI'T,(TO Hm"BTU)
m donned by the Cupertino Municipal Code,Chnpmr 9.12,sm the Health and Safety
Code,Section 25532(.)'! HEATING UNIT(OVER 100,01k)BTU)
❑Yes • 0 No- PAID
- VENTILATION PAN(SINGLE RESID) Date Rreciptp
kimmkosl the.pplteem....[,.a defined ytheoccupanty Ale. it Qu 0r devices Which BOILER-COMP(3HP OR 100,000 BTU)
tt harallous air conmminanu as defined by the Bay Area Air Quality Management TOTAL:
Dunn?
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have read the harsNous ma mals requirements under Cbapur 6q5 of the Cali- AIR CONDITIONER _ ISSUANCE DATE
forma Haim&Safety Code,Sections 25505,25573 ab 255th.1 understand that if the NEW RESIDENTIAL MECIL SQ.FT.
building does not currently have a tenant.not it is my responsibility to notify Ne=opent
.f requimmeaswhich run4run prier m isxuanceofp Certificate n�c`pangy.
\ ( �- L 9
Owner nr authnnxed.gem'r+'- � Date ISSUED BY:
OFFICE