28897 APPLICANT TO FILL IN'INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LF.CTRICAI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECIIANICAL
BUILDING PR(1JECT IDEM'IFICATION 28897
R .DINGADDRESS: ♦ � - SANITARY NO. APPLICATION SUBMITTAL DA'fl
2 7 ��
407- 7 �,vN� a 5
OW R'$ MH: �% P L: iLTORWAlv1E_ ♦�LIC�JO. ��
�G�' NIC CONTROLp
ARCHITECT/HNGINELR: LIC NO: I5 �� ❑
I Ry1'
CONTACT: PHONE: BUILDING PERMIT INFO
_ ❑ Consultant Fen Paid by Applicant(Initial) BLYC ELECT PL MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FCC
1 hereby atiirm Nat 1 am littrtud under provisions of Cheper Y(commencing JOB DESCITIPTION
°O
Z
u1
-
RFS-ID-- N—TIA
L,F in full force and effect. PERMUISSUANCE ❑SFDWL
KITCHEN REMODEL� F, License Class Lic.s
Z APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPEnacr
7y
ARCHITECTS DECLARATIONPANELS ❑MUUH-UNIT ❑STRUCTURAL
ZOrhi� Ivndemtvnd my plans shall he used as public recnNs MODIFICATION
OZ-M UPTO200AMPS ❑INTERIOR El CHIMNEY REPAIR
G Creamed Professional2014000AMPS IMPROVEMENT
aV pyj OWNER-BUILDER Ce Conti ON OVER 1000AMPS
y I hereby afHnn that 1 Bin exempt Gram the Contractors License Law for the [I BATH REMODCl/RC•PAIR �DEMOLITION
x a G U following(Tomo.(Section]031.5,Business and Professions Code:Any city or county SIGNS EL[CTRICAI. ❑OTHER
W W rn which requires a permit to cantonal.aper,improve,demolish,or repair any structure
^on prior to its issuance,also"dims the epplicam for such permit to file a signed statement SPECIAL CIRCUITIMISC.
N that he is[!caused pufsuannn the provisions of he Coatrucmfs License Low(Chapter 9
�C (commencing with Section]00()of Division 3 of the Business and Professions Code)or TEMP.MEIER OR POLE INSE COMMERCIAL:
c eG
that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^,m Section]f13 LS by any epplicam fmnpennit.ubjectx the applicanrose"
d penalty of 1'OWLR IIIiVICI?S
t mmadom five hundred dollars 01500). ❑TENANT ❑FOOD$C•RVICE
061]1,as owner ofthproperty,or propertor my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
da the work,aad the structure is not intended or offered forsale(Sec.704sr,Business ❑OTHER
Gm and Pmf,,sioms Cale:The Contractor's License Law does not apply to en owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDEN9'[AI.ELECTR SQ FT.
sale.IL however.the building or improvement is sold within one year ofcnmplction,the SQ.F3'.FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pl1.res
a n tweet of the property,am exclusively d contracting Cod licensed contractors t. TOTAL'
ranstnet the project(Sec.]044,Pns .w and I'mfensi.ns Code:)The Canwc¢rts Li.
censefaw does not apply to an owner of property who builds or improves theremm,and QT'y, PLUMBING PERMIT FEE
who canunets for such projects with a mrtraomr(s)I lcented pursuant la the Contr.etoes
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,Il&P C for this reason
caner Dem ALTI/EkaQRA1N&VENT-WATER(HA) VALUATION
RKF.R'SCO PHN 0 UiCLARATION BhtiKFI,OWPR TECT.DEVICE
1 hereby aRrm under penally of perjury one of the following aled.a tions:
❑Ihuveand willmabnain o Certificate of Consent n self-insure for Worker's Compn- /RAINS-FLOOR,R F,AREA,COND.
..Iran,as provided for by Section 370ft of the Labor Code,for the performance of the STORIES TYPP.CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP /
I have and will maintain Worker's Compcnwtion
Insurance,e. mby
3/IXofNe LabrCale. Section.
GAS-EA.SYSTEM-1 INC.40 HTS OCC.GROUP AI'N
YIN, Cooperation, y an laroartand Policy month, arc:
artier. f�a�AsPolicy ad, GAS-LA.SYSTEM OVER (EA) VJ sy p it
R RIFTI !XHMPTIONFROMWOR S
COMPENSATION INSURANCEGREAM11INDUSTRL WASTE INTERCEPTOR
(Thissectian need not berninpleed rthe,....tlsGn�bondreddoll ($100) IUII.IIINGDfV1SIONITHS
or len.[ GREASETRAP
PLANCHF..
Icenifythatimhe ad,prrmpre, o.I.become
cs d jecihis the Wises Canthi[ SEWER-SANITARY-$ PA.200
nm employ any person iany mannan.n m hccnme subject to the Wnrkc 'Cnmpen- P.NF.q�YjFT!
Z
Applicant WATER nT California.eUete
� 0 Applicnnr WATER IfEATER WNE CfR GRADING FEE - Ii llltl(J
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,yo .hoald WATER SYSTEM? G
ai become subjectno the Worker's Compensation provisions of the Labor Cotte,yo must SOILS FEE
II,I forthwith comply withsuch provision or this permit shall be deemed revoked. WATERSERVICE
Q
57- CONSTRUCTION LENDING AGENCY - NEW RESIDE LPLMB. SQ,Ir PAID
UQ Thereby affirmthat there ixanmstrnnion lin did,agency for the varlmmancen Data Receipts
L4 Pthe work for which this permit is issued(Set.300,Civ.C.)
Leader's Name TOTAL:
{U Lendc/s Address L: ;
1 certify Nut 1 have must this epphe.ian and nam Nm Ne abuse information is BUILDING FEE
Ul4 cones,l agree to comply withall city and county ordinances and state laws refuting m QT ME ANICAL PERMIT FEE
7
U F7 building construction,and hereby authorize representatives of this city to enter upon the X SEISMIC FEE
above-mentioned property for inspection purposes. RMD'ISSUANCH
(We)agree to save,indemnify aadkeep harmlessthe City of Catania again ELECTRIC FEE
liabilities.judgments,costs and expenses which may In any way acerae against said City AL'ERORADDTOMECH.
inconsequenceofthegr.ntingofthispennit. PLUMBING IEE
WIC 7--
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR NDLING UNIT(TO 10, CFM) MECHANICAL FEE
SOfIRCE ,UTATIONS.
AIR HA -LING UNIT(OV I' 10'"CFM) CONSTRUCTION TA%
Sigrumre of ApplicanfiContractur Date HXHAUST OOD(W/D HOUSING MITIGATION PEL
HAZARDOUS MATERIALS DISCLOSURE
Will Ne epplicam or future building aecupam Wore.,handle haxednus material HEATING UNIT(In 100,000 BTU) ,
as defined by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)] HEATING UNIT(OVER 100,000 HI Of
❑Yes 7 N VENTILATION PAN(SINGLE RESID) PAID
Date Receipt K
Wolonsl the air contaminants
m Puts a building by the nt Bay Area
or lily Ma Management
BOILER-COMP(311P OR I(D,0(p BTU)
ems haraNuus air comuminanta ax defined by the Ray Arcn Air Quality Munegctnenl TOTAL:
Dist n?
❑Vuv E]No [{OILIiR-COMPIOVHR IW,WOIITU)
I have read the amounted,materials ma,mmments under Chapter 6.95 of the Cah- AIR CONDITIONER ISSUANCE DATE
forms Health&Safety Coda.Semire,25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MUCH, SQ.FT.
building dtxs not currently hese.larval,Na it is my responsibility to notify the occupant
of the requirements which must be net mi.rto isswmcc of a Cenificote of Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE