28975 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITDIPLUMIIING-MECHANICAL 28975 O (��C
B111LNGPim ECF ID-ENTIFICATIIIN o J J
)ILDINGADDRESS`. SANITARY ND. APPLICATION SURMITTALDA'II
'R'SNAWIC: PHONE: N'I RACTOR'S NAW { LIC NO: L
1 G O� N/C CONT/R�$,Lp�
4H�H'ECI'/CN01 r � LIC NO: DURESS:
III D
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CONFACT7 PHONE_: BUILDING PERMIT INFO
UV �1;0 `� ED Consultant Ftts Paid by Applicant(initial) _RTLyQG�1 ELECT .UMB .0
LICENSED CONI RACTOR'S DECLARATION f•� `
1 herebyaffirm that I am licensed under provisions of Chapter 9(commencing QTY ELECTRIC PERMIT FBP.
I I g JOB DES IPTION
n00 with llloncm]UOe effect.
Division Sof the Business and Profeasionx Gwlc.and mylicenu is RF_CIp�NTIA
TWO 1 PERMIT ISSUANCE ❑SFDWI. ❑KITCHEN REMODEL
in full 1'oree and effect.
�U License Cleats Contract...
APPLIANCES-RFSIDF.NTIAI.
rFn 60. ❑um nnwanr ❑ADDITION ❑PLUMBING REPIPE
ARCHITECTS DECLARATION 0MULTI-UNIT CSTRUCfURAL
M4 l understand my plans,hull be rd
used as public recos D PANELS MODIFICATION
o UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-I000AMPS IMPROVEMENT
MOWNER-BUILDER DECLARATION OVER IWOAMI'S ❑PATH REMODEIIREPAIR ❑DEMOLITION
Contractor's Q 1 hereby union that 1 nm exempt from the License Law for the
x 0 W F following niewp(Section]031 S,Nosiness and Professions CoM:Any city or county SIGNS ELECTRICAL ❑OTHER
41 y LLO� which requires a permit In emalu a,oleo improve,demolish,or repair any swcture
pdoo its isx..ree,id, requires the applicant for such permit to Cite a signed statement SPECIAL CIRCUIT/MISC.
y nthmanowelcenwitpSectionoisoof Division 3 the,Businmfa Licenu low(C odem9
(commencing with Section 7fxW)rf Division)ol'tha Business and Professions Code)or TEMP.MI?'fCR OR I'OL81NS'L COMMERCIAL:
0. a that he i,exempt Nercfmm and the basis I'or he alleged esernin a t Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
M
/t co
iq5 no Section 7031.5 by any applicant for a permit scones the aMlicanuDEVICES a civil penalty of POWER DEVIC
u+^ AM' ❑FOOD SERVICE
ml ntnin than five hundmd Dollars(SSW). - IMPROVEMENT❑6asuwnerof the progeny,or my employms with wages as theirsnle compensadon. SWIMMING POOL ELECTRIC
w 11 do the work,and the comemmis not imeaded urc�ffcrtd hostile(Sec.7044,Business C OTHER
0. and Pmfessians Code:The Cmnmemes License Law des not apply to an owner ofOUTLETS-SWITCHES-FIXTURES I
^ progeny ube builds or improves thereon,and who does such work himself or throulllif x4
his own empluyces,provided that such improvements are at intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
who.IL however the building or improvement is sold within one yearef completion.the SQ.Ff.FLOOR AREA VSQ.Jy;.
own
er-builder will have the burden of proving that he did not build or improve for put. r\7
pose of salt.). _ ^1
C hes owner of the progeny, ve
am exclusively contracting with licensed contractors L
to TOT L: �O
consumer the project(Sec.7(144,Business and Professions Cole:)The Commemr's Li- 10 s(j
conse law does not apply it)an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE ®� � M.
who commas for such projects with a commetor(s)licensed pursuant to the Cco raemrs £iA7
0
License sin Law. PERMIT ISSUANCE 1, O�
lam exempt under Sec. ,E&PCforthis froom i
Owner Data ALTO R-DRAIN&VENT-WATER(FA) ,1 TION
WORKER'S COMPENSATION DECIARAI'ION BACK FLOW PROTECT.DEVICE `?1,
1 hereby affirm under Penalty of perjury one of the following declarations `
4 ❑Ihave and will mainluinaCenifcamaf Cnnscnno self-imurc for Warkcr'a Compen- DRAINS-FLOOR,ROOF.AREA,COND.
smion,as provided fnr by Section 3700 of the Law,Cade,far the performance of the I STORIES TYPE CONSTRUCTION
work for which this leant,is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as pef ire)by Section -
3700af1oLabor Cole,lin the performance afthewask for whichthis phonim is iss ed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
M r ante caricnmd /w
Policyy No.:u.:y GAS-EA.SYSTEMOVE (EA)
/p' /d PFION MOM WOR City'
PF. 5 TION INSURANCE I� GREASOINDUSTRL WAST RCF.P OR
(This section need not becompleted ifthe peram is before hundreds lars( ]all) BUILDING DIV U ES
or less. GREASE TRAP PLANCHF.CK FEE e
1 cenify thus in the performance of the work forwhich this permit is issued,I shall
not employ any person in ns manner so as m become subject to the Workers*Com SEWER-SANITARY .200 FT.
Y pen- ENERGY FEE
Z ,alien Laws of California.Dae1A01 0116.,
zApplicant WATER ' T/ELECTR GRADING FEE
i NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WAT6 SYS EATING
a ' become subjecto the Workr's Conmpensation provisions of the lather Code.you must SOILS FRE
L>•1 fnthwith comply with such previsions or this permit shall be deemed waked. WATE . VICE
Q
CONSTR BUT ION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.FT. PAID
U 0 l hereby affirm thin there is a construction lending agency for the performance of ReceiplM
F the work for which this Permit is issued(Set.3097,Ci v.C.) TOTAL:
0 U Lenders Name
lamocas Address T
I cenify that 1 have read this application and smm thin the above infomtation is BUILDING IRE
IA comet, ingme to comply with all city and roomy nNinences and state Paws relatingm QTY, MECHANICAL PERMIT FEB
U building ennsvuainn.and hereby authorize rcpmmnmtives of this citymenter upon the !ELERIC
EEC 51.
atmve-mentioned prnpeny for inspection purposes. PenMil'ISSUANCE
(We)agree m save,indemnify and keep hennlcss the City of Copcnino against FEEALTER OR ADD TO MECH.macquenceofthegraningid this t. �� NG FE
APPLICANT UNDERSTANDS LI.COMP 'WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)SOURCP EGULATIONS. `` NICAL
/ � AIR HANDLING UNIT(OVER Il1,00)CFM) CONSTRUCTIONTAX
Si team of pplicanUCc tmemt time EXHAUST HOOD(W/DUCT)
HA ZA S MATERIAL DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or building etc ant smrt orhandlc htizallous material HEATING UNIT(TO I00,000 RTU)
as defined by the Cupertino Municipal Code, .hapmr 9.12,and the Health and Safety
Cade.Section 25532(a)7 t HEATING UNIT(OVER I W,IIW BTU)
❑Yes 0N VENTILATION FAN ISINCI,E R/SIO) PAID
Will the applicant or future building occupant use equipment or devices which Doc Receipt p
Ir
emit hazardous air comaminams as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100)7(10 BTU)
0 L
Ldoesom
$AOIR
R-COMP(OVER I W,(k10 BTU)
s ❑Noe rend 0e harordouv materials requirements under Chapter A95 of the CaliONDITIONER ISSUANCE DATE
&Safety Code,Secuom 25505,M533 and M539,I understand that if theRESIDENTIAL MECH. SQ.IT
not currently have a tenant,thin It is my mapmmsibilay mo notify the Occup tet
mems which must be met Iar m issuance ofa Cenificme of Oseupancy.
irmAd agent Dae i ISSUED BY:
OFFICE