28882 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL 2 Q 8
BUILDING PROP?CT IDENTIFICATION v v
BUILDINGADDR SS: SANITARY NO. APPLICATION SUBMITTAL DATE.
I�'� e 6 ��
s UW GR'SN ME: PHONE: CpIJT A I'ON'. T. L
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CO ACT: v PHONE: BUILDING IF,RMITINFO
/'.n BA �/NI'/p�17r i(I�sDA^�sl�a(a{�..' ❑
consultant Fees Paid by Applicant(Initial) .DG ELECT PLUMB MECH
` LICENSCD CON'1'RAC'fOR51113C1,ARATIDN QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QZ withllface]ofcfIcf Divisiun3of the Busines.und Professions Cade,and mylicenuis RESIDENTIAL:
fie se'tewd eB< �T PERMIT ISSUANCE
<U Licenu Class�Lim.M -` � � ❑SFDWL [I KITCHEN REMODEL.
Dae Columnar APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE.
I,,,pe�jl ARCHITECTS DEC A'I �1,- PANELS (?MULTI-UNR ❑STRUCTURAL
Z O n 4 I understand my plans shell be used as public records
MODIFICATION
OZ m - UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4 ul Licensed Professional ]pl-IIXNIAMPS IMPROVEMENT
sJgg ] OWNER-BUILDER DECLARATION pyliN["AMPSElBATH REMODEUREPAIR EIDEMOLITION
1 hereby affirm that I am exempt from the Contractors License Law mine,3 L O following mason.(Section 7031.5,Rosiness oral Professions Code:Any city or courtly SIGNS ELECTRICAL ❑OTHER
16 which requires o port m construct,alter,improve,demolish,or repair any structure _
prim to iu issuance.also requires the applicant for such permit a file a signed statement SPECIALCIRCUIT/MISC.
p. that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
�� (commencing with Section 7000)of Division 3 of the Business and Professions Cost TEM P.METER OR POLE I NST. COMMERCIAL
p e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y• Section 101 LS by any upplicamfora,dourasuhjccts the applicant to a civil penalty of, POWER DEVICCS
y ❑TENANT ❑I'OOD SERVICE
y not marc wne Me hundred gallas y employees
O ❑ Las me work,
the the smigor myyemntended or
Nfered asthen(Sm.compensation,Busies SWIMMING POOL ELECTRIC OTHER EMF-
W � will dothssima;and the sir Contcurre nuou's not Limit oraw dos sal apply 1...Business C3 OTHER _w
_ and arty who
Cede:The Con thereon,
Licenu Law does not apply tow owner of OUTLETS-SWITCHES-TEXTURES / �•�cm U'
his o
Property who builds or improves thsuch improvements,and who d«s such work himself or through
hie own owever,th building that such entissoldw are not intended or offered for NEW RESIDENTIAL[LELTR SQ Ff.
sale.ILboweveclhehui the bur improvementisat he
noneyear orharp tpletionnbe SQ.FT.FLOOR AREA $/SQ.FT
owner-buildegwill have the burden of proving that he JiJ not build or improve 6r bur-
❑1,as owner of the progeny,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.]U44,Business rand Professions Cale:)The Commcmrs O-
ramLawdoesnotapplyus un owner of puiialasho builds or improves thermal and QTY. PL ING IT FEE
who contracts for such pmjuls,with a contmcur(s)licensed pursuant to the Carnivores A 9It
License law.m & anPERMIT ISSUANCE
❑1 aexempt under Sec. .B P C for this mn
J, 1101
Owner Date ALTER-DRAIN&V ? Dpn its IALL%kN
WOR NEWS COMPENSATION DECLARATION. PACK PLOW PROJECTOrr.VI
I hereby affirm under penalty of perjury one of the following declarations: f J1.
❑I have and will maintain a CenificamofComenl to self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,All
)N STORIES "TY CON$TRGCfIDN
sation,a provided for by Section 3700 0(the lylror Cede.fur the ped'ormanee of the
is for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Wokees Conarmanion Insumnu,as required by Section
.fl of the Lahr Cnde,for the perfonnwce of Me work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40U'PhEI'S
My WorkCoOCC.GROUP APN
e s Compensation I sueance carrier and Policy a r
Carlo. L'EItT'I CA' fFLX,M oticy
WORKERS' OAS-BA.gYSTP.M-0VER 4ICA)
COMPENSATION INSURANCE GREASFANIIUSTRL WASTE INTERCEPTOR
(This sation need nm be completed if the permit is fororehundred dollars($100) - BUILDING UIVISI ON BES
or leas) GRL'A56 TRAP
I unify that in the performance of the work for which this permit is issued,l shall PLANCHECK FTC
not so
employ any person in any tanner u w
as to become bjectto the Worker Compen- SEWER-SANITARY-STORM HA.200 PT.
0 z scion L owa of Calif..!..DamENERGY FT
Applicant C
WATI7R IIGTCR WIVENTMLECI'R
GRAD G FEE
aVJ NOTICE bj APPLICANT.IL ager making this visions of of Exemption,you should WATER SYSTEM/1'REATING
became subject to the Worker's Compensation provisions of the Labor Cale,you mint 50 R:'
CkI forthwith comply with such pmvlsinns or this permit shall be demand revoked WAI'FIR S1iRVICL'
Q
CONSTRUCTION iONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.PT. PA
U0 Thereby effirmthouhercis.cstm
anoion lending agency for Ne performance of Data Rueipnp
F the work for which this permit is issued(Sec.3097,civ.C.) .
O U L.ndees Name
Lenders Address TOTAL:
r y I unify that 1 have read this application and soak that the above information is U ING P E
�^ y correct.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U building consuuction,and hereby authorize representatives of this city at enter upon no SEISMIC PEI:
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(Wil agree to save,indemnify and keep harness the City of Coleman against ELECTRIC IT!
liabilities,pagments,m,m and expenses which may in any way accrue against said City ALTER OR ADD TO MICH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER Midland CFM) CONSTRUCTION TAX
Signature of ApplicwUCouramor - Datc EXI IAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Cade,Section 2553260! _/' HEATING UNIT(OVER 100.(111(1 BTU)
C]Yes `-/A�_ VEM'NATION FANS INGLE RFSID) PAID
lam Recei
Will the apponnumant rfuture building by
occupant
ayAe.Air equipment or IIMana which BOILER-COMP(3HP OR 100,000 BTU) '
emit hawNoue air commninnms as defined by the Buy Areu Air Quality Management AI.
L(0Jwn�,V,M1h.Bz'd
BOILER-COMP(OVER 100.0011 BI U)
Yes 1'r�i N�
read the hazardous tsmurisls mquimnumx under Chapter 6.95 of the Coli- AIR CONDITIONER ISSUA D TF,
&Safety Cak,Sections 25505,25533 and 25534.1 undemmmd that if the NEW RESIDENTIAL MECH. SQ.FT.
o currently homnatifytheucupant
cnis=hich must be met prorm issuance ofaCenif �1�t55I n L!nr¢ed agent ��� I I'm TOTAL: ISSUED
OFFICE