28453 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING•MECIIANICAL' 28453
,
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE'
O NF.R'SJJAMi: PHONE: O RACTO NpMF.: LIC NO
CAME:
IAV �. 1—
NIC CONTROLN
ARCHITECT/ENGINEER: LIC NO, ADDRESS: rV ❑
n� t—
CON'T'ACT: PHONE: BUILDING PFRMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT. PLUMB MECH
❑ ❑ ❑
LICENSED CONTRS DECLARATION QTY ELECTRIC PERMIT PEE:
I hereby affirm,that I ren licensedd under endo ons of Chapter 9(commencing JOB DESCRIPTION
D atZ with Section 7000)of Division Sof the Nusinasu.d nd Confessions Cade,vnJ my license is
PERMIT ISSUANCE RESIDENTIAL
n full force end c t /`
Q Uz U License C ss Lid,p ' ❑SFDW L _ ❑KITCHEN REMODEL
N6L Dara Contractor APPLIANCES—RESIDENTIAL. DADDITION '54UMBING RE-PIPE
Fpm ARCHITECTS DECLARATION PANELS []MULTI-UNIT STRUCTURAL
Z o n Za I understand my plans shall Is,used us public records MODIFICATION
0 pp UPTO 200 AMPS ❑INTERIOR DCHIMNEY REPAIR
Licensed 11 fiesiamnal 281.1000AMPS IMPROVEMENT,
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the ContractorOVER]"AMPS's License Law for the D BATH REMODEIIREPAIR D DEMOLITION
Se O ILU following reason.(Section 7031.5,leanness and professions Codc:Any city or roam,a. SIGNS ELECTRICAL. El OTHER
fs7 a.W I. which confires a permit to construcl,eller,improve, wm
demolish,or repair any scm _
prior to its issuance,also requires the applicant forcuch permit to file a signed statement SPECIAL CIRCUIT/MISC.
amtheislicensecipursumnothe....wonsoftba Convectors License Low(Chapter 9
ll'0p (commencing with Section 7")of Division 3 of the Business end Pmfeaions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
Ill.qqx` C that he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
W..y Section 711 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES []TENANT ❑1700D SERVICE
tsl not ream than five hundred dollars(8500).
� < ❑ SWIMMING POOL ELECTRIC IMPROVEMENT
11 do the work,and the he Contractor's
not intended Bra w(to for sale(Sec.to an Business []OTHER
W and Professions Caeca:The C then' .Larch Luo does not apply is if owner of OUTLETS—SWITCHES—FIXTURES
property who huiWs or improves t thereon,and who doessuchnh work himself or through
his own employees,provided that such intprnvmnents are not intended or offered for NEW RESIDENTIAL.ELIiCTR SQ IT
sale.lfhowevee the building or improscinenl issnldwithin one yearofrompled ithe SQ.f ..FLOOR AREA $/SQ.FT.
er-hi ikler will have the boner of pawing thm he did not build or improve for Aur- '
q:se ofaale.). -
I,as owner of the property.am exclusively contrasting with licensed contractors to TOTAL:
construct the project(Scat 7044.Business and Profess ns Code..The Conwnnrs Li,
cense Law does not apply to an owner of property who builds or improves damon,and QTY, PLUMBING PERMIT FEE
whocontracts for such pmjecls with a contractor(.)licensed pursuant to the Comracmrs
License Law. PER SS CE
❑1 am exempt under Sec. ,B&P C for rcu.an :
Owner Date ER—GRAIN& NIT—WAIT R(EA) VALUATION
WORKER'S COM P17NSA'1'ION DECLARATION BACKFLOWPROTE . EVICE
I hand will mai under penalty of or Coy oma of the l'nRowing deallmtionn: -
❑Ih.vennd will maintain aCenifcmeol Cunnennn aelGinmrefnr WnrkclSS Cnmpcn- 'DRAINS—FLOOR,ROOF. BA,COND, STORIES TYPE CONSTRUCTION
soon.,as provided for by Section 39181 of the lahor Cale,for the pert clam nae of in.
work for which This permit is issued. FIXTURES—PER TRAP CA
1 have and will maimain Warkaa Compensation Insvona.,as required by S ren
3'100 of the lobar Code,fonhe performance a(the work for which this permit' sued. GAS—EA.SYSTEM-IINCAOU S OCCGROUP APN
My Wor ars Com emotion Insurance carver and Policy GAS—EA.SYSTEhLOVER4(EA)
Carrier r H� Policy No.:
C• FICATTIII' _ EO�KIONFROMWORKERS'
COMPENSATION INSURANCE GRFASFIINDUSTRL WASTE.INI'ERCE R
(Thissection need not be<amplmcJ ifthc pewit is foroneh dreddidis($100) BUILDING DIVISION FEES
or[cgs.) GREASE TRA
PLANCHECK FEE
Iartily that in the perfowtnccafthe work for which sperM.is issueJ,lshall S •R� N Y—STO F'r
not employ any Person in any manner to as to become stme t m the Workers'C,,.,n• ENERGY FEE '
,7. onionl.awsof Califomia.Date
z O Applidant - WA ATF.R WI /BY,Ii GRADING FEE
NOTICE TO APPLICANT:IL ager making this Ccnificate n'Exemption.y( hot lel WgTh:R SYST. PING
a [^ I+ecnme aunjea m the Workers Compensutinn pnrvi ion of in Labor C. y t SOILS FEB
fonhwithdit with Workers
Coomonhia perp ilsom bed reedy C. WAT ICE
Q
CONSTRUCTION LENDING AGENCY NEW IDENDALPLh1B, SQ.FT. PAID
V 0 Ihmeby affiw that there isaconnmctinn lending egencyB theperfomonceof Data Receiptg
Fthe work for which this permit is issued(Sec.3097,Civ.C.)
lenders Name 'TOTAL:
V Lenders Address L:
0. I certify that I have read this application and state that the ebov drowmion ie BUILDING FEE
Vl correct.l agree to comply with all city and county ordinances and state la srclmingm QTY. ME ANICA1,PERMIT FEI3
U a' luildingcnrtraOian.and hummyamh... represenmtives of this city to en upm the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT UANCP,
(We)agree msave,Indemnity and keep nnmdeas the City of Cuperunau ' st ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accrue against stud Cit LTF.R OR ADD TO M ECII.
incense enceof the gran ting of this Perna. PLUM BING FEE
APPhIG NT UNDERSTANDS AND WILL COMPLY WIT ALL NON-POINT AIR HANDLING UNIT(TO1(1,008 CFM)
S)UR :REGIII,ATI MECHANICAL EEE
Y.O(� �� AIR HANDLING UNIT(OVER IO,WO CFM) CONSTRUCTIONTAX
gnat AppRcan 'ontfador [)are EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant store or handle horrendous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crate,Section 25532(x)? HEATING UNIT(OVER 100,coo BTU)
❑Yes o
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building avapant ane equipment or devices which a Data Receipt p
•emit himrdaus air came Lias defined by the Bay Arca Air Quality Managem?ht BOILER—COMP QHPOR PANIC BTU)
District? n /
10
❑Yes BOILER—COMP(OVER 100,100 BTU)
No
1 rtad the hazvdous materiak AIR CONDITIONER
hh44yy requirtmems unser Chaptcr695 of Ne Cnli ^ N ISSUANCE DATE
forma H.IUI&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. �'
building dLs not cuwnUy havegtenan.thatitis my respnnsibiliry to oaf, a captain U..
of a come awhichm. atP^ r ssuaneof.Ceni e�f nc� aG:H �NO �1L7
Ov uthnmedagem - ate TOTAL: ISSUEDBY:
OFFICE