28737 APPLICANT TO FILL•IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PrRMIT PLUMBING-MECHANICAL TIO
BUILDING.PROJH: IDRISTIFICNI ION G v
737
BUILDING ADDRIiSS; SANITARY NO. APPLICATION SUBMITTAL DATE
OW BR'SN 7PHONE�& G C,jypCTOR'SINAME: Lr�� l LIC NO:� Z NIC /ON DI.# �
ARCHITECT/ENGINEEW LIC NO: ADDRESS. ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG El ECT PLUMB ME H
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herehy affirm that 1 am Rcetem ander provismas of chapter 9(emenstr ,eing JOB DESCRIPTION
WQWZ with Section]000)of Division 3pfhe Businessland Professions Code.and my license is
H ly� Nfvll force and effect. PERMIT ISSUANCE. �� RESIDENTIAL:
OgFDWL [I KITCHEN REMODEL
P>UZO License Clens Can[re
APPLIANCES—RESIDENTIAL ❑ADDITION O PLUMBING RE-PIPE
hQP�i DaIG COnlr'ECL
v ARCHITECT'S DIipLARATIDNPANELS ❑MULTI-UNIT ❑ 'IURAI.
Fah
'Z Oy17J- Iundersmnd my plans shall eJ us public records MODIFMOUIPICA'rION
OZ W "'L UP'10200 AMPS
F4(rW Licensed Profasipnul 2111-1(100 AMPS [I INTERIOR [I CHIMNEY REPAIR
�W OWNER-BUILDER DE RATION IMPROVEMENT
C ¢ 1 hereby affirm 1h:n 1 am exempt from the nwmnr's license Law for the OVER 1000AMPS 0 BATH REMODEIIREPAIR 0 DEMOLITION
ig0,ij followingreason (Section)03 L5,Business and Pmfes.ions Code:Any city or coonry SIGNSELECTRICAL 0OTHER
su which tectonics o permit to construct,alter,improve,demolish,or repair any swewre
,for m its ieuane,abo regnires theappliamt ou,iehiomtit to Elenxiynm1,,mmnma SPECIAL CIRCUIT/MISC. Jam`
{ y that he is licensed monsoon,,,dic pmviounxnr the Gmtmdors license Law(Chapter9
P� �O (commencing with Scainn]000)of Division Sof the Business end Professions Code)or '1'IiM P.METER OR POLE 1NST COMMERCIAL:
d Q y that he is exempt therefrom and the basis for the alleged exemption,Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
4• Section 7031.5By.,applicant for a Pamir subjects the applicant to a civil penalty of POWER DEVICES L s OTENANT El FOOD SERVICE
y
not more than five hundred dollars($500).
FzQ 01.as owner ofthe property,or my employees with wages as their able compensation, SWIMMING POOL 1:LECIRIG IMPROVEMENT
will do the work,and tl c,lobo re is.....haircuts offered(or sale(See 704,L Business ❑OTHER
and professions Cods The Commacmrs Licenso Low doe,not apply or an owner of OUTLETS—SWI'PCHES—FIXTURES
4' ionpeny who build,or improves thereon,and who docs such work unowif o,thmngh ,
his own employees,provided that such improvenem,are not mended m offered fpr NEW RESIDENTIAL.ELECTR, SQ PL
sole.If,however,the buildingu1 improvement is sold workforce yearafcompletiuo,the SQ.FT.FLOOR AREA $/SQ.F,
owner-builder will have the burden of proving that he did not build or improve for pur- -
pose of sale.).' ,
0 I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
natme,the project(See ]DW,Business and Professions Code:)The Cornelius Li-
cine,Law does nor apply to an owner of property who builds or improves thereon,and Q9'Y, PLUMBING PERMIT FEE -
who commen r'or,uch projects with s aommutmts)licensed ponam t or he Commmor,
Licenso Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,R&1'C for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner
Date' J 0 U
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
1 hereby affirm under penalty of seperjury one of me following declarations:
Cr have and will for
etion 37M of ContinuoCode,forth, Worker's Compen- DRAINS—FLUOR,ROOP,AREA,GOND, IUs TYPECONSTRUCTION
w.k f as provided fpr by Sermon 3]0)of the LnMs Code,for rbc perfammnce of the yft
wmk have and
this maintain
is issued. , I4XTURES—PER TRAP
1haveandwillmaimainhe performance
ofthlonrkfor ce,as which
per by Section
' J]0)of lM1e lahorCode,fonhe pertprmance nflhe work for which this pemlit is issued. GAS—EA.SYSTEM.I INC.4OUTLETS OCC.GROUP APN
My Workers pcnsarionlnsurance�arr Brand policy,
Cartier. �1�(yl1 t Policy No.: r �2��Q6/� GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRPASFIINDUs Hit,WASTE INTERCEPTOR
(Iris section need not he completed Bthe permit is forone hundred dollars($100) Nl11LDING DIVISION FE[S
or less.) GREASE TRAP PLANCHECK FEE '
I cenify 1hwin the performance efthc work forwhich this permit is issued,Ishall SI?WBR—SANITARY—STORM EA.2001"1'.
not employ any person in any manner so as m hecome subject to the Worker,'Compen-, ENERGY PEE
O Applicant
Laws of Califnmin.Date WATER HEATER WNENf/ELECB
O Applicant - GRADING FEE
rN. NOTICE Tject mHe War: 's If.afteCrarmakingthix Atimi,o of Exemption,ode,you ould
WATER SYSTEM/TREATING
become subject m the n,h pr Coon,or this provisions of the noxi Cole,you must SOILS FEE
LtI
forthwith comply with such pmvisipm,,r this memoir shall be dttmeJ revokrd. WATER SERVICE
Q
UO CONSTRUCTION LENDING AGENCY NEW RfSIDENTIN,PI.MH, SQ,FII PAID
Ihere hy affirm film mem ieacensfnmdnn lending agency for the perfnrmaned of -Dare Receipt#
Or. the work for which this penult is Issued(See.3099,Cie C) -
F' Lenders Name TOTAL:
Lenders Address TOTAL:
y 1 cenify that I have read this application and state that the union information is BUILDING FEE 3
.y mrtecl.I agmemn'mPly with all city and county uminwccs and smut laws relating to QTY. MECHANICAL PERMIT FEE
U Z building construction.unit hereby authorize representatives of his city to enter upon the S131SMIC PEE
above-mentioned property for inspection purlriwc. _
(We)agree mslave,Indemnify and keep hmmlesxthe Ciryof Cupertinoagainst PERMIT ISSUANCE
ELECTRIC FEE
liabilities,judgments,costs and expenses which nay in any way accrue against said City ANTER OR ADD TO MECH.
in oosegvence of the(part of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00(1 CFM) MECHANICAL FEE
SOURCERF ATIONS.
/� AIR HANDLING UNIT(OVER 10,010 CFM)
p/�Y— /Q CONSTRUCTIONTAX
Signe fAppllanl/Comrry a Dae EXHAUST HOOD(W/DUCPI HOUSING MITIGATION PIiE
!!�� - IIAZA}BOUS MATERIALS DISCLOSURE
Will the applicant nr future building occupant stare or handle l o,cmar,material I IEATING UNIT(TO 100,000 BTU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and he Health and Safety
Code.Section 25532on! HEATING UNIT(OVER 100,110)BTU) �,,,.. ll�`..••..,,....
O Yes ❑Np VENTILATION FAN(SINGLE MID) PAID —
Will the applicant or future building oecupare use equipment or devices which 1e Receipt X
Grail hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER—cAMP IMP OR 1110,000 BTU) d
District'! TOTAL; U
❑Yes ❑No BOILER—COMP(OVER 100,000 BTU) -
I have real Ne ha"ablus materials requirements under Chapter 695 of Ne Cali- AIR CONDITIONER •117 ✓f IXUISSHANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 undersea d But if the NEW RESIDENTIAL MECH. SQ,Fr.
buildmi,docs not curremly have a termtlt,that it is my msponsibiliry turbidly the occapanl
of the requirements which must he mer prior to issuance of a Certificate of Coconut,. T
Owner or authorized agent Date TOTAL: ISSUBOBY:v6e
OFFICE