28654 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL - PERMIT NO
'BUILDING DIVISION 'APPLICATION/PER ITPLUMBING.MECHANICAL ' 286,54,
BUILDING PROJECT IDEN'DFICATION
BUILDINGADDRESS: - - SA NIT RY NO, APPLICATION SUBMITTAL DATE
�-
OWNER I NrpPIIONF:: C RACY R'S NA LIC NO: 'l
e e-1A ✓ i it. �v Nl CONTROL#
ARCHITF .NGINEER: - LIC NO: ADDRESS: -
b • tA2 -v o .' w 1
CONTACT: PHONE: - - BUILDING PERMIT INFO
kA 141/ Consultant Fees Paid by Applicant(Initial) BLDG - El.ecr PLUMcx
LICENSED CON'TRACTOR'S DECLARATION 7 QTY ELECTRIC PERMIT FEE
'I hereby of ird that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
a00❑aZ with Section 7").f Division 3oflhe Business and Pml'sslons Code,and my license is - RESIDENTIAL:
In full lbrce and effect. /�� y� `, PERMIT ISSUANCE sr
U p License Class Lic.p '^ " �y ❑S WL '0 KITCHEN REMODEL
4'z V] APPLIANCES'-RESIDENTIAL DITfON ❑PLUMBING RE-PIPE
y6 4 Dat Contractor
ARCHITECT'S DECLARATION PANELS - -O MU TI-UNIT ]STRUCTURAL
C Z w I understand my plans shall be used as public records MODIFICATION.
UPTO 200 AMPS
❑ ,D INTERIOR DCHIMNEY REPAIR
e�+�q u] NI ION
Licensed Professional 201-IOOOAMPS IMPROVEMENT
ej y'2� • OWNER-BUILDER R.a them iumpo, OVER Bush AMPS . D BATH REMODEURF.PAIR ODEMOLITION
CC 1 herehy uffrm that I R-exempt from the Contractor's.License Lew for the kkk
X>=-U following reason.(Section 7031.5,Business and P.pso'ions Code:Any city or county SIGNS ELECTRICAL D OTHER _
which requires it permit 10 mrerua, her,improve,demolish,or repair any simulate
�y prior to its issuance,also requires the applicant for such permit to filea signed statement SPECIAL CIRCUIT/MISC. ../ .,
�., that he is licensed pursuant to the provisions must Contractor's License Law(Chapter 9
�y G� (commencing with Sention](Im10)of Divisi.n3nf rbc 8ualnessand Professions Cider)or TEMP.METER OR POlf INST. COMMERCIAL: tfI
0.qi o a Nat he is exempt Therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION' D DEMOLITION S
if 0. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEV VNSDTENANT OFOOD SERVICE
not.oro Non five the pred roperty,
r yempl - IMPROVEMENT
C 0 ❑Laske wor ,the psestruy ormyemntended with wageseredf stheir sale 114, a iri.n. SWIMMINGP LLTRIC X
552
sell doNe work,and thestnmwreisnot intended or offered for sale(Ser.1114,Bu in DOTHER
Wy3 and Professions Code:The Convectors License Law does not apply to an owner. OUTLETS-S ITC XTURFS �/_
property who builds or Improves thereon,and who does such work himself or through
his own employees,.provided that such improvements are not intended or offered for NEW RESIDENTIAL EL SQ ET.
'side.If,however,the building.,improvement is sold within.ne yearofcompdetion,theSQ.FT.FLOORrJREA $/SQ.PT.
owner-builder will have the burden of proving Nat he did act
build orimprove for pur-
pose of cele.).
EI I,as owner of the property,am exclusively contracting with licensed c.nbacmrs .
oy
construct the project(Sec.7fW4;Business and Professions Code:)The Cnmractor's Li-
close Law does not apply To an owner of properly who builds or improves thereon,and QTY. PLUMBING P FEE -
who contracts for such projects with v contradmi a)licensed partner,To the Contractods -
License Use. PERMIT ISSUANCE
D I am exempt under Sea B&P C fonhis reason
Owner - Date LTER-DRAIN&VENT-WATER(EA) _ VALUATION .,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herehy affirm under penult,of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compeu- DRAINS-FLOOR,ROOF,AREA,COND.
,.tion,as provided for by Seclimi 3700 of the Labor Code,for the perporeminw oI the STORIES TYPE CONSTRUCTION
work for which this pert is issued. FIXTURES-PER TRAP s
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe Labor Code,for the performance ofihe work for which this permit is issued. GAS-EAAYSTEM-IINC.40UTLETS � - OCC.L] ROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: - GAS-EA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE GREASHINDUSTRL WASTE INTERCEPTOR
(This section Beed not be completed iftheportnh is forone hundred dollars p$IW) " ING DIVNFEES,
or less.) - GREASETRAP - PLANCHEC
(certify Net in me perfonn5nce of the work for which Nis permit is iasucJ,Isbell SEWER-SANITARY-STORM EA,2001T.
not employ any person in any manner ao as to becmne tab G6�I m the Worker.'Campeau- - ENERG 2Q
cation Laws of California.Dace�__�G,— WATER HEATER WNENT/FLECTR
�jO O Applicant /_ ,/�C �� - 7GRADINGNO
TICETOAPPLI�fm ing Ceri- of Exemption,you should WATER SYSTHM/IREA'rING become subject ro lite Workers Gimpensetion provisions.f the Labor Calc,you mustforthwith comply with such provisions or this peonitsholi be deemed revoked. WATER SERVICECONSem is ac ONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQIFT'.
U0 I fan
that pemereisawmwction lending agency for the of Date Raceipr#
fL the Leaders for which this permit is issued(Sec.3097,Civ.CJ
O U
Leaders Name' 'TOTAL:
Lia Lender's Address
- s T T
1 certify that 1 have read this application and.ctam teal One above Iowa
rclmion is BUILDING FEE
Ft Tap correct.I agree to comply with alleity and amort,'ordinances and state laws relmingm QTY. MECHANICAL PERMIT PEE '
U 7.. building conswetiog and bercby authorixere,resenttives of this city to entcrapon the SEISMIC PEE
hos above-mentioned property for inspection purposes.
(We)agree or save,indemnify and keep hornless the City of Cupertino again, PERMIT ISSUANCE ELECTRIC FEE -
liabilities,judgments,costs and expenses which may in any way accrue against said City gLTER ORADD TO MECH.
N consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS'AND WILL COME TH ALL N.POINT HANDLING UNIT GO IQOm CFM) MECHANICAL FEE
SOURCE.REGULATIONS. -
ANDLINGUNIT(OVBR10,000CFM)TI?i�k�! CONSTRUCTION TA X -
Signmure.f App •Gmlr orDa EXHAUST HOGO(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIA DISCLOSURE
Will Naapplicaomrfaro.bottom,occupantsmre or handle houmlmsmaenal HEATING UNIT GO 100,000 BTU) 4n1
�
as defined by the Cupertino Municipal Coda Chapter 9.12,and the Health trod Safety +� w 8 I,gn
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
�Y Otho • PALO
VENTILATION PAN(SINGLE RESID)• I.
Da
Will the applicant futurebuildinb occupant use cqulpmm rdoiens which BOILEROMP(3HP OR 100,000 BTU) re
W^ ��
sJJJ _emir ha.N s contaminants as defined by the Bay Area Air Quality Management -C 11•j
District" L!• 1,t.3+Ca,TOTAL
''7Yes - ON. - - BOILER-COME(OVER Im#),mXI BTU) •ttllyU
AIR CONDITIONER s
I have read the hazallous materials requirements under Chapter 6,95 M the Cali- ISSUANCE DATE
Form.Health&Safety Code,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH.' SQ.FI'.•
building does not cnrtendy have a tartan,that it is my responsibility to notify the occupant
of rhemmorements which must be met it to issuance of.Cenificam of Oer.p.r,.
Owner.,authorized agent Date ISSUED BY:
OFFICE