28747APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
ROILDING PROJRCr IDENTIFICATION
PERMITNO.
28747
BUILDING AIDRHSS -
107Th R&U/64- s'Im., Ca t.QT.,ro . r9 9SOrS�,
SANITARY NO.
APPLICATION SUBMITTAL DATE
scr :17/ ri9'S
OWNER;6NAME: f • P_Q_ .._ s
cYYT ` J, /`([•'8
CONTRACTOR"NAME: I -IC NO',
N/C
❑
CONTROL#
ARCHITECDENGINEER: LIC NO:
ADDRESS:
CONTACT PHONE:
.� V� OTir/dz T£4 •
dais) 46/ - 9e Poo1
-
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
IILDG ELECT PLUMB MECH
❑ ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 con licensed under provisions of Chapter 9 (commencing
with Section 7000) ofluvision 3 what Businessand Pndessiona Code, and my license is
infulleChn.md effect.
License Class
I Date— i Connector
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
]SFT)WL El KITCHEN REMODEL
❑ADDITION PLUMBING RE -PIPE
❑MULTIUNIT El STRUCTURAL
MODIFICATION
❑INTGRIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/RF-PAIR ❑ DEMOLITION -
❑OTHER
pLRM1'I'ISSUANCE -
APPLIANCES -RESIDENTIAL
j ARCHITECT DECLARATIONPANELS
I a e-ollu d my plans shall be used as public records
I
Licensed Professional
OWNER -BUILDER na me Coal
1 hereby affirm an 1 am oxempt Inmt the CosionmChi License Law for the
following reason. (Section 70315, . elle xs and ve di inns Code, Any city nr wunrY
improve, demolish, or repair any structure
which requires u permit m abet the applicant
'do rtoits cense cprsu requires theosoffinr Conperminnfle a ense Law
e(Chapt em
that be is licensed pursuant 7 the provisions of the Commemrs License Law (Chapter
Cade)or
(commencing therefrom
of Dosis n3 themeeged essanJon. Any
(cat he
that he is exempt therefrom and the bads for the allege) exemption. Any violaion of
• Section703 1.5 by unyupplicant fora pennitauepat. the up,lamintto a civil penalty, of
not mom than five hundred dollars($M(o,
I] I, os owner olthe property, or my employees with wages as their sole compens tion,
will do the work, incline nrucurc knot intended oruRefed for sale (Sec. 7044, Business
and Professions Code: no Contractors License Use dues not apply to on owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such impmvemerns are not intended or offered for
sale. If,however, the building or improvement is sold within one year of completionthe
owner -builder will have the burden of proving that he did not hui Id or improve for pur-
,,aofsale.). I
O 1, as owner of tiro pmpeny, .,it exclusively emarinling with Morenad amanteon In
n iswet the project (See, 7044, Business and Promesions Co.,., The ----
cerise
whoconuacts forsuch projects with ucummearod Iicensediunuam mace Commcmr's
License Law.
1 em exempt under Sec. , If & P C for this reason
Owner Uwe
-
UPT02IXIAMPS
201.10OAMPS
OVER I" AMPS
SIGNS i?L1?C'1'RICAh
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL, '
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
[]OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ FT
SQ. FT. FLOOR AREA $/SQ. FT.
I '
pp fTSS
f7
27 s ATION
�1
..11MF I NV
Is,
TOTAL
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. VICH
WORKER'SCO IHNSATIONDECI.ARATION
I hembyaflirm under penalty ofperjury one ofshe following declarations:
o ofConseno self -insure for Worker's Courtier-
I] I have and will maintain a Cenificmu
a , tim as prnvidel for by Section 37M of the labor Cede, for she perfommnen of the
work for which this Permit is issued.
I] I have and will maintain Workers Compensation Insurance, as acquired by Section
37W ofthe Luba Code, for Ne performance of the work for which this permit is issue d,
My Workers Compensation Insurance carrier and Policy numbersm: s
Carrier: Policy No.:..
DRAINS- FLOOR. ROOARA, CONED.
�I 1
-
TY PE CONSTRUCTION
AI'N
"
FIXTURES - PER
GA A. E-IINC.40UTLUIS,(3CC.GROUP
YS'I'GM-OV 1 7
' CERTIFICATE OF EXEMPTION FROM WOR KIIRS'
COMPENSATION INSURANCE
('Nis section need nos becompletcJ ifthe pcntdt is furone hundred dollars (SIM)
or less.)
I certify that in she performance ofine work for which this permit is issued, l shall
not employ any penon in any manner so m to become subjecfto the Workers' Comre pe
section Laws of ColRomlo. Dote
Applicant
GREAN N Ll. W . EIN'I'ERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PL.ANCHECK FEE
SEWER -SANITARY -STORM EA. 2W FT.
ENERGY FEE
WATER HEATER W/VENT/HLFUI'R
GRADING PEE
NOTICE TO APPLICANT: If, after making this CeniScam of Exemption, you should
become Subject to the Workers Compensation provisions of Ne Labor Code you must
forthwith comply with such Provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby uffinn that thea isaconswction lending agency for the performanceM
the work for which this Permit is issued (Sec. 3097, Civ. C.)
Lender's Name
WATER SYSTEMOREATING
SOILS FEE
WATER SERVICE
PAID
'Dam Receipt is
NEW RESIDENTIAL PLMB. SQ. Pr.
"
"TOTAL:
Lender's Address
TOTAL:
BUILDING FEE
I certify that I have mad this application uad state Nos the abuse information is
correct. l agree to comply with all cityaml cousnyoNimtnces and state laws relating In
building construction, and hereby authorize minescomtives of this city to char upon the
above-mentioned property for inspection purposes.
(We) agree th save, indemnity and keep harmless the City of Calamine against
Iiabilities,judialmols, cults and expmn, which only many way name against said City
omequenceafthc thing of this Permit.
APPI. FUNDI"SAND WILL COMPLY WITH ALL NON -POINT
SOURCE EGULA'
/ O1/
QTY_ MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ALTERORADDTOMECH.
PLUMBING FEE -
MECHANICAL FEE
ALR HANDLING UNIT (TO 10AX) CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRUCTIONTAX
tg eof AppheanUcoz' DInr_ ate
IlAZAR0005 AT IAS DISCLOSURE
Will neii,lieatn or future hnildiagtmenpnat smrchr handle hamrdoas'material
as defined by the Cuperiro Municipal Gde. Chapter 9.12, sad the Health and Samty
Code, Scene. 25532BO?
❑Yes 0 N - -
Will the applicant or furore building t use equipment or devices which
mit hazardous sir contaminants as def by the Bted by the Bay Area Air Quality Management
District?
❑Yes Na
I have read the nauudous mamnals auimmems under Chapter of Ne Cnli-
q o
forma Health & Safety Coda Sections 25505, 25533 may 25534.1 undersand mm if the
building docs not currently haven anent, Nm it is my responsibility m notify the occuPam
of me asphiremems which must be met prim to issuamm oft Ceti fcaa of Occupancy.
EXHAUSTHOOD(W/DUCr)
HOUSING MITIGATION FEF,
HEATING UNIT fI'O ioLo(10 B' I' it)
HEATING UNIT (OVER 100.000 RTU)
PAID
Date Receipt#
VENTILATION FAN (SINGLE RPSID)
BOILER -COMP LIMP 1 W,(Nk) BTU
BOILER )
TOTAL:
BOILER- COM P(OVER IUO,ITIa IIDO)
AIR CONDITIONER
ISSUANCE DAA
U♦ r!)j
ZUOwner
ISSUE U BY:
NEW RESIDENTIAL MECH, SQ. FT.
-
or authorimd agent - Date
TOTAL:
OFFICE