28995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT-PEN ONLY -
CJTYOFCUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISIONAPPLICATION/PERMIT PLUMBING-MECHANICAL O (J C
BUILDING PROJECT IDENTIFICATION - o J l�
BUIIAING AQD/DRESS: - SANITARY NO. APPLICATION SUBMITTAL GAFF
PHONE: CO ACTOR'S MF,: LIC NO:
l,4XI NIC coN koL#
`•�ARCHITECf/F.NGINEERI LIC NO: U ESS, � - ❑ �
CONTACT: - PHONE.: - BUILDING PERMIT INFO
' + ❑ Consultant Pecs Paid by Appllwn/(Initial) BLDG CECT PLUMB PATCH
e.�c � 73-l�$J'. �❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION - . QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{Q{yy�Z with Section]0 )of Dividim 3 ofthe Businesv and Pmfessmax Code,and my license is PERMIT ISSUANCE RESIDENTIAL JO
F is full fomes JPl - _
�UV Licens less �' - Lica 0(09 - OSPDWL O KITCHEN REMODEL
ti7W at'�ogir -4 Conaannr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUM RING RE-PIPE
Fpm ARCHI9'HCT'S DECLARATION PANELS ❑MULTI-UNIT 0STRUCTURAL
OZ Y1�2 I undustaod my plans shall be axed as publio recoNs - MODW TION
:1 UP TO 200 AMPS //. 1
ICJ 4�O Licensed Professional .. ❑INTERIOR ( 2J NEY REPAIR
yy OWNER-BUILDER DECLARATION 201-1(X10 AMPS IMPROVEMENT
Y�'� 1 hereby affirm that i am exempt firman the Contractors Ui pise Law for the OVER 11X10 AMPS O BATH REMODEUREPAIR'O DEMOLITION
aO0.U following reason.(Section 7031.5,Business and Professions Code:Any city or county I - ❑01'HER
C¢F which rc res u t to con.arud,alter,improve,demolish,or rc SIGNS ELECTRICAL
W N qui Perot p pair any swnure
vfm.J prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 -
W�t]O (commencing with Section 9000)of Division 3 of the Business and Pmfessiomx Code)or TEMP.METER OR POLE INST. COMMFR IA
ay#�c y` that he Is exempt therefrom and the basis for Ila alleged axempdan.Any violation of - El NEW BLDG/ADDITION O DEMOLITION
Wm'
Section 7031.5 by any.applicant for a permit subjects the applicant too civil pared,of POWER DEVICES
ZyZy�' not more than five hundred dollars($500). El TENANT E:1FOOD SERVICE
dp O has rata oY Oe property,or my employees with wages as thur sale cumpenxetioq SWIMMING POOL ELECTRIC 'IMPROVEMENT
will do the work,and theannemre is not intended or offered for snle(Sic.7044.Business O OTHER
W and Professions Code:The Contractor's License Use dons not apply ns an owner of OUTI,F,TS-SWITCHES-I:IXTURE. -
property who builds or improves thereon,and who does such work himself or through 4� '}
his own employers,provided that such improvements tips n I intended or offered for NEW RESIDENTIAL GLECTR S Gp
sola If.however,the building or improvement is sold within one yearofcampletion,the FLOORAREAs $/SQ.Ff.
owner-builder will have Ne human of proving ten he did not build or Improve for put- i �1,0' 9
O 1.as owner of the property,ani exclusively contracting with licensed wntraerms tn' I TOTAL: p
construct the pr Jest(Sec.7044,Brininess and Pmfewitar,Coda')no Contractor's L1- y
cense Law does not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE k LVl" 6
who c-mracts for such projects with a contmnor(s)licensed pursuant m the Contractor's r]'Yf
License Law. - - _ (/(+U
ElIamexImpinnder SCC. ,B&PCI'arthisressan PERMIT ISSUANCE
Owner
ALTER-DRAIN&VENT-WATER(EA)
Doc ` VALUATION
WORKER'SCOMPENSATION DECLARATION
lowing BACK FLOW PROTECT DEVICE
ve and sell]mmunder panalted,of Cty of oyoneoftheinarre n declarations: y ..
Olhavv and will maintainetionor 3vem ofConsentLabor Cook,for the Worker'sce of
DRAINS-PLOOR,ROOF,AREA,COND. - STORIES TYPE,CONSTRUCTION
cation,as provided for by Ss I... 3]1X1 ol'the Labor Gude,probe performance of the -
work far which this permit is issued 'FIXTURES-PER TRAP
I have dna will maintain Workers Compensationw rkfor which
h rcquir'.I by Section '
3]yW the Labor Code,for the InsumnmmameoftheoilieX oar�wphyi?ch thispermit is lss�e`dI GAS-EA.SYSTEM-1 INC.40UTLET$ OCC.GROUP - APN
Crime part. InsumnfFamic Policy No.'y�•/�Jq1(0�7 GAS-EA.SYSTEM-OVER 4(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTR[,WASTE INTERCEPTOR
(This section need not be complaW ifthe permit ix parent,hundred dollars($RI(p' . 4- BUILDING DIVISION FEES
arias.) .'=s GREASETRAP PLANCHECK FEE
I cenlfy that in the performanceofthe work fa ssi ieadds pertain is issueq I,md
'• not employ any person In any manner so as to become subject te the Workers'Grope. SEWER-SANITARY-STORM EA,200 FT. ENERGY EEE
cation Laws of California.Dam
O Applicant - WATER HEATER W/VENT/EI.ECTR GRADING FEE NOTICE TO APPLICANT:Jr,after making this Certificam of Exemption,you should
2 become subject to he Worker's Compensation p
WATER SYSTCM/1'RF.ATING v '
a trovisions of the Loror Code,you mora SOILS FF.E ,
Da fMnmp
owith cly with such provisions or this permm
it shall be deemed revoked. WATER SERVICE
0. Q
p z CONSTRUCTION LENDING AGENCY
r NEW RESIDENTIAL PCMB. SQ.FT. END
Ihereby which affirm that isacotSec,ion lending agency(onhepaformuncenf Data Recaipta,
the work for which this permit is issued(Sm.3099,Civ.C.)
Leader's Name
ow Lenders Address TOTAL
TOTAL:
y ani that 1 have mad his nppli.don and state thin the above information is BUILDING FEE
(A corren.I agree to comply with all city and county ordinances and state laws palating to QTY. MECHANICAL PERMIT FEB
�.7 building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned progeny for inspection purposes. _
PERMIT ISSUANCE
(We).911V m save d t and fy keep hvmdexx the Gly f C penino against ELECTRIC FEE
ladalithes,Judgments,costs and expenses which may in any way ac against said City �ALTERORADDTOMECH
in consequence of the grunting f this permit !PAID -
Do
G FEE
.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CPM)
SOURCE REGULATIONS.' ICAL FEE'
AIR HANDLING UNIT(OVER IO,WO CFM) UCTIONTAX
Signature of ApphrsnVConbacmr Dam EXHAUST HOOD(W/DUCT) MI9'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building ociramm uneor handle hazardous material HEATING UNI'f(To 100,000 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety "
Code,Section 25532(.)7 HEATING UNIT(OVER'100,000 BTU)
❑Yes "7No "
-
VENTILATION FAN(SINGLE RESID)• Will thea licant or future SaidIin - te Receipt#pp g occupant use equipment or devices which
emit hazardous air Conmminevts.1 defined by the Bay Are.Air Quality Management, BOILER-COMP QHP OR 100,000 BTU)
Dismal
Oyes ONe HOLLER-COME(OVER 100,000 B. -
I have read the hazardous materials r4throments under Chapter 6.95 of the Cali- AIRCONDI3'IONER - _ ISSUANC E
food.Health&Safety Gree,Sections 2.5505,25533 and 25534,I understand that if the NEW RESIDENTIAL MECH. - SQ.Ff.
b'oilding tices mmvrrently hour a tenaoq that h is my rexponsihility to notify the occupant
requ
of the irements which must be met prior to issuance of a Certificmpa
eof(kcuncy. -
Owner or authorized agent Dam ,TOTAL.
ISSUED BY:
OFFICE