28933 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEKI`INO BUILDING-ELECTRICAL P13RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 289.33
BUILDING PROJECT IDENTIF'ICA'TION �J
BUILDING AUURESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ori 8 a eecis (� �
OWNER'SNAME: . PITONS: C N'TR LTOR'S NAME: LIC NO:
s CO CONTROI.q
ARCHITECT/ENGINEER: - LIC NO: )UkESS:
607
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATION
Chapter
QFY ELECTRIC PERMIT 17EE
I hereby nilirm that 1 am licensee under provisions of Chapter 9(commm�cing JOB DESCRIPTION
0Z with Section?000)of Division 3 ofthe Bminescmtd Professions Codo,ond my license is RESIDENTIAL:
O PERMIT ISSUANCE.
ad p infail fomented effect OSFDWL El KITCHEN REMODEL
�UO License Class - Lie.M
" W Date Cn ncmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
I
Fly ARCI ECARATION - PANELS a ❑MULTI.UNIT ❑STRUCMRAI,
Z Z 1understand m all Tall be �� rccnres - MODIFICATION
O',z. V UI'T0211(IAMPS
F.y.1: Lice ❑IN9'ERIOR ❑CHIMNEYREPAIR
201-1000AMPS IMPROVEMENT
E NER-HUIL)F.R DECLARATION OVER IIMq AMPS
a erchy affirm Nat I am exempt from the Comntctor's License Law for tiro ❑BATH RIiMODEUREPAIR DEMOLITION
i65,O d U following reason.(Section 7031.5,Business and Professions Code:Any city or countySIGNS CLF.CTRICAI. C OTHER I
-
t'r 3 w ya which requires a permit m construct,alcor,improve,demolish,or repair any suucwre ' )
prior I.its issuance,also natimsda,.,dicam far such permit to file as]gnedsmrom it SPECIAL CIRCUIT/M ISC a
that he is licensed poramnt.the provisions of the Contractor's Licenm I...(Cuts,9
YI�qCO (commencing with Section 7000p+(Division Sof the Business and Professions Conic)or TEMP.METER OR PULE INST. COMMERCIAL:
the he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WSeen..70315 byeny applicant]or.pemut subjects thenpplicant ma civil pcmdy of POWER DEVICES
yyyyyyr`G rot marc
tan five hundred deflect P$500). - ❑TENANT ❑FOODSERVICE
Q ❑I,as owner of lire properly,or dry employees with wrgev ns theirxole compensation, SWIMM I NG POOL ELECTRIC IMPROVEMENT
C will do the work.ands c,taremre is oat intended or offered for alc(See 70414,Basin,. []OTHER
m and Professions Cock:Tire'Conaucmr'+License Low docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that,such improvements arc not intended or offered for NEW RESID17NTIAL ELECTR SQ ET.
sale.If.however,Ne building or improvement is sold within one year ofcompleime,the SQ.FT.FLOOR AREA $/$Q.FT.
owner-builder will have the burden of proving that he did not build or improve for fam
pom of sada). _
❑has owner of the property,am exclusively contracting with licensed contractors. T
smxbnct me project(Sec.704o
4,IIminesx and ProfProfessns Code,)The Commmnr'I U. t
examLow does am.pplym.owner ofproperty taItlids�rimprove,Ncmun.Ind QTY. PLUMBING PERMIT FEE OCT � '
whocnmmcts forswhpt jec.wbhu en tractnr a nal urrom the Conuocmre nf] �^aa
Llcenu Taw, PERMIT ISSUANCI? 2 t) 9 JU
❑ I am exempt under Sec. ,H PC for this reason
ALTER-DRAIN&VENT-WATER(HA) 'JIT 1 Ur LU,1j:VALUAT1ON
Owner_ Date
0MPENSA3lON DECLARATION HACK PLOW PRIOR OCT.DEVICE
1 hereby affirm under pcnahy of perjury one of Ne following dedemlions:
❑Ihuvc and will maintainu CeniOcum of Consemmxlf-in.rc hes Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. - S'roR11i$ TYPE CONSTRUCTION
.tion,no provided for by Section 37M of the Labor Cole,for the performance of the
work for whichmi,permit is issued - FIXTURfiS-PER TRAP
I have and will maiamin Worker's Compensation Insumnce,us beamed by Section
3700cifthe LaborCrMe,for the perfom.peeofthe work for which this permit is issued GAS-EA.SYSTEM-]INC.4 OUTLE'S OCC.GROUP APN
My Workers Comparison Insurance rmerand Policy nwnherare:
Carrier Policy No.: GAS-EA.SYSTEM OVER 4(E U -
CEIYTIFICATE or EXEMPPION PROM WORKERS'
COMPENSATION INSURANCE GREASIENDUSTRI.WASTE INTERCEPTOR
(Thin o,dion need net be completed iflhe pemtit is f oonc hundred dollars($1011) BUILDING DIVISION FEES
oa3c..) UREASE TRAP
PLANCHGCK PEE
1certify dent Inthe andommne as to became
foe whichthis the WLrissued,Ishell
note. toy any person in any mannersn as to brooms,uM1'enmthe Worker' SEWER-SANITARY-$'TGRM CA.200 FL
p l .pen- ENERGY IIiH
,� .tion Laws of Califnmia.Dote
O WATER HEATS /ELECTR
zO
NOTICE
GRADING RE
rN. NOTICG TO APPLIC.11 If,after makingflu Ccnificam of Exemption,you Wp ,R SYS_' R TING
become subject to tiro Workers Compensation p visions of the Ln r d nn must SOILS FEE
W .a
forthwith comply with such previsions or Nis pe it she rise s voted. ATER ERVIC '
Q /�
CONSTRUCTION Lli on EN CY' iC J W RES1DIiMfTAh PLMR. SQ.FT. PAID
V O l hereby which rte thin there is sued sS ni ad ;agency fur the rfo ( Dam Rtt<ipl M
0 theworkfo,which this permit is issue)ISw.309 ,C v.CJ
O U Lender,Nan¢ _ TOTAL:
lenders madly
TOTAL:
T�.t G 1 mrtHy the 1 have read information application and state that the above infomtion is � BUILDING FEE
F 0 correct 1 agree m comply with all city ono county ordinances and nate laws relating to QTY. MECHANICAL PERMIT FEE
L) z building construction.and hereby authorio,representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned praper y for inspection pummi PERMIT ISSUANCE(We).9.m.ve,indemnify end keep harmless the City of Cupertino against EITCI'RIC FEE
Iiabilities,judgromm s,costs and expenses which may in any way accrue against said City
ansequenee of the gratning of this p mit. ALTER OR ADD TO MECH. PLUMBING PEE
APPLICANT UNDERSTA SANT WIL, COkLY WITH ALL NON-POINT AIR HANDLING UNIT Go 10.000 CFM)
it. MECHANICAL PERPERSOU EREGULATION. //JP
AIR HANDLING UNIT(OVER IIhOW CFM) CONSTRUCTION TAX
a
;natureo ApplwaAZARDOUS MATE. IALS DISCLOSURE Dole EXHAUSTHO(NoOMMUCT) HOUSING MITIGATION FEE
Willtheapplicant.furore building...Fou poreor].role It
ole material HEATING UNIT(To l I OO,WO B'IU)
as dia M1y Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cede,Section 25532(x)1 _ HEATINOUNUOVER 10010CNIBTIE
O Yes _ 0N VENTILATION FAN(SINGLE RISID) PAID
Will the applicantir' toinants a building occupant use equipment m devices which
- Dam Receipt
emtrict?nlnus air contaminants as defined by the]lay Area Air Quality Management BOILfiR-COMPOHPOk.Ifp,0110 B1V)
District? TOTAL:
❑Yes ON. BOILER-COMP(OVER IIq,gYIBTU)
AIR CONDITIONER
ISSUANCE DATE
I have read the havrdoua materiels requirements under Cha er fi 95 of the Celi-
faint HmIN&Snfciy Code,Sections a tiore2.55115,2553]rod25534.1 to out,
the
Nutifthe NEW RESIDENTIAL.MECH. SQ,PI'. !f
mormngdtes& Safety ohaveatenant,that itismy rand 2554.1tonotifynd dhotoccupant
of the respite eau,which moot he met prior at Issuance of CxnlOcate of Oceup.cy. .
Owan-ormthonrcd agent Date TOTAL: ISSUED BY:
OFFICE