28857 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEiRTINO '- - BUILDING-ELECTRICAL. PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL - O O C
BUILDINGPROJECT IDENTIFICA'T'ION ' o o J
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
/o!o! Cenlc 81✓d�. , ' C elf4itio Cyt
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
I ��V O ?.Z5--
. ;N/C - CONTROL#
ARCHITECf/F.NGINEER: XIC NO: ADDRESS: ❑
CONTACT: PHONE: - - BUILDING PERMIT INTO
t. '❑ COBSultaut Ful Paid by Applicant(Inidap BLDG ELECT PLUM MECH
s - '❑ ❑ ❑.
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 heresy arum that 1 am licensed OldeBusiness
Emu
ofChapterCode, q my licenens JOB DESCRIPTION
FJaz anal finch ido)nf Division 3af the Business and Professions Code,and my license is
WD L cense Ch,s c0ect. PERMIT ISSUANCE RESIDENTIAL'
�W� ° r. � ❑SFDWL ❑KITCHEN REMODEL
Uz License Class Corm - APPLIANCES—RESIDENTIAL
yQ� Dere Contmumr ❑ADDITION El PLUMBING RE-PIPES
ARCHITECT'S DECLARATION El MULTI-UNIT ❑STRUCTURAL
Zpn lunderemnd my plans shall be used as public rccoNs .,a PANELS - " -. MODIFICATION
cz-a UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F1 {�r. Licensed Profeselocd 201-I0A%)AMPS IMPROVEMENT
¢y+ [jpr OWNER-BUILDER DECLARATION OVER IOW AMPS [I BATH RF. DF: CIT
G re• 1 hereby affirm Thal 1 am exempt became,Contme a,License Law for the
ippi55,�O U following reason.(Section 7031.5,Business and Prafessians Gude:Any city or coumy SIGNS ELECTRICAL ❑OTHER
which requires n permit niamawc6 alter,improve.demolish,permit t or repair any structure
tprior hat hoslicerunce,alsoal Irequires emarviplieant for sucContractor mRleasigned smmmem SPECIAL CIRCUIT/MISC'
W GQ� mmpletwill with
purwunt tnthepf Division
of the Contractors License Law(Chapter.Cde).,
(commencing with Sution]o00)of Division3of the Business ane Profeseians Cruie)or TF.MP.ME'fER OR POLE(NST. a COMMERCIAL:
F pt m rG that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
..to Section703LS by any applicant for a permit subjects the applicant to a civil penalty of POWERDEVICES El TENANT ❑FOOD SERVICE
W yyyy not more Nan fldo hundred dollars(S5W).Q IMPROVEMENT
E]1,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the stmeme,is not intended or offered for sale(See,7044,Boomevs ❑OTHER
m and Professions Code:The Contractors Llcetae Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES "
property who builds or Improves themor,and who does such work himself or through
his own employees,provided that such improvements me not Imcaded or offeree for NEW RESIDENTIAL ELECTR SQ BE
sale.If,however the building or improvement is sold within one year ofmmpletian,the - SQ.FT.FLQg1 d 1 $ISQ.FL
ern Id 111 the b do fprovingtht he ld tb Id ormprove for par �� . pf
posit of ale), TOTAL: T 1
❑'I;n o f the property,a xcdusbelycontracting m
th licensed comencrs to s ^/ �0 /
construct thproject(S c 9044 Business dP f ., at C )Thwm
e Coners LI t, T- K Q�
verse Law does at.[apply) a oldrofpnpny who builds mprove,thereon,end QTY, PLUMBINGPERMIT FEE '/ V
who contracts fr.such pralecAwlh acommcc (s)licensed pursuant mthe Contractors ��' 'C/,�v•r s
License Law. PERMIT ISSUANCE /�
El I am exempt under Sec. - ,B&P C for this mason
Own
ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Owner pore 1 hereby affirm under penalty of perjury,one of the following declamtimis
e ❑I hardened will maintain eCedifcateof Consenttoself-insumfor Worker's Compen- DRAINS—PUH)R.ROOF,AREA,COND.
action,ie presided for by Section 37M of the Labor Code,iia the performance of the STORIES TYPE CONSTRUCTION
work for which this permit n eemed. TURES— TRAP "
E] 1 have and will maintain Wrker's oCmu,wi sm on hnsumnce,as ramired by Section -
3700 ofthe labor Code,forthe performance offle work for which this permit is issued. GAS—G.SYSTEM- INC.4 OUTLETS DICE.GROUP APN
My Woiker's Compensation Insurance carter and Policy somber arc:
Carrier:• Policy No.: GAS—EA.SYSTEM-0 NR4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GR`ASUINDUSTRL WAS INTERCEPTOR
(This section need oaths asmplwediFlhc permit is[oranoh ednllars C81 W) • BUILDING DIVISIONFEES
m less.) TR .
PLANCHECK FEE
Icertify that in the Performance ofthe work drawn' this permit is issued,lshall .�y _SA. STOR A.2W FI.
not employ any person in any manner so as to become si ject to the Workers'Comps ENERGY PEE '
,Z sation Laws of California.Date -
Z(2 Applicant WA TLR WNE .LF.CIR GRADING FEE
0 NOTICE TO APPLICANT:It;after making this Cerlific eaf Exemp 'hould TBI SYS'CGM TING -
l1 become an dd to the Worker's Co.din.t Ian prrvisirnx n the Labou must SOILS FEE
(�
forthwith'comply with.such prosi..ons or Nis permit shall It deemedrevo WATER SERV E '
CONSTRUCTION LENDlNGAGENL NEW DENTIA(.PLMB. SQ.FT. PAID'
(hereby affirm that there isawmwetion lending agene) onhc pertnmmnveofDem Receipt#
(r the walk for which this permit is Issued(See.3099,Civ.C.) - - -
Q V herders Name _ '
TOTAL:
{>a LeadersAddress
I - -
Ar m certify that I hove read this application and xhne that the ab a information Is' BUILDING PEE
V) correct.l agree to comply with all city and county ordinances and atam arelmin QTY. MECHANICAL PERMIT FEE
V 71 building construction,and hereby authorize representatives oft hie city m e the SEISMIC FEE
above-mentioned property for inspection proposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,c
osta and expenses which may inany way recmeogaies!said City ALTER OR ADD TO MECH.
in dsequence of the graming of this accmil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH LL N N-POINT AIR HANDLING UNIT(TO IgWO CFM)
SOURCE REGULATIONS. ' MECHANICAL FEE
C
AIR HANDLING UNIT(OVER I QWOCFM) CONSTRUCTION TAX
Signature of Applica_nUConon r Data EXHAUST HOOD DVDULT) HOUSING MITIGATION FEE
HAZAR S MATERIALS DISCLOSURE
Will the applieent orf to building oecupavtsmre or hanJlehazardous matuial HEATING UNIT(TO IOO,WO BTU)
as defined by the Cupertino cipnl Code,Gnpter 9J2,end the Hevhh and Safety
Code,Section 25532(a)^ I IEATING UNIT(OVER 100,000 BTU)
QYes No - PAID
VENTILATION FAN(SINGLE RESID)- - Dam Receipt#
Will the applicant nr future building occupant use equipment or devices which BOILER (3HP OR IOO,IXIII BTU)
emit hazardous air contam —
inants as defined by the Bay Amd Air Quality Macuptor eel TOTAL:
❑
DlsMctt BOILER—COME IW,OW BTU)
Yea ❑No -
(have read the hazardous materials requirements under Chapter 695 of the Cull .AIR CONDITIONER ISSUANCE DATE
fmnia Health&Safety Code Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.Fp.
building does not currently have a tenant,that it is my repactilbility to notify the occupant
of the reyuitements which et be tpriano sen fa Certificam of Oceupmcy.
I Ownerorantncomdagent Date !"' TOTAL: �.
ISSUED BY:
"' OFFICE '