28467 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-F.LF.CTRICAL PENMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL (v"
BUILDING PROJECT IDEMn F-ICATION
ILDING ADDRESS: SANITARY NO. APPLICATION SUNMITI'AI.DATE
16)25-0 5cE1,11c llVD. 6-uPr2TINo CA 9s7oI 'I bsissil S
alibillNER'S NAME: PHONE:-777 p OMRACTOR'S NAM& - LIC NO: N/C CONTROLN
Attliki /k �- TIIIA�fIL-1 I/ VI /4S .
RCNITELT/FNGINEER: LIC NO: ADDRI-SS: ❑
ONTAC E PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDQ ELF, PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ,'pfijr ❑ ❑
1 hcrehy uffirm that I am lictowd under provisions of Chapter 9 h arou'r,ag QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
�Owith Seeinn'I000)of Division 3 of the Business avd Professions Code,and my license is
i PERMIT ISSUANCE RESIDENTIAL: -
U mfail
raveto.Class effat. ❑$FOWL [I KITCHEN REMODEL
iM Dabe Clens Contractor
APPLIANCIS-RESIDENTIAL []ADDITION [1 PLUMBING RE-PIPE
'� Lal Dare - 'S DEC r
F,p,z ARCHITECTS DECLARATION PANELS ❑MULTI-0NIT ❑STRUCTURAL.
C p y Z understood my plum shall h used as public records MODIFICATION
rt-�Mvt CI 11PT02IX1AMP5 ❑INTERIOR C1 CHIMNEY REPAIR
I:� WWW Licensed Professianel 201-1000AMPS IMPROVEMENT `
OWNER-BUILDER DECLARATION Comoeu OVER 1000 AMPS ❑BATH REMODEUREPAIRYDEMOLITION
PC a 1 hereby uffvm thin I um exempt from the Contrucmrs License law for the
ippi55,�C
at following reason.(Section 7031.5,Business and Professions Code:Any city ,,county ti1GN5 ELIiC'TRICAI. ,- ❑OTHER.
m O F' which requires a permit to construct,ulmi,improve,demolish,or repair any structure
prior to its issuance.also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUH'/MISC.
thutheishcensedp....co ,,thepmvi,ionsof the Contractor's License Law(Chapmr9
CC0 (commencing with Section 7000)of Division Sol'the Business and Professions Code)Or TEMP.ME'IER OR POLE(NST. 72X COMMERCIAL'
aOY�opt that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
aqq$ {+• Section]031.S by any applicant fora permit subjec¢theapplicamI rally of POWER DEVICES
na'm'y ❑TENANT El FOOD SERVICE.
F.
Z P, t come than five h grope dollma y clop. - - IMPROVEMENT
C 1,mpwner of the progeny,or my enrployms with wages heir scom
ole ens ion SWIMMING POOL ELECTRIC
yQ and dothewmk,and the smlcmre isnot.La,emnntended Law Out apply tus
o an owner
a El OTHER
41 and ery whom Cnde:TTe Qonweors Lice me Law oat reply himself owner o' OUTLETS-SWITCIIIS-FIXTURES
progeny who hulls,or improves Hereon,and who d such work dea,or Nmugh
his own employees,provided that such mens is o arc not intended t oRemd for NEW RESIDENTIAL ELF.CTR SQ FT. qR�p,
sale.ILhowever.r willthe have theburdmpmvcm,nt lshr did noneyld orimmNctior Nc SQ.FC�FLOOR I p,� ESQ.PT.
owner-builder will have the burden of proving th he did aril build or improve Ibr put-
pose of owner as owner of the pmpeny,am exclusive, contracting with licensed cannon, m TOTAL.: AUG •p
conswct the project(Sec.9B4q Business a Pree'slon,Coto)The Cammmtar'e LI- /�Vu 1 1995
come Law does as applymen my trot open,who build,m improves Nercoa.and QTY PLUMBING PERMIT FEE _
who commcu for such projects with aco pans)housudparsuam to the Contrectora C')Y L
License Law. PFRMI SS UANECE _ ur Lur`H11N
❑I.exempt under Sec. .B Si P C far this reason Q
A F.R- IN&VENET-WATER(I.A) VALUATION
_ Owner Date
WORKER' OMPIW- SATIONDECLAHATION ACK LOWPRO'TUCT.DEVICU
1 hereby affirm made .11,of perjury one m the following d laratinns: J ,
Y ]lhuveandevillmaintaina ' ateofCanunt 1. If.in,.vmmkera o f t
DR S-FLOOR,ROOF,AREA,CONED. STORIES TYPECONSTRUCTION
ioo,as provided fmby Section 39( the Labor Cod a penbrmmac
work for which Nis permit is issued. O / FEE/TURES-PER TRAP
❑1 have and will maintain Workers Crimpers 1 ante,as red Section
3900efthe Labra CodgforthcNformance it for whitis .1 isiasued, AS-EA.SYSTEM-IINC.40UTLETS DEC.GROUP APN
My Worker'a Compensation Insurance tamer an Poumber.arc.
,
Cartier. Policy No.:n GAS-EA.SYSTEM-OVER 4(ITA)
C17RTIRCATE OF EXEMPTION FROM RKfiNS'
COMPENSATION INSURANCE GREASEIINDUS'TRLWASTE INTERCEPTOR
IThissenionamul not Mmi
completedifthepertisforone undreddollars($100) NUILDING DIV ISION PI?ES
or less.) GRBASE TRAP pLANCHECK FEE
I certify that in the performance ofthe work forwhich unspent ' moed.lmull SEWER-SANITARY-STORM EA.2S)Fp.
not employ any person in any mannerist m to become subject to the W s era'Compen- ENERGY FEE
s ition laws of California.Date WATER HEATER W/VENT/9LEC1'R
Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after staking this Cenifcum of Exemption,you should WATER SYSTEM/TREATING
become subject to the Workers Cton,mi tion previsions of the labor Cole,you must SOILS FEE
W forthwith comply with such previsions or this permit shall he deemed revoked WATER SERVICE.
�Z CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
V l hereby affirm that hem is a construction lending agency forth,performance of - Date Receipt#
W t••t the work for which this permit is is,ued(See.3099.Civ.C.)
O CJ Lenders Name T TAE:
Lkl Lenders Address TOTAL:
y I certify that I have=it this application and state that the above information is BUILDING PER At
In corect.l agree to comply with all city and county ardlnnnces and state laws relining to QTY, MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize representatives of Nis city to enter upon the SEISMIC FEE
ubove-mentioned property for inspection pcaptives.
(Art agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FE
incrmes,witer man,craningm ffii,esmit. tnuy inanyway accrue against suit City ALTER ON ADD TO MECH.
crinsryuenre man,granting of this permit. PLUMB( F
APPLICANT UNDER. . NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO u,"CFM)
SOURCERF tLATIO - MUCHANTC EE '
�P y� AIR HANDLING UND'(OVIiR 10,00(1 CFM) CONSTRUCTION TAX
Si lamo pplic - anuos or D Dane EXHAUST HOOD(W/DUC)
HOUSING MITIGATE PEE
HAZARD SMAng Occupant
WII plicateto Tum buildCge,Chantsmrear beadle Health and Safety HEATING UNIT LTO 100,000 BTU)
es defined by the untold icipal Code,Chapter 9.12,and the Health zeas Safety
Cnde,Section 25332 HEATING UNIT(OVER III0,000 BTU)
Cl Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID
Om ReceiptN
Will us air coma in future building occupant theBum equipment of Marta which BOILER-COMP(3HP OR 100.0W BTU)
-mit horallous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
rslrct^ BOILER-COMP(OVER 100,000 BTID
❑Yea ❑No
I have read raaN
the haous..costs rtqude
immems under Chapter 6.95 of the Cali. AIR CONDITIONER IS$UA .DATE
fomia Healm&Safety Cale,Secdon,25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL SUCH. SQ.IT.
building does not etiooml,once mount.thsta knty miponabinly,,ratify the necupant
of the requirements which most M met pfire,.issuznre of a CenlOcam of Occupancy.
Owner nr authorized,gem Date TOTAL: ISSUED BY: DID
M )
OFFICE