28862 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES=USE BALOPOINT PEN ONLY
'.CITY OF CUPERTINO '. BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28862
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I ISANITARY NO. APPLICATION SUBMITTAL DATE
c2 673 Sc o Fi coo ',D2 1
OWNER'S NAME: PHONE: CO ACTOR'. NAME: LIC NO:
D
NIC CONTROLN
RCHITEC7/ENGINEER: !_a ,r LTCC O: ADDRESS:: ❑
CONTACT: PHONE: - _ BUILDING PERMIT INFO
'❑ Consultant Fees Paid by Applicant(Initial) BLDG ' ELECT u MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEEhereby affirm that I am licensed under provisions of Chapter 9 b mnme ming JOB DESCRIPTION
�a'Z thSection 701 of Division 3 of the Business and Professions Cade and my license is 'RESIDENTIAL:
00 infall f d feet PERMIT ISSUANCE
�UEU License class LmN ❑SFDWL `�❑�y�lTCHFN REMODEL
F LLI Date Cantramtr , APPLIANCES RESIDENTIAL L1 ADDITION ` I AIRING RE-PIPE
N � ARCHITECTSDECLARATION _ ,QMULTI-UNIT �❑STRUCTURAL
FOh PANELS
Z O y z 1 understand my plans shall bt used as publienerds 'r t ' MODIFICATION
OZ— UP TO 203 AMPS 1
Fs4 W Licensed Professional El INTERIOR CHIMNEY REPAIR
201-IINgIAMPS - -IMPROVEMENT
Fid�j OWNER-BUILDER DECLARATION
ON OVER 100h AMPS F1 BATH REMODEUREPAIR [I DEMOLITION
C4 � I hereby affirm that 1 nm exempt from the Contractor License Law fur the
iryy�O y U fallowing roason.(Section 71131.5.Business and Professions Cole:Any city or county SIGNS ELECTRICAI. ❑OTHER
which requims'a petal t to construct, Its P demolish,or rep y structure
prior to its issuance also mquireas the applicant fsuch permit l file a signed statement SPECIAL CIRC UIT/MISC
that he is licensed pursuant to the powimmis of The C t t _License' L (Chapter9
'(commend ng with Sect on]000)ofDivision Jo[The Business and Professions Gule)or 'TEMP.METER OR POLE INST. COMMERCIAL'
LL q o a That he is exempt therefrom mm the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m
Section 7031.5 by any applicant far a permit subjects Theapp summa civil penalty of POWER DEVICES
'Z IMPROVEMENT
i+ mam(5
not re than five hundred dolla500). [)TENANT El FOOD SERVICE
Q71,nsownerof the property,or my employees with wag,sas theirsoleenmpensatinn, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sec.0144,Business 0,OTHER
and Porifto las Code:The Gmhumo's License law does not apply It nuowner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves Thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ E. -
sale.If,however,the building or improvement isxold within one yearof completion,the SQ,FT.FLOOR AREA $/SQ.IN.
owner-builder will have the burden of proving that he did not build or improve for put. -
0 I,as owner of the property,am exclusively emar aging with Ikened amtmcus,Id TOTAL:
oraeLa the es noct(Sea]M4,Business and Professions Code:)The eas themon, OCT 11 1995
use Lnwdace not apply loan owner(if mona(y who builds orimproves thereon,arJ QTY. PLUMBING PERMIT FEE
who seLaw,for such pr Jail:with aenntmcmr(s)licensed pursuant to he Contractor's
License Law. ' C YLL !Nn1O
FII am exempt under Sec. ,B&P C Ter chis reason' PERMIT ISSUANCE �� Vur VJ LhI�IIYV
Owner. Date ALTER—DRAIN&VENT—WATER(EA) VALUATION
�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations: _
I have and will maintain a Confetti,of Cons,nuo self-insure for Worker's Conger- DRAINS—FLUOR.ROOR AREA,COND.
cation,as provided rar b Section 3]00 arms,Labor Code,for the STORIES TY ONSTRUCTION
y, performance of the
work for which this permit is issued. FIXTURES—PER TRAP
❑1 have andLa will maintain Wooer's Compensation work for
hi h required by Station - _
My Wt the Labor Codefor the mrn once of ad Policy
this permit is issued. GAS—EA.SYSTEM-I INC.4OUTLETS OCC GROUP APN
My Worker's Compensation Insurance courier and Polley tuber mc: -
Cartier: Poli Nn: GAS—EA.SYSTEM+OVF,R4(F.A) ,
CERTIFICATE OF EXEMPT IO ORKP S' `
COMPENSATION INS ) GREASFJTNDUSTRL WAS I E INTERCEPTOR
(This section need not be completed) pc sforonI d dollars($100) BUILDINGUIVISIbNPEES-
orless) GREASETRAP
j � PLANCHECK PEE
Loy any Person
in the perfo n •(fth or fo ethic this permit is issued,I shall
not employ xn SEWER—SANITARY—STORM EA.200 PI'.
p y ypersoniny r osmhew e'uhj tto the Workers'Compen- ENERGY FEE
,Z saunaApplicant
Laws of California.nDate
O - WATER HEATER W/VP.NT/ELF.CTR
O Applicant �
GRADING FEE
tiNOTICE TO APPLICANT:If,aft, king this Certificate of Exemption,you should WATER SY$TEMzpREATING
abecome subject Id the Worker's Com snian provisions of the Labor Code,you muss _ SOILS FEE
W forthwith comply with arch Provisions or this permit shall he deemed Hinged. WATER SERVICE
{ir Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U Ifar hereby affirm that them isxcansweti0lending agency for the performance of Dote RecoiptN
11s0 the work for which this permit is issued(Sac.309],Civ.CJ
pU Leadea Name - "
TOTAL:
{3I Leader
' Address
I -
certify that I have reuJ Nix application and store that the above information is BUILDING FEE '
o-Fi TSA correct lagreemcomply withnll cityand e�unty�rdinances andmxTe lawsrektingm QTY, MECIIANICAL PERMIT FEE
I,z building concoction,and hereby authorize representatives of this city m enatrupon the SEISMIC FEE
above-mentioned property for inspection pmpm ae. PERMIT ISSUANCE
(We)agreo to save,indemnify and keep harmless tha City o[Cupertino ogainst ELECTRIC FEE
liabilities,judgments,costs and expenses which may in anyway accrue against said City ALTER ORADD TO MECH.
consequencein of the granting mmis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NPOINT HANDLING UNIT(TO IO,OfID CFM)
SOURCE REGULATIONS. O MECIIANICAL FEE
ox AIR HANDLING UNIT(OVER 10,000 CPM) CONS'TRUCT'ION TAX
SiIT of AppliumWColtractor Dat T HAUST HOOD(W/DUCT)
HAZARDOUS NEWtRIALS DISCLOSURE HOUSING MITIGATION FEE "
Will the applicant or future building occupant smreor on hazardous me octal HEATING UNIT(TO I W,000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,matte Health and Safety
Code,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTS]) -
❑Vea No VEN'PILATION FAN(SINGLE RESID) PAID
Date Recdptif
Wrdill the air contaminants as
building by the utase Area
AirQument ordeviceswhich BOILER—COMP(3HP OR 100.000 BTU)
mit hazardous air cnnmminanu as defined by The day Area Air Quality Management - '
ismidl
❑_ BOILER—COMP(OVER 100,000 BTU)
• Yes � F7 No .
1 have read the hazardous materials re uircmenLs under Coulter 695 of the Cali AIR CONDITIONER
9 P ISSUAN DATE
Ibmia buildingHealdo,&Safety Lok,Sections 25505,u,my and 25534.I understand that if the ISE RESIDENTIAL MECH. SQ.PL -
ofherdceensntswhicyhastbeaset6NatoismyresponsCeriWeirl,lifyccupan he y. _
of he which most be met prinrmissuenee ofa CeniOeme of Occupancy.
Owner or authorized agent Date - : TOTAL: ISSUED BY:
OFFICE,' t'