28598APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
CITY OF CUPERTINO - eau-Inrvc
BUILDING DIVISION APPLICATION/PERMIIT PLUMBING
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/]MZARDOUS MATERIALS DISCLOSURE
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❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATION -
1 hereby affirm dun 1 on licensed under provisions of Chapter 9 mmormacing
wiNSccuon]000)ofOivision3ofdw Business avec PrafessionsCode,andmybameis
' full fame and t.
Iianscate" - 29 Lin« i3 a g y
Dalc�Conuactor
i maddersu•M'my planta, (chhtan W sed as p public rtsvtds
Liarwil Professional
OWNER -BUILDER DECLARATION
I hereby offum that I an exempt tmm the Contractor's License Law for de
fallowing reamn. (Section ]031.5, Burn. and Professions Code: Any city w county
which requires a permit m ronsnu0. div. improve, demolish, w repair any swcmre
prior m its -stance. also rectums thcapplicsnt for such permit to file a signed swement
dui he is licensed pursuant mthe previsions ofee Convacmr's Li<mse law (Chager9
(tantamount,wid, Section 7") of Division 3 of the Business and Professions Cam)or
that W is exempt therefrom and the basis for the aeegM exemption. Any violation of
Saturn ]03L5 by any applicant a Panamasubject the applicam m a rivil pwdry, of
vw more than five hundred dollars ($500).
❑ I, ss ownvof ted gvpeny, m my empltyres with wages ss their sole cnmpeosdon
will do We wma Codec he Cod rim's Lnaed woB, don, notapply . am Business
and Profession Code The eaves her m License law rices not apply s if owner of
and who does such work himself of through
Property who builds m improves thsuch
QTY ELECTRIC PERMIT
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
PANELS t
IIP TO 200 AMPS
201-IWOAMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
- .
SPECIAL CIRCUIT/MISC.
TEMP. MPR OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWOCHES - FIXTURES
OBATHREMODEUREPAIR ODEMOLITION
his own employeese Provided that such improvements are not intended
i offend for
far
NEW RESIDENTIAL FlECTR SQ FT.
ou the
sde.If, however, thebuildingndm
is sold withinaneildor
mroer-buadv ofprovint
win have rod awes of coving em he did rept entad or improve (or par.
umber far
sale.).
TOTAL:
0 1. toL to owner of the property, am exclusively contracting with hansedmto
roawa the goject (See ]044, easiness and Profession Code:) The Contmator,mmors Li-
QTY PLUMBING PERMIT
cense law does not apply to an owner of property who builds or improves thereon and
whocouuacts forsuch projects with. conuactoKs) ficeasd pinsomm 'the Comrsma,
PERMIT ISSUANCE
Liana Law,
O l am exempt trade, Sens. ,B&PC for It, reason
ALTER - DRAIN &VENT- WATER (EA)
Danner Dam
WORKER'SCOMPENSATION DECLARATION
1 hereby aR undo penalty of prjury one of the following declarations:
❑Ihaveaodwal mainuiva Certificate of ConsentmseH-itsureforwmker's Compen-
sauon, as provided for by Section 3700 of the lade Cod, for the pada f the
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND,
ITXTURES -PER TRAP
for wtich las permit is issued
w I have and will maintain Wwkcrs Compensation Insmm�tt required by Sava
]00 ofthe Labor Code,forthepM mavtt of the workf ich eisperminisissuW.
GAS-EA.SYSTEM-IINC.40UTLETS
My Wark e4tmpensation surmee camriv and P - nui9 �err are:
GAS -EA. SYSTEM -OVER 4IEA)
Carrico ey NO.: ,-f
17
CERTIFICA PITON FROMW RKERS'
GREASE/INDUSTRL WASTE INTERCEPTOR '
MPENSATION INSURANCE
(This satin am be completd if the permit u fm com hundred dollies P$Ry
or less.)
GREASETRAP
z,Z
O
feet' dui in the perfommarceofthe waakfor wthicM1 Nis permitis issuaLlxhall
rmn employ y person in any moaner so ss m became subject so the Workers' Comprn-
sation to s of Cdifomia. Date
Applie -
SEWER-SMTfARY-STTIRM EA. 200 IT.
WATER HEATER WIVENTIELI=
Fy
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NOTI iD APPLICANT. B, after making this C -ficats of Exemption, yet should
subject to the Wmka's Comprnsatiot provi arts of due palm Cie, you trust
toed ithromplywie suchpmvisiea a his hall be domed revokg
WATER SYSTEM/TREATING
WATER SERVICE
] z
UO
CONSTRU O. AG Y (/ii
Thereby affi nth turn' cy(erf
s Xm' eo
NEW RESIDENT4ll,PLMB.
O V
work for whi h e 3099. Civ.
ndv's Name
CL
CL
E h
�.)
adcr's Address
arts d m i ed h nd some the above w wvution is
ronect. l a,�a m romp with nd ory vry -nags and store laws relating m
building ronswetion.andhereby authorise soman ofthis city in enter upon the
gTITAL:I
QTy. MECHANICAL PERMIT
above-mentioned Pmpeny fm inspect apo".
(We) agree tO save. iv - mad kap hamdess ec City of Cupertino against
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
liabiliu<s,jodgmavu, rows penes whieb may in my way accroe against saW City
memors,aaceafthe ngofthis pwtt.
AIR HANDLING UNIT (TO 10,"FM)
APPLiCA, N TNDS D WILL COMPLY WITH ALL NON -POINT
SOUR
AIR HANDLING UNIT (OVER 10," CFM)
,/I19
/]MZARDOUS MATERIALS DISCLOSURE
RFSIDFNTIAI:
Will the apQ6 torfutua budding axvpant some or handlc Wasdmis material
ss defined by the Cupecom Municipal Cade. Chapter 9.12. and the Healdt and Safety
Cade, Section 35532(a)?
HEATING UNIT UD 110,000 BTI)
HEATING UNIT (OVER 100.000 BTU)
❑Yes ON.
VENTILATION FAN (SINGLE RESM)
OPLUMBINGRE-PIPE
Will the applicant of future building accupent use equipment or devices which
emit haradous aircanuminants as defined by the Bay Area Air Quality Management
Dison,
HOLLER-GDhIP (31dP OR 100,000 BTU)
BOILER-COMP(OVER 1W,"BTt)
OYes ONO
AIR CONDITIONER
I have rood the Intendants mmmids requirements orderChapter 695 tfthe Cali-
NEW RESIDENTIAL MECH. SQ. FT.
umu Hale &Gmy Code, abroas 25505, 25533 aro 25534,1 uMersmod dent it the
ca notify the occupant
building does nott mamendy have a tenant that it is my bounce
m
of the requireevu which most a: ren plot m bounceOf a Certificate of Occupancy.
of
OBATHREMODEUREPAIR ODEMOLITION
4 OFFICE
28598
SANITARY NO. APPLICATION SUBMITTAL DATE
D
NK CONIROLK
BUB -DING PERMIT BTO
ELECT PLUMB MECH
❑ ❑ ❑
FEE
JOB DESCRIPTION
RFSIDFNTIAI:
'
O SFDWL
O KHcHEN REMODEL
EJ ADDITION
OPLUMBINGRE-PIPE
EJ MULTI -UNIT
❑snucruRAL
El INTERIOR
`EDIFICATION
iMNEY REPAIR
IMPROVEMENT
OBATHREMODEUREPAIR ODEMOLITION
OOTHER
COMMERCIAL: -
11 NEW BLDGIADDMON O DEMOLITION
O TENANT OFOOD SERVICE
IMPROVEMENT
OOTHER
0Agp➢
tjOCT1819-
n..
FEE
BUILDING DIVISION FEES
PLANCRECK FEE
ENERGY FEE
GRADING FEE
SOBS FEE
Dam Receipt If
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAM
Date Receipt#