28715 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28715 v O��Na�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATF
e�TEL, N ► v6-aS
W ER'SN ME: f�'E: D ONTRAC�OR'Sy MF' _ LIC NO:
6 a \
NIC CONTROLp
tCHITECDENGI EER: LICNO. ADDRESS: Vr ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD EL PLUMB MEC
LICENSED CONTRAC OR'S DECLARATION QTY. ELECTRIC PERMIT FEE _
1 hereby affirm Him Earn licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 71"BoI'Diviona Jofllm Bminemand Professions Code,nndmy license is RESIDENTIAL:
Fy�WF in fall functional effect. PERMIT ISSUANCE CSFDWI. ❑KITCHEN RGMODLL
6O�jU License Clans - Lic.k APPLIANCES—RESIDENTIAL �DITION El PLUMBING RE-PIPE
H¢0. Date Contractor
Iii,
ARC CmS DFCLARAO DMUI.11-UNIT STRUCTURAL nyplra 'ANELg
lA
vnutnM1liMODIFICATION
Z
so el U11T02oPAMPS �'�'IN'I'ERIOR •;0CHIMNF.Y REPAIR
F[/JF cense oras° 206111W AMI5 IMPROVE ENT
OWNER-BUILDER DECLARATION Cameron � OVER 1000AMPS DBATHREMODEIJREPAIR ODEMOLITION
Fa C mW Q I hereen.(Sect o nl 1 nm exempt from the Cameroon's Code:License Law for the _
LiyS W V following massa(Satins]onstr Puniness and Professions h,oAny city nr county SIGNS ELECTRICAL ❑OTHER _
u, LLO poor to I"' which requires a permit re mnmmm,autter.pplicant
improve.forsuch demolish m repair any structure _
thatheslicenedpursurrt no threse
thehovisicoarthe Contrator'sLicensle aeaw statement SPIiC1A1,CIRCUIT/MISC.
�{nyy poncomnciag licensedpursuantmlhcpmvisinnssftf Contractor's License Law(Chapter4
W COOtcat he
ixempth Sectinnorand of Divisions Infuse Business andon.Anyvi Code)or TIiMIt MHfI?R OR POLEINST. COMMERCIAL:
d tat n eG Nm he is exempt therefrom and the basis for one alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section to L56y hundred cantnsS50%nil suhjens Ne applicant to acivil penuHy of POWER DEVICES CIMPROV' CFGDD SERVICE
F. t mare then Eve cpropedmllan(SSW). IMPROVEMENT
SC DLasowner .the property, their sole SWIMMING POOL ECI'RID
will do fework,and the mmnurc istoimrnded Lawdofur sale ISec.o an Business ❑OTfiF:R
W ego end Professinns Cala 1Tc Cnmrenors Licenu law does not apply no an owner of OUTLETS—SWIT H flXTURES
property who builds or impruveo thereon,end who does mch work himself or through
his own employees,provide)that such improvements are not intended or offered for NEW RESIDE IAL - CPR SQ FT.
sale.14 however.the building orimprovensmis soltl within one year of completion,the SQ.IT.FLOOR AREA $/SQ.FF'.
moa,-bm1der will have the burden of proving that he did not build or imp rore fur Ent,
pore"Earle.). La` taeJF;
1,as uw are,of the property, it,exclusively comiactiog with licensed contractors no
construct the project(Sec.7IW4,Business and Professions Code:)The Contractor's Li-
cense
i-c se law Jess not apply to an ownerofproperty who builds or improves thereon,and QTY. PLUMBINGP IT FEE
who contracts for such projects with a eonrucionto licensed pursuant m the Commalorn
License Law. 1'IiRMI'1'ISSUANCE
❑Monte 'n tun la Sec. ,B&P 1'nr this ramnn _
ACIER—DRAIN&VENT—WATER(BA) VALUATION
WORK r S—WMItINSATION DECLARATION HACK FLOW Pltorrr T,DEVICE
I hereby n0irm under penalty of perjury one ofthe following decimations:
I have and will maintain a Certificate of Consent to xelrinsure far Worker's Compete DRAINS—PLOOR,ROOF.AREA,C D.' STORIES TYPE CONSTRUCTION
option,as provided for by Section 3700 of the Lihor Cale,for the performance of the
work for which this permit is issFIXTURES—PER P
D ued I have and will maintain Worker's Compcnmtion Insurance,as required by Section
3]W ofthe Labor Code,for the Performance ofthe work for which this permit is ismed, GAS—EA.SYSTEM-11 4 U us OCC.GROUP APN
My Workers Compensation Insurance artier and Policy number are: -
Carrier: Policy Na: CAS—P 1.SYSTEM-OV Rot
CERTIFICATED[:EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASCIINOUSTRL WASTE INTERC
(This section need not Is,completed Hthe permit is formic hundred dollars(SIM) BUILDING DIVISION FEES
or less) GRI!SETRAP PLANCHECK FEE
I cenify Nal in the perfomtunecsf the work for which this permit is issued,I shall SEWER—SANITARY—STORM EA.2W FI.
'nm employ any person in any manner m as m become subject to the Workeno Compen- ENERGY FEE
O Z nation Lows of California.Date WAITR HEATER WNENT/ELECfR
Z Applicant- GRADING FEE
y
NOTICE PIT APPLICANP.If,after making this Certificate of Excitation,you should WATER SYSTEMITREATING
abecome subject to the Workers Compensation provisions of the Laln+r Code,you must SOH_S Flili
Lkl forthwith comply with such provision or this permit shall he deemed revoked. WATER SERVICE
CONSTR ULTIONLF.NDINO AGENCY NIiW ItESIUF.NT1ALl'LMH. SQ.FT. PAID
W O wI hereby fnn hat there iaa ccinn lending agency for the performance of Dem Benefit of
the k for which this turnout is issued(Sol,3097,
Civ.CJ
0 Lender's Name - TOTAL:
LULenders Address TOTAL: '
ly�t I certify that I havo read Ibis applicationand store that the above information is - BUILDING ITE
it 11/1 correct 1 agree to comply with all city and county ordinances and state laws relating to UT.Y. MECHANICAL PERMIT FEE
V z building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above mentioned property,for inspection purposes. PI:RM11'ISSUANCE
(We)agree m.wvc.Indemnify and keep harmlem the City of Criterion agvinsn ELECTRIC FEE
liabilinicajudgments.costs and expenses which may in any way secure against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT UNDER.TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOUR( n SGULATI .'S. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
'Refiatiffit mAppianJ(.md1 nr Date EXHAUST HOOI)(W)DUCT)
HAZARDOUS MATE-RIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material IIMA'1'ING UNIT(TO loop"BTU)
m defined by the Cupertino Municipal Code,Output,9.12,and the H.1th end Safety 1 ,_
Cade,Sating 25532m)? HEATING UNIT(OVER 100.000 BTU)
E3 Y's FI No VENTILATION FAN(SINGLE RESIDE PAID
eipl a
Will the applicant or future building occupant use equipment or devices which BOILER (3HP OR IIXI,IXXI BTU) ' as
til hazardmao air commorems us defined by the Bay Area Air Quality Management A
)iurlat? - LSV'.
F1 Yet E]No BOILER—COM 11(OVER 100,001)BTU) t 4utti
C1{l. l
I have mud the mount.uo mmerimisrequlrementx no der Chapter 6.95 of the Coli- AIR CONDI'1'IONER ISSUANCE DATE
maim Health&Solely Code,Sections 25505,25533 and 25534.I mndemm�d that If the NEW RhSIDENTIAI.MECH. r SQ.FT.
building does not curten0y hnvcamnunt,that it is arty responsbility ito notify We acupmn, -
o[there uiremenuwhlch mon he ma prinna ivuunce afaC rtifcateal Oeeupuney.,
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE