28626APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAI
�✓� I �J 1�ONi ZS'7.�050�{ I ❑ Consultant Fees Paid by Applicant (Initial)
_ pe z 1 hereby of irm Nat 1 am liansal ender povisions of Chapatti 9 (commencing
O O withSmtion]f1110)of sionJofthe Business end Professions Code, and my liciomeis
a in full force and effect.
6 V U Liceree Class Lic, a
QL Date Comra for
1-zly o>n 1 ARCHITECTS DECLARATION
O Z YI ❑ understand my plans shell be used us public wropix
S� t Licensed Professional
N( OWNER - BUILDER DECLARATION
�y1 1 hereby of inn Nat 1 am exempt from the Contractors Lieonee Law far the
3 G {V. following room, (Section 711111, Bushes, and Pmr ,Ions Cale: Any city m mommy
O } which requires a Permit to construct, she,, improve, demolish, or repair any mmcome
...777 prior m it, issuance, also requires the applicant forsook p mob no file asignedwatemem
S } that heishemand pursuanuo Neprovisionx dthe Cmamcrwx License Law(Chapta9
(commencing with Seclam 7") of DivisionJofthe Bminessand Pmfesmoas Code)or
W y o � that he is exempt therefrom anti the basis for the alleged exemption. Any violatian of
i� no Section] 031.5 by any applicant fora permit subjects Ile applicant o a civil penalty of
F Z ;s. eras more than five hundred dollars ($511(8.
i 60 E] I, as owner of the property, or any employees with wages us their sole compensation,
v R do the work, and the moisture Is not inlanded nrnffe ed ba mle(Sec. 7044, Business
and Prow,mom Cade: The Contractor's License Taw does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided Nat such improvements are nut intended or offered far
sale. IL however, the building or improvement is mild within one year of complains, the
owner- hadder will have the burden of proving that he did not build or improve for par -
pose of sole.).
❑ 1, as owner of the property, am exclusively contracting with licensed convocmrs to
examined the Former (Sin. 7044, Business and Professions CmdeJ The Commences veraw QTY,
who contracts for such pruiects with a contractors) licensed pursuant o the Contmaars
License law. '
❑ I inn exempt under Sec. ,B& 1' C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRmr under peered t, of perjury one of We following dedamtiom.
I have and will maintain a Cent ficam of Consent o sel4lnsure for Worker's Camper.
sation, its provided for by Section 3700 of the Labor Cale, for the perronn erne d the
work for which this permit is issued,
❑ 1 have and will maintain Workers Compensation Insurance, u required by Section
37W of the tabor Cale. for the performance of the work for which this Permit is is.wed,
My WorkEr.'.g �agytygyglinn}p inn rtler and PUlicylminheram:
3l7ifC CFII
Carrier: OW Polley No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE:
(This second need not be completed ifthe permit is forth hundred dollars ($ IINB
or leas)
I certify but in the performance fthe work for which this pemdt is ismod. I shall
not employ any Person in any manner so as to become suhjuno the Workers' Compen-
O z sari.. Laws of Califam_ ti. Date
O
Applicant
y NOTICE TO APPLICANT: IL after making this Cri ifiwre of Exemption, you should
a ; become subject to the Worker's Compensation provisions of the labor Cale. you must
forthwith comply with such provisions or this permit. ball bo deemed revoked.
5 Z CONSTRUCTION
verrilNG AGENCY
L)Q l far whilHmn pane i isand(Sec. 3097, ding agency for0te Performance of
0 r+ Newark fur which this permit is issued (Sec. J(19], Civ. C.7
O LJ Lender's Name
ikI Lender's AAJfess
py 1 certify that I have mad this application and stain that the above information is
h corten. I agree at comply with all coy and county ordinances ox this state laws relating a QTY.
building conservation, famand hereby tuNonureprcsentativcs ofthis city menrer upon the
s.
above-mentioned (urbanity an keep ho
(We) agree to cave, a urbanity and keep keyless the City of Cupertino against
inconsequent ofinecos¢amdof this 'which may in any way acme against said City
.sequence of me granting of this permit.
APPLICANT tNDERSTANDS AND WILL COMPLY WITH ALL VON{ {'DINT
S RCE R
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle harardoos material
az defined by the Cupertino Municipal Cade. Chapter 9. 12, and five Health and Safety
Code, Section 25532(u)? '
❑Yes Fl No
Will the applicant or future building occupant use equipment or di which
�:mit hourph us air commitments as defined by the Bay Awn Air Quality Management
District?
"I 7w, 1] No
1 have read the hmaNaus materials emparemems under Chapter 6,95 of the Cali -
femia Health & Safety Cale, Sections 25505, 25533 and 25534. 1 understand that if the
building dies not comon ly haven tenant, that it is at, revparm ility m unity the occupant
of the reyutrcmems which must be mn prior to issuance of a Cedificam of Occupancy.
V4
ELECTRIC PERMIT I FEE
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPTO 2110 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
SQ IT.
FEE
PERMIT ISSUANCE
ALTER — DRAIN & VENT —
BACK FLOW PROTECL DI
FIXTURES— PERTRAP T
GAS — EA. SYSTEM'I INC. 4 OUTLLTIS
GAS — EA. SYSTEM -OVER 4(EA)
GREASEANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER — SANITARY— STORM EA. 200 FT.
WATER HEATER WN HNT /ELECTR
WATER SYSTEMGRRATING
WATER SERVICE.
NI ?W RESIDENTIAL PLMH. SQ. FT.
MECHANICAL PERMIT PER
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (I4.) lojigil CFM)
AIR HANDLING UNIT (OVER IBM) CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER IIRLBBO BTU)
VENTILATION FAN (SINGLE, RESID)
BOILER —COMP (JHP OR 1 00,000 BTU)
BOILER — COMP (OVER 100,000BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH, SQ, PT.
OFFICE
JOB DESCRIPTION
28626
SANITARY NO.
APPLICATION SUBMITTAL DATE
R —1 LA
N/C
CONTROL N
BUILDING PERMIT INFO
BLDG
ELECT PLUMB ME IT
-f!q•
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
-
❑ KITCHEN REMODEL.
DITION
11 PLUMBING RH -PIPE
LTI.UNIT
El STRUCTURAL
SOILS FEE
a
MODIFICATION'
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
T0TAL:
❑ BATH REMODEUREPAIR El DEMOLITION
❑ OTHER
SEISMICFEE
COMMERCIAL
❑NEWBLDG /ADDITION ❑DEMOLITION
C3 TENANT C1 FOOD SERVICE
IMPROVEMENT
❑ OTHER
0
SQ, FT. FLOOR AREA
�� 1
MAR 121996
�*XU
PLANCHECK BEE
ENERGY FEE
GRADING FEE? 1
��
SOILS FEE
a
PAID
Data ipt N
T0TAL:
BUILDING FEE? �,
SEISMICFEE
ELECTRIC FF
I
PLUMBING
MECHANICAL FE
CONSTRUCIO AX
HOUSING MITI N FEE
PAID
Dam R. t M
TRIAL:
ISSUANCE DATE