28460APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
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SANITARY NO.
APPLICATION SUBMITTAL DATE
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❑ Consultant Pees Paid by Applicant (Initial)
BL111.DING PERMIT INPO
BLDG E T� PLUM MECIL
LICENSED CONTRACIOR'S DECLARATION
affirm
I hereby am Nat I am licensed under provisions of Chapter 9 (commencing
with Section900fgnf Division Sof Ne B.1m, mdProfessions �od� liceremis
tn full force unJ �S �( rmy
HiQ I�
Licen Contr
Oem Contracmr
ARCHITECTS DECLARATION
I understand my plans shall be used as public recoNs
QTY IiLECT'RIC PERMIT PFEE'rYyL`
LOB DESCRIPTION
RESIDENTIAL.:
❑SPDWL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE-PIPE
[]MULTI-UNIT []STRUCTURALZ
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
Q BATH REMODEUREPAIR [I DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPhIANCI!S-RESIDIiNT1AL -
PANELS
UPT02MAMPS
Licensed Profe..leal
atI amam DECLARATION
1 hereby affirm Net 1 am exempt OWNER-BUILDER the Contractor's License law for the
following..at.fSeefion 703 1.5, Business and Professions Code: Any any mcoumy
which requires n permit m continua, aper, improve, demolish, m repxir'my stmcmm
priorto its issuance, also requbce the applicant forsuch perntu) filen signed smmmmtt
that he is licensed paroman1. the ptnvisions omrucmr's License Law (Chapter 9
(commencing with Section 9000)of Div" n3ofN usinessand PmfessionsCode)ar
Nat he is exempt Nerefmm and Ne cis for Ne all •eJ exemption. Any violation of
Section 90315 by any applicant apennitmbject cupplicamto.eivilpennityof
meamothanlivehundredJ .1,($50(8.
❑ Lasowncrofthepro y,ormyempinyeaswiNw rens Neirsolernmpenmti.m
wiIId.thvwmk, and s.uaurcismofintendedoreffe dforeale(Sec., RNG,Buslness
end Professions e: The Contractor's License Law not apply m m1 awner of
property wit 'dJs or improves thereon, aW who dnex uch work nowelf ser Ihmngh
his ow splayecs, provided that such improvements u not intended or offered for
set. I. however. the building or improvement is sold wit a meyearofoompletion, the
aw er-builder will have the burden of pmving that he did of build cr improve for pur-
an of sale.).
❑ caner of the properly. ata el ely contra" with licensed rontmemm m
con. met Ne pot t (Sec. sand Pro . cions e:) The Contramm's Li-
ce Law d«s p o rofpmpc whols.0 s marprovesthereon.and
who aroma fe, ch swith.cim Ks) licensed pursuant Contractor's
Lice aLow.
c
❑1 exempt.. er ,B&PC forthis lesson
201-IOMAMPS
OVER IOIXIAMPS
SIGNS ELECTRICAL
•IALCIRCUIT/MISC.
TER METER OR POLG INST,COMMERCIAL'
s
M
F.W BLDG/ADDITION�DEMOLITION
SANTFOwD SERVICE
I PkOVBM: qn
❑OTHER j7 d
0
(�
LV'� V
POWER DEVICES
SWIMMING POOL FLECTRIC
'LETS-SWITCHES-FlXTURR
NEW RESIBEI IAL ELECTR SQ I'I.
SQ. FT. FLOOR ARBAY'�yz1,
•jr 'l /
`�/
'
-
IVS FT.
3e/O+
T .
QTY PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER OW IN PRIG VENT )IWATER (RA)
BACK
BACK FLOW PROTECT. DEVICE
Owner Data
VALUATION
(�TVI�T Ii/'►/s
WORKER', OMPENSATION DI!CIARATION
- hereM1y affml unJ enulry of perjury one of the lollowing declarations:
❑ Lha and willmain aCenifcate ofConsenuo sel4insurc far Workers Compete
cation, mvided for y Section 3700 of the Labor Code, for the performance ofthe
VV,or ichthis rot '.
lavers wi min Worker mpensation Insurance, as required by Seatlan
39Wofthe la ode, for theperfmntnn •nl'the work far which this permit is issued
'My Wo mr,m ti Insurancecarrier dPoliTy n 1�
Cartier Ed, No.: (l
CERTIFICATE OF EXEMPTION WORKERS'
COMPENSATION INSURA E
(This section nse notbecomplen,difthepernitis B mehunJrcd Jollers($I110)
o IessJ
l cenifythxtin mperfnnnanceoOheworkfor whi Nis rmit is issoed,lehall
employ any pennn in any manner azl a. rbecome. so u 1 W rkers'Compcn-
nLnws of Cnlifomie. Dine
App ant
DRAINS- FLOOR, ROOF, AREA, COND.
STORIF-S
OCC. GROUP
TYPH CONSTRUCTION
APN
'
FIXTURES -PER TRAP
GAS-EA.SYS9'EM-1 INC. 0 OUT] ETS
GAS -EA. SYSTEM OVER IEA)
GREASPJINDUSTRL WASTE INTERCEPTOR
BUILDING, DIVISION FEES
GREASE )RAP
PLANCHECK PEE
ENERGY FEE
SEWER-SANITARY-STORM EA. 200 FT.
WATLk HI!ATER WNEN'I'/f3LECTk
GRADING FEE
NOU TO APPLICANT: IL afro this Qty t ate of E minion, you should
bjecsso the Worker's Cme, ti t0�m�1 of the -bar Code, you must
fnnhwith mply with such prava thi i shall he coed revoked.
O S' S�SII (�IDINGAGF CY
Thereby mant 'ietman'ce.309,Cing'ency far the performance of
the work for which is sued (Sec. 3099, Civ. .)
Lenders Numc is is
WATER SYSTEM?REATING
SOILS FEE[Z7
WATER SERVICE
PAID
Data Receipt
NEW RRSIDENTIAL PLMB. SQ. PT.
TOTAL:
Lenders Addmss16
1«nify tbm lhav read isapplicationan xnathat Nc ebnve informminnis
coma.l agrtemcomplyw all city end county Ninances and state laws relating to
building amstmetion. and her aurimixerepre mtativcs of this city to enter up.n the above-mentioned pmpeny farins etionpurpo s
(We)agree to save, inJemni dk harmless the City of Cupertino agram
costs and expenses which may in any way accrueugainst said City
consequence of the granting a his permit"s
DWILLC LY WITH ALL NON-POINT
S n t ctor Dat
aHAZARDOUS MATERIALS exac pa DISCLOSURE
Will
ythe Ctiaamt or furore Building«cupantsmre nr handle hvzardousmeterial
as de, Sec by 25 Cupertino Manic"pal Cade. Chapttt 9.12, end Ne Hca1N and Safety
Code, Section 15532(x)7
❑ Yee
Will the sic acuant oranni. rare building occby
nt use Buy Area Air Qualitmcna or y
,.sit ictzallom air contaminan efined by Ne Buy Area Air Quality Management
ant
Manages ement
DlmdaY
El Yes Nn
v<bad the h two alartuirenums, under Cha ter 6.95 ofthc Cali-
9 p
I, isHeal[gdoe S. od .« ms,,hani, 25 endnaibii 1sino1 dthat if Ne
b ilAing does no leen ly nanpthai my eponsibilitymnn ify Nc mcupant
'nheregoirel w N me 1 re e.l'a Cuxif duce s
E s�
ZSETSMIC�E
Cliabilides,judgmentc,
EES.
L PGP. ��AIR
QTY. MECHANICAL PERMIT FEE
P13RMITISSUANCG00
LTER OR ADD TO MECH.in
AIR HANDLING ON ITG 011,000 CI'M)
HANDLING UNIT(OVER IO,000CITa)
ION TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT TO IfN1,gX)BTU) -
p
'1
HEATING UNIT (OVER I00,1100 BTU)
PAID
D jt)Rccciptp
(�G TOTAL:
VEN'fILA'flfIN PAN (SINGLE RBSID)
BOILER- COME CHP OR I Wind BTU)
BOILER- COMP 100,000 BTU)
�.
��
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY.
NEW RF_SIDLNTIALMF:CH. SQ. FT.
raxthorixrn ag n
ate
L'i
OFFICE