28696 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY
CITY OF CUPERTINO IBUILDING-ELECTRICALPHRMITNO.
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL 28696
BUILDING PROJECT IDENTIFICA'11ON
ILDINGADI)RBSS: G � � SANITARY NO, APPLICATION SUBMITTAL DAT[
890 q
NHR SS NNIApMfF G PHONE.4.11 CONT ACfOR'g NAMC: W LICNO, • 1
/wNo GiO NIC CO/N/T1ROL
ARCHIq,Cf/ENGfNE.k: LICan PDD FSc, / AXeiLi f�, <p4 C1,71a ^��D ❑ ��(a
CONTACT: ,'g� 1 PHONE
/ 5��'Lf sJQ 1. y BUILDING PERMITVINPO
/� "36\�O QQ O ❑ Consultant Fees Paid by Applicant(IBlti _ _ _ BLDG- ELECT PLUMB MECH-
��LV YYY i44-JJJIIF"iiiUUU J 1 �. ;R, ❑ ❑ ❑
LICENSED CONI RACIOR'S DHCLARA'1'ION QTY ELECTRIC PERMIT FEE
1 hcmhy itfirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION.
Rd0Z with Section 70(10)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
4100 wt s PERMIT ISSUANCE
l!�JJ Li ein fitvsesClam rm and effect. Lic.p ❑SFDWL ❑KITCHEN REMODEL
560. Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RF.-PIPE
ARC HI'I'ECf:S DECLA RATION El MULTI-UNIT El STRUCTURAL
F) Z - PANELS
Z O'�',Z„ Ivndemmnd my plans shall he used as public records MODIFICATION
024— UPTO 201 AMPS
�. eased Professional [I INTERIOR [I CHIMNEY REPAIR
201-IOW AMPS IMPROVEMENT
f� ,..1I -
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEVREPAIR El DEMOLITION
pp,.tY W Q I hereby affcn that 1 ran exempt from the Contractors License Law for the s
pd O TY V fWl.wing reason.(Section 7031.5,Business and professions Code:Any city o1 county SIGNS ELECTRICAL ❑OTHER
Y
0 3watch riyuircs a pedow to construct.dor.improve,demolish,or repair any sauctare
^•4-• Q prior to its issuance,also acquires the applicant for such,ermino file aligned statement SPECIAL CIRCUIT'/MISC.
I� 2J that he is licensed pursuant to the provisions of the Containers License Low(Chapter 9 '
4 �GC0 (commencing with Section7M))of Division 3 of the Business and Professions Core)an TEMP.METER OR POLE INST.. COMMERCIAL:
a q c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X1 4• Semina]031.5 by any applicant for a permitsuajectsthe.,plic.....a civil penalty of 'POWER DEVICES
set - ❑TENANTOFOOD SERVICE,
not.,,as than live hvntlmd dollen(g500).
� < Lesownerof ane norm In cesm.ffer e.as their rale cam OTHER EM1iNT
E C ❑ ,rape y yemp y g pensation. SWIMMING POOL ELECTRIC /+
will de theliew, o the he comCrousnnti Liceez,Law
m,I,to an Business ❑OTHER —� `
and Pm6wlonn Code:The C.ntrnet.r's License Lnw does Trot apply m m owner.f OUTLETS-SWI'fCI1E5-FIXTURES
property who builds or improves thereon,and who does such work himself or through Of
his own employ.,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT SQ FT
sale.If,however,the building or improvement is sold within one yearofcomplece,the SQ.Ff.FhOORAREA LSQ.PT.
owner builder will have the burden of proving that he did not build or improve for put
pose of sale.). '
❑ h as owner of the propertyam exclusively contracting with licensed contractors to 034
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
seLaw does not apply toanowner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commetor(s)licensed pursuant tothe Contractor's
License Law. - I'I.RMH ISSUANCE -
❑I ran exempt under Sec. ,B&P C for this reaa.n
ALTER-DRAIN&VENT-WATER_ (EA) VALUATION
Owner TIODate ��
Wm under Penalty
DECLARATION RACK PLOW PROTECT.DEVICP.
I hereby off under penalty of perjury one of the following decimations: cro
❑Ihavc and will maimuinaCenificute nt Cnreanroself-Insure for Worker's Compcn- DRAINS-FLOOR,ROOF.AREA,GOND, STORIES TYPO CONSTRUCTIONesti..,m provided far by Section 3700 of the Ulaw Code,for the performance of the
work for which.his permit is issued. FIXTURES-PER TRAP
I have cad will mention Worker's Compensation lovemarm.us ruluircd by Section
37W of the Latin Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM.I INC.4 OUTLETS' OCC.GROUP APN
My Workers Compensation Insurance carrier mud Policy number are:
/Carrier: Policy No.: GAS-EA.SYSTId FOVER 4(EA)
CERTIFICATE OP EXEMPTION I7ROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTC INTINCEPTOR
[Thissuction need not hecompletW ifthe permit is forum foretell dollars(S W) BUILDING DIVISION FE1S
or less) GREASE I'kAP PLANCIIECK PER
lemifyshat in the performanceofthe work forwhicnthispermit ismmal.Ishall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manners.us to became suhj.t to the Workers'Car.,.- ENERGY FEE
,Z .anion Laws of California.Date
Z O Applicant
WATER HEATER W/VENT/ELECfIt GRADING FEE
ray NOTICE TO APPLICANT:If, for making this Cerrifcam of Exemption,you should WATER SYSTEM/PREATING
a became subject m the Workers Compemmian p.......as of the Labor Cada yna must SOILS FEE
4TJ
forthwith comply with such Provisions or this permit xholl be deemed revoked. WATER SERVICE
FL
5z CONSTRUCTION LENDING AGENCY NEW RESIDF.NTIALPLMB, SQ.FT. PAID
V O I for by whiffrhis Pe there issue (Sec.
00lending agency(ortae Performance of Dam ReceiptN the work for which this permit is issued(Sec.J09],Civ.CJ
O(-'' Lender's Name TOTAL:
Lender's Address TOTAL:
Os 1 certify that I have read this application and state that the above information is BUILDING FEE
In correct.I agree to comply with all city and county ordinances and state laws relit ing to QTY, MECHANICAL PERMIT PEE
V Z building construction,and hereby authorize representatives ofihis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)wy a to save,indemnify and keep bannless the City of Cupertino against PERMIT ISSUANCE - ELECIRIC ME
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in asequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CENT) MECfIANICA1.InGE
SOURCEREGUL S.
421611-t— AIRHANDLING UNIT(OVER 10,01111 CFM) CONSTRUCTIONTAX
i,rwwxof Apphr.wVComraetor Dam CXHAUST H00D(W/DUC'p HOUSING MITIGATI PCE
HA2ARD0 MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,01)BTU)
as defined by the Cu,enla0 Municipal Code,Cha,mn 9.12,and the Heahh and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER I00,"BTU) O
❑Yes E]No PAID
VENTILATION PAN(SINGLE RES ID) ^
Dar
Will the applicant or future building.cepa.[use equipment on devices which 41 Receip
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME DHP OR 100,000 BTU) wi,j tlur�
D
istrict? BOILER-COMP(OVER 100.000 BTU)
s E]No
read me hasrdoun materials mi,eirements under Chapter 6.95 of the Calm AIR CONDITIONER ISSUANCE DATE
&Safety Craft,Swouris 25515,25533 and 25534.1 t ndetsmtd tam if The NEW RISIDEN]'IAL MECH. S0.PT.
nm currently have a tcnazi that it is my responsibility to notify the mountain
ments which must he met priorto issuance ofa Certificate of0ecuponcy.horizedagcnt Date TOTAL: ISSUED BY:
OFFICE