28730 APPLICANTTO FILL IN INFORMATION WITHIN REO.LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'BUILDING-ELECTRICAL - I� PERMTTNO. ^ O
BUILDING DIVISION, APPLICATION/PERMIT PLUMBING-.MECHANICAL L
BUILDING PROJINTC IDENTIFICATION '
BUILDINGADDRESS: - SANITARY NO. - APPLICATION SUBMI'TPAL DA
Ss sl.0 ti` o/+K X10
" OWNE 'SNAME: PHONE. - C.O.N1TRACTOR:S A -L LIC NO:',.
f ft� S.. W _U-�{'Li 3d Svl .. NIC ;.CONTROL#
ARCHITECT/ENGINEER: LIC NO: • ADDRESS: .' ❑ f
/ GO G S T9S/l r
CONTACT • - PHONE: _BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) 'BLDG ELECT- PLUMB MECH
.: - LICIiNSEDCON'FRACI'OR'S DECLARATION QTY ELECTRIC PERM IT FEE
I hereby affirm that I son lie enttd under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Seminn]tN1(1)oTDivision3of the Business and l'rofexsions Csde and my license is RESIDENTIALr
00 in full force enA effect. - -,b
PERMITISSUANCE
-U' License Cl C' t" CS'f Lic.# JD �d� - ❑SPDWI. TCfIT:N RT:MOUEI.
y-el'Z.a Oma s Can incutr APPLIANCES-RESIDENTIAL []ADDITION RING RE-PIPE
lFn..� ARCHITECTS DECLARATION PANELS
- ❑MULTI-UNIT' ' STRUCTURAL,
Z py ZF I uneersmnd my plane shall he used as puhlic recoNs MODIFICATION
UP TO 200 AMPS
O Z L G • ❑INTHRIOR I ❑CHIMNEY REPAIR
0.'iU Licensed Professional - 201-1000AMPS IMPROVEMENT
OWNER-BU
K •1 ILDER UECLANAHON a
Q 1 hereby affirm that 1 am exempt
0. from the Contractor's License Law for the OVER 1000AMPS ❑PATH REMODF.IIRFPAIR ❑DEMOLITION s
u13U following reason.(Section]031.5,Business and Professions Code:Any city or county .� SIAS ELECTRICAL 1" ❑OTHER
Y.ped which rage res a permit t construct,r h p demolish,mr,c, y ormeame
poor to its issuance,also requires the ppl t for suchpc to File a signed statement SPECIAL CIRCUTUMISC.
�j therh I Jp mit tl p Rh C t .to,',l ,a jCh pt -9 s
CyyX00a (commencing with Section7000) fD"' l tune Businessand Profe nsCole)u TEMP METER OR POLE INST.' COMMERCIAL: J
e W that h s exempt thecfr n 1 the h f the alleged exemption.Any v la t n f ❑NEW BLDG/ADDITION ❑DEMOLITION
Sectors 7031.5 bapplicant f peapplicant to a ervil Penalty of POWER Dt subjects the EV ICI?S -r
y y ❑TENANT El SERVICE
'Z not more than f� hundred dollars . -
�C ❑1,es ownefthe properly,or myy ara,temployees with wages vth
s eir solccompenmtinn, SWIMMING POOL IILECI'NIC- j IMPROVEMENT
rofl
p� willdo the work,and the structure is not intended or offered foraale(Sec.]014,Business ❑ TH R
C] and Professions Cade:The Contractors License Low does not apply to an owner of OUTLET'S-SWITCHES-FIXTURES
property who builds or improves the...and who does such work himself or through If
his own employees provided that such haprovernents am not intended or offered for NEW RESIDENTIAL ELECfR SQ FT - `
Ie.If, c .Ne building anmprovemct is sold within one year of completion.the . , SQ.FT. LOOR All EA, $ISQ.FT
owner houlde,will have orm burden f proviii,tit,he did r build or improve for put
E)1,as owner of Ne property. exclusively t i g with licenud contractors to TOTAL: -
A
construct lie Project 1,5c,1044 Faminessand P finsions CmIv 1 The Commerce.,L-
cense law docs not apply to an oss netof property w Im builds of improves thereon and Q'rY PLUMBING PERMIT FF,P. - YlaP
who cuntmcts for such proJeds with a comranor(9 licensed punuarn la the Contractors 4P
Licemclxw. PERMIT ISSUANCE . `m
❑I am exempt under Sec. ,B&P C humus reason. ,
Data ALTER-DRAIN&VENT-WATER BEA) VALUATION L'
Owner WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE Ler-h
I hereby affirm u d Penalty f Perjury must following dadat'
V
. and will maintain aC ofConsant ofirrWorkersCom,pa, DRAINS-FLOOR,ROOF AREA CORD. s STORIES TYPPCON..
STRUCfI01
some,as provided for by Scci m 3700 mlhe CubrCodq,I. 11he domenamo of 0a
work fee
have
this maintain
issued. FIXTURES'-PER TRAP
❑ I have and will ode,for Workers ante of the w firwanrkfor re,h required by Section
' JIOO of the Labor Code,for the performance of the work for which this permit is issued. GAS-I?A.SYSTEM-I INC.40U'1'LETS _
My Worker' Compensatiop lnsur�areareriermal Pdmyny�"hcr art: - - - OCC.GROUP AI'N
Carrier: tsie[3�" Policy No::("C 9VZ//5 : GAS-NA.SVS'fEM-OVF.NY(F.A1
{'CERTIFICATE OF EXEMPTION FROM WORKERS' -
•' COMPENSATION INSURANCE ' GREASf%INDUSTRh WASTE INTERCEPTOR -
(Thisseelicamednm bcrom,leteJ iftmit heperisforanehondncddoEars($l(xu - ,+ BUILDING DIVISION FRES
orless.) GREASE TRAP v PLANCHECK FEE
I certify that in the performance ofthe wmk for which this Perini(is issued,I shall SEWER-SANITARY-STORM HA.2011 FT
�, emion employ
sany Person"in any
�manner Yl bec�g(e yubjer,m the Wnrkeii Compen- - ENERGY FEE "
00 APPhcam �BILCX%r-C -A-ar YYL 1' WAI HR 11EATERW/VENT/HLEC'1'R s- i GRADING FEE
Uj NOTICG I�PLICANT:If,after making this Certifmme of Exempiton,you should WATER SYSTEMTREATING
ya 5 become subject to the Worker's Compensation provisions d the Labor Code,you most - SOILS FEE r
Wn..�
forthasultaorn,l,withsuch ra,mosmthis peroul,hll be rammed reked WATER SERVICE ,
a
CONSTRUCTION LENDINGAGENCY NEW RISIDENTIAI.PLMiI. SQ.FT. PAID
U O work far
ewhichtmthnh is...d Scchomlend'ng agency for the performance of , _ Data Recciprp
. 0L * Leader's
which(his permit is issued(Sec.3fWl,Civ.CJ r..
,
U Lender's Name ✓- - _, TOTAL:
Lender's Address - j s' 'AL:
1 certify that l have mad this application and stere that the aitove information is BUILDING FEE "
.IrI cartel.I agree m Comply w taan
t all city and armory ordinances d walela laws rcluting QTY, MECHANICAL PERMIT TEF,
U building conemallin,and hereby authorise representatives of this city to enrtruppm the SEISMIC FEE
above-mcmioned property for inspection purposes. -
(We)agree to save,indemnity and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs andexpenses which may in any way secure against said City ALTER OR ADD IO MECH.
in ousequence ofrhe granting ofthis permit. PLUMB ING FEE, 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITT)10.000 CFM)
SOURCE RF /i��AThONS. MECHANICAL FEE'
/J.l•-f--•s ',� el/96 AIR HANDLING UNIT(OVER III,1XIp CIiN) CONSTRUCTIONTAX
F namre•ooff Apprppllicaant/CCoonnrmcm ]late r. 1 aEXHAUST b10OD(W/DUCT) HOUSING MITIGATION FEE '
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcvni orfumre huddingoccupum suite or handle huamdous material HEATING UNIT TO 1(10,0(10 BTU)
as defined by the Cupertino Municipal Crede.Chapter 9.12,and the Health and Safety
Code,Swdnn25532(ap . ' HEATING UNIT(OVER 00.000BTU)
[I Yes ❑No; .t. - -
VENTILATIONPAN(SINOLERFSIp) - PAID
Data ReceiptIt "
WJr rhe apps cam r hulloing by the Br use equipment(r deuces which BOILER'COMP(114P Oil 100,000 BTU)emit numerous err contaminants_.defined by the Bay Area At Quality Management
District? TOTAL:
❑Yes No BOILER-COMP(OVER 103,000BTU)
I hoe read rhe haiuNoos materials requirements under Chaptei 695 itl the Culi- AIR CONDITIONER - - - ISSUANCE DATE.
forttie Health&Safety Code.Sections M505,25533 vest 255W.1 understand that if(he NEW RESIDENTIAL MECH. SQ.FT '
building does not cumntlyhave a mount,that it is my responsibility to notify the occupant
of Ne teyvirements which must be met prior to issuance of a Cevificam of Occupancy.
Ownerorandismiatd a gent Date - - "' TOTAL: ISSUED BY:
OFFICE `