28726 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL,POINT PEN ONLY
CITY OF CUPERTINO BUILUING-ELRCTRICAL PERMIT NO..w
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. 28
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
19 L I Z a�NA(]�){[� , 3 a S5
OW 'S E Q CONTRACTOR'S ME: LIC NO: -
���� N/C CON11101,p
AKUBJECT/ENGINEER: LIC NO: ADOIESSS: F-11 6V
CONTACT: PHGNE: BUILDING PERMIT INFO
P�1 t 6- 336 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�(� ❑ ❑
LICENSED CONTRACTOR DECLARATION 11 QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
2 with Sation]OIXpof Division3of Ne Business and Professions Cudc,and mylicense is -
O in full force t PERMIT ISSUANCE
k.
our License Class e tt LSS Lic p S I ❑KITCHEN REMODEL
NQ Dvm Contnsmr W APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F.�an CH FACTS DECLARATION PANI:IS - ❑MULThUNIT ❑STRUCTURAL
OZ PJ'^ i understand my plain shall tin used As public records MODIFICATION
:1 UP 9n 300 AMPS ❑INTERIOR ❑CHIMNEY REPAIR.
g�g0 Licensed Profeauonal 101-1000AMPS IMPROVEMENT
�Y Oot I A.exempt
DECLARATION OVER PROAMPS ❑BATH REMODE PAIR DEMO IT ON
O 1 hereby.(firm Nat 1 1. exempt from dhe Gmaumoo License Low for the
3 d UF. following reason.(Section 7031.5.Business and Profusions Calc:Any city m county SIGNS ELECTRICAL ❑OTHER
Cyawhich requires a permit to conswet.obe,improve.demolish,or repair any sweture
�N.-1 prior er ids isauantt.also reyvires the applicant lnr sucM1 permit to fileesigncd stammcnt SPECIAL CIRCUIVMISC.
that he is licensed pursuant to the provisions of the Commcmr'c license LAW(Chapter 9
�y<0 (commencing wiNSection 1.1 or or the Business and Pofessium Code)m COMMFR IAIe
p O TEMP.METER OR PDLE IN5T. ��
d p,M q
that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
tired uy'
Section]OJ LS by any applicen[foru permit subjects the applic.m roacivil penalty of POWER DEVICES
Z yt mote Nan five hundred dollars(55(10). ❑TENANT ❑FOOD SERVICE
< 01,as ownerof the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
O will do the work.and the stmetum)s not intended or on'cred forsale(Sec.7044,Business ER
end Rofesximw Cafe:The Contmena a License LAW doss not Apply m Ad owner of OUTLETS-SWITCHES-FIXTURFS
properly who builds m imposes thereon,and who does such work himself or though
his own employees,provided Nat such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ Fr.
sale.If.however.the building or improvement is sold within one year of completion,the SQ.Ff.FLOOR AREA r/SQ,pT.
owner-builder will have the burden of proving that he did not build or improve for pun
pow o(m1eJ.
❑I,as owner of the property,am exclusively contracting with licensed aintmetom to TOTAL: -
rotmoct Ne rioter(Sec.7044,Business And Professions Cade:)The Contocmrs Li-
cense Law doss not apply to an owner of property,who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who ecramets far such pmjccts wIN a emamerm(s)licensed ismomattu the Conunetoes
License LAW. PERMIT ISSUANCE '
I Am exempt under Sec. ,B&P C for this reason
OwnttDine ALTER-DRAIN&VENT-WATER(EA)
VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
IhembY affirm under Penalty of Penury one or the following declarations: '
❑on,as provid l for by
a tion 37M oft a Labor Code,sure Ter Workers ce of the
DRAINS-FLOOR,ROOF,AREA,COND.
action,as povidW for by Section 3]00 of the labor Code,for the performancc of Ne STORIES _ TYPECONSTRUCTION
work which this permit is issued. Fl%TURES-PER TRAP p t
have and will maibain Workers Compensation Insurance.us required by Smtion
37M of the labor Code.Srtthe performance of the work barrmw�hiichh sass met is issued. GAS-EA.SYSTEM-I INC.4 OUTLETSMy OCC.GROUPp s/� APN
Cower
rompers ion los cc carrier and Policy NoY nU"rf"n z} ��8� GAS-F.A:SYS'1'EM-OVF,R4(F.A7, NOV wj IJ
C.RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINIIUSTRL WASTE INTERCEPTOR
(]Tissemion need not be completed ifdhc permit is far one hundred dollars($Rq) U I [�xVI$IQEf-EF,S
or IessJ GREASETRAP PLANCHECK FEE
Icenify Chat.the per(omuncaofNe stork for which Nis tpeornit he Worker,'
employ ofCnrson Tare anner sn as obecfyn uject m the Workers'Campen- SEWER-SANITARY-STORM EA.200 FL ENERGY FEE
Z Applicant sof Califon' .1 me R -f V WATER HEATER WNENT/ELECUZ
GRADING FEE
y NOTICE bj APPL CANT:IL after making this Certificate Exemption,you should WATER SYSTEM/IRfiATING
a �
become subject to the Worker's Comisor thispaovdoaao e,denied Labor
vokCode,you most SOILS PEE
� foMwiN comply with such provisions or this pemut shell be deemed revoked.- WATER SERVICE IN
0
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT, PAID
V I hereby affirm Out there is a construction lending agency for the prommance of _Dem ci
V. Fthe work for which this permit is issued(Sec,3097,Civ.C.)
Lender's Name
Landle,Address TOTAL: f TOTALxo* :
L I certify Nat I have read this Application and state Out the above information is BUILDING FEE
N
correct,IAgree to comply with all city And county ordinances and state laws relating to QTy. MECHANICAL PERMIT
U building construction,and hereby authorize representatives of this city to"arms).the FEE SEISMICFEE
above-mentioned pmpeny for inspection purposes.
(We)Alma do s.ve,indemnify and keep harmless the City of Cuperinoagainst PERMIT ISSUANCE ELECTRIC FEE
.abilities,judgments,costs and expenses which may in anyway ameme against said City ALTER ORADDTO MECH.
in consequence of Ne standing of Nrecruit.is pit. PLUMBING FEE r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GG to."CFM)
SOURCE REGULATIONS. MECHANICALE
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
HAZARDOUS
Signawrc of ApplicaR Dam EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE
HAZARDOO US MATERIALS DISCLOSURE
' Willy to Curemnofumreipal Code,ng hanumrc2,handle Health
oand Safety HEATING UNIT ff0IW,000 BTU)
C defined io the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
Coda,5eml ea 23332(n7? HEATING UNIT(OVER 1 ,0k)BTU)
❑Yes []No VENTILATION FAN(SINGLE RMID) PAID
Will Neu imam or future huildin ttv m use a Dam Rccmpt p
pp gn a quipneuality Management
BOILER-COMP
District? dour air conuminents as Defined by are Bay Arta Air Quality Management (3HPOR IOO,fM)O BTU)
District? TOTAL:
❑Yee ❑No BOILER-COMP(OVER 100.000 BTU)
I have rod the hazvdovs mamdals AIR CONDITIONER ISSUANCE DATE.
mg25533 an.Mer Chapter 6.95d t at C.Ii-
fomu Health&Safety Cale,Seniors 25505,25533 and 35534.1 urrdersmnd Nat if the. NEW RESIDENTIAL MECH. SQ.Ff.
building s not currently have.mount,Nut it is my responsibility m nodfy Neoccupont
ofthe mine vhichms emelpdg oismancenf.cerufic.r 7 �,/�•y� / g
f O .7 / V /(�.
rte or authorized eSem Date/ TOTAL: r.
ISSUE l
OFFICE