28812 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP C()PERTINO - '� BUILDING-El ECTNICAI. PERMIT NO. ^^ ^ 1
BUILDINGDIV[SION APPLICATION/PERMIT PLUMBING.MECIIANICA1 LIX/YV L
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRP.SS: 41111 SANITARY NO. APPLICA'T'ION SUBMI DATE
OW R'S yAME' )NE: CONTRACT 'S NAME: LIC NO',
iTar .yo mea 985=6000tuner NIC CONTROLp
ARCHETE(TEANGINEER: LIC NO: ADDRESS:
CONTAcc (/_7 PHONE: - BUILDING PERMIT INFO
6 e Coo Br ye qSs-60 61 CBBSUIIanI pass;Paid by Applicant(Initial) BLDG' ELECT PLUMB MECH
k A % I
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
a2 wirh$eQioo]HW)of Division3 of the Bpsinessand Prefessions Ctaie,ad nmy license is
in full farce and effect PERMIT ISSUANCE Rol EMDAL
aU�
QUZt� License ClassCoSFDWL C KITCHEN REMODEL
nn APPLIANCES-RESIDENTIAL
�Qp Date
Connector []ADDITION El PLUMBING RE-PIPE
(F.. ARCHITECT'S DECLARATION [I MULTI-UNIT ❑STRUCTURAL
Z p Z 1 understand m lana shall be used as blit records PANELS
Y P Pu MODIFICATION
OZ—, UPT020f1AMPS El INTERIOR ❑CHIMNEY REPAIR
Licensed PrafessmnW 2111-1f0HAMPS IMPROVEMENT
Oat am exempt BUILDERDECLARATIONContrION
y 1 hereby affirm the I nm exempt Item the Cnmrnmor's License law for the OVER IODOAMPS ❑BATH REMODEI/REPAIR �DEMOLITION
yq 3 L F (allowing reason.(Section 7071.5,Business and Professions Cade:Any city or nnmY SIGNS ELECTRICAL C OTHER
fs� li which teal v permit to construct,vlter,improve,demolish or repair any swnum
ray
prior it)in Issuance,also papdres the applicant for such permit a rile a signed statement SPECIAL CIRCUIT ISC.
Y that he is licensed pursuant o the previsions of the Communities License Law(Chapter 9
(commencing with Section 7000)of Division 3 ofthe Business and Professions code)or TEMP.MUM OR POLE INST COMMERCIAL'
IE E K thal he is exempt ro mfrom and rhe basis fnr the alleged exemption.Any vmliumn of C NEW BLDG/ADDITION C DEMOLITION
YY.•
ZZ� Section 7031.1 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES CTENAM' CFOOD SERVICE
, not more than rive hundred dollars(S50B,
�Cq O I•as owner orthe progeny,nr my employees with wages as Their sole compensminn, SWIMMING POOL ELECTRIC IMPROVEMENT
will do Ne work,and the structure is not intended or offered foraale(Sec.7044,Business COTHER
3 and Pmfeed-ma Code:The Convector's License Low does ma apply m an owner of OUTLETS-SWITCHES-FIX'HURES
Q' Property who builds or improves thereon,end who does such work himself ar Ihroagh
his own employees,provided that such improvements ore not intended or offered for NEW RESIDEMIAL ELECTR SQ FT.
sale.IL however,the building or improvement is sold within one year ofeompletion,the SQ.FT.FLOOR AREA S/ML IT.
owner-builder will have the burden of proving that he did not build or impnrvc for par. KT//
pose of sale.). O( U
1,ruowner ofthe pmm
property.am exclusively contracting with licensed oontmi.contractors Q 7
construct the project(Su.7044,Business and Professioonss Code:) nt
e:)The Comnor'v Li.
cense Law does not apply to an owner of progeny who builds or improves thereon,and TY PLUMBING PERMIT FEE
who contracts for such projects with a emanations)licenmd pursuant to the Committers
License Law, PERMIT ISSUANCE
❑ I ma exempt under Sec. ,H&PC for this mason
Owner Date -
ALTER-DRAIN&VENT-WATER IEA) Q/4 VALUATION
�. -/• /J 6 0 3e
'WORKER'S COMPENSATION DECLARATION PACK FLOW PROTECT.DEVICE.
I hereby.Runt under Certificate
enahy oeperjuryaneofthe fnlbwing Worker Cr
Clhave and will for
me Com 37UI of Cmvem to selCode,for Obe Wforma Crupper. DRAINS-FhOOIt,ROOP,AREA,GOND, STORIES TYPE CONSTRUCTION
sortion.as provided for by Section d, of the Labor Code,for the performance of the -
El I for which this permit is issued. FlXTURTS-PER TRAP
1 have and will maintain Workers Compensation Insurance,at his Iscri by Section
MWoMheVedrCWaningthe
suranceperformance r and Policy
forwhichthis permit is issued GAS-EA.SYSTEM IINC.4OUTLETS
OCC.GROUP AM
Ch Worker's Compensation Insurance carrier Policy number art: i
Cartier. Policy No.: GAS-EA.SYS'TP.MOVER4(PA)
CERTIFICATE OF COMPENSATION
INSURANCE
N#ROM WORKERS'
COMPENSATIONIN513R is for GRLASFIINDUSTRL WASTE INTERCEPTOR BUILDINGDIVISION FEES
(This section need not becnmpleted ifthe permit i..fortune hundred dollars(SIOp) GREASETRAP i
or less) PLA F. E �(J
Toy any fastperson
performance astobekfnr subjectch i.due li,is Workers
okes ed CanapesI shall.
SEWER-5NITARY-STORM FA.2(0 FI'. qq
not employ any person in any manner so as to become subject m she Work<r%Cmmpen- TA FENEER4 GYFEE
0Z sedan laws of California.Date
0 Applicant WATER HEATER W/VENT/FiLECfR GRADING FEE
rz n(Il1/u
P.
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMfH1EATING
P become subject the Workers CompensationaMn e
provisions of Ne LCo ,you must, g'ITS FEE
Wforthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION AGENCY NEW RCSIDENI'IAI.PLMB. SQ.IT. PAID
UD Thereby affirm that theree isix.nmswdinn boding agency for the performance of Dole Receipt is
W !tet the work for which this Permit is issued(Sec.3097•Cie C.)
0 V Lenders Name TOTAL:
Lender's Address TOTAL: /
ow certify that 1 have mad this application and state that the above information is BUILDING FEE / L
t,Cn correct.l agree to comply with all city and county oNinanacs and state laws Thangto QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives of this city to ever upon the SEISMIC FEE /
`•s above-mentioned property for inspectionpuHmsea' ELECTRIC FEE
PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino.geinss C / �t
Iinalums,judgtnenu,costs and expenms which may in any,way accmeugainst said City ALTERONADDTOMECH. PLUMBING PEE �bq,�Z
in com,ta ace ofe rhgaming of This r
pemit.
APPLICANT DERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOLATIONMECHANICAL FEE
URCERT S
AIR HA DLING UNIT(OVER iff"CFM) / so�/
Q CONSTRUCTION TAX 0.]ii C
Sig of ApplicanVCanmuctor ate EXHAUST HOOD(WNUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wll the applicant or Tose building occupant Hort nr handle harardnus material HEATING UNIT(TO IOU,000 BTU)
as defined by the Cupertino Municipal Code,Chnpmr 9.12 and the Health and Safety
Cede,Section 25532(.)^ HEATING UNIT(OVER 100.000 BTU)
❑Yes CNo VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or furore building gaup B y A co Air rut or devices which BOILER-COMP(HIP OR 100,(00 BTU) ^h/S�
emit hvxmdnus air cnnmminants as Jcfincd by the Bay Arco Air Quality Management TOTAL: QU60
District? Yes ❑No BOILER-COMP(OVER 100,000 BTU) a
1 have read the haemdaus materials AIR CONDITIONER
rryuiremrnla under Chapter 6.95 of the Cali- ISSUANCE DATE.
to Health afcDCade,Sections 25505.25533 and 25534.1 triennium that if the NEW RESIDENTIAL MECIT. SQ.P.
buildingdo mcumen0y .tenant.that it is my respnnstbJOyo notifyt occupant
of them lopt is�town poor to�uartce gf qFe t`oa�f py�/.e#pw}ayaf
LIana
I •✓ /(/ Y
rsuthodu /e- Date TOTAL: ISSUED B .
OFFICE