28820 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.'2' 8
' BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL • 2QO
BUILDING PROJECT IDENTIFICATION ttJJ V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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CONTACT: PHONE:
BUILDING PERMIT[NFO
El ConsultantFees Paid 6y Applicant(Initial) BLUq ELECT PLUMB - MECH
LICENSED CONTRACTOR'5 DECLARATION QTY. ELECTRIC PERMIT FEE LhRaT JOB DESCRIPTION
I hereby aRum that I am licensed under provisions of Chapter 9(eotanencing
yD05 with Section 7000)ofDivision 3 ofthe Business and Professions Code,and my license is '
FDENTI
aOOF+ infullforceandeffecl. - PERMIT ISSUANCE
G U U License Class Lic.# L' ❑KITCHEN REMODEL
y• ie Dale Comraemr APPLIANCES-RESIDENTIAL rADDFION El PLUMBING RE-PIPE
'Do, � ARCHITECTS DECLARATION � LUNIT �STRUCTURAL
PANELS
z O�Zy I understand on,plans shall he used as pu 1ir reooN, MODIFICATION
9 Q _ UP'1'0200AMPS ❑INTERIORpp ❑CHIMNEY REPAIR
W
Licensed Prnfessional 201-I(X10AMPS IMPROVEMENT Ail J®
�` !a) OWNER-BUILUEk DECLARATION DYER I(AMIAMPS ❑BATH REMODEUREPAIR El DEMOLITION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
„7e 3 L F following reason.(Section 7031.5,Business and Professions Cade:Any city or county 'SIGNS ELECTRICAL ❑OTHER _
which requires a permit to conswm,.Iter,improve,demolish,or repair any staname _ Fill 'Imova
��0 prior m its issuance,also requires the applicant forsuch permit m file a signed statement SPECIAL CIRCUIT/MISQ }rVp x"9�
that he is licensed pursuant to the previsions of the Contractor's License Low(Chapter 9 ,!^`
QOO (commencing with Section 7X10)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
6 Fy m oL Net he is exempt therefrom and the basis for the alleged exemption.Any violation of ElNEW BLDGIADDITION LJ DEMOLITION
P� {Z
1ection7011.111 any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
�+ net are than flee hundred dollar,($500).
� Q I,asownerofthe rt,amemlo es,with wa theirsolccnm reation. SWIMMING POOL ELECTRIC IMPROVEMENT
D ❑ prose y y p y gcs rte pe
will do the work,and the structureContractor's is not i tendedLivens n Law do fm sale(Sec.to an ownBuser ss 0 OTHER
and Professions ills m The eremLiana Law does ran apply s if owner of OUTLETS-SWITCHP.S-FIXTURES
4i 3 property who builds or improves thereon,and who nd, such work himself or through -
his own employees,provided but such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PI'.
owde Lhowever the have
b orimprovementof issoldhewithinoaild of completion, - SQ.FT FLOOR AREA SISQ.Flt.
owner-builder will have Me bollen of Anteing that he did m[build or improve for sur-
pose ofseleJ:
❑ I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cence
i-c nse Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a communist s)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
E] 1 am exempt under Sec. ,B&P C for this reason
Owner Date ALTER-BRAIN&VENT-WATER(EAG VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE CIIJ P� vv
thereby amrm undo penalty of perjury one tithe following dedatutiana J `J
•❑ I have and will maintain a Certificate of Consenno self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPECONSTRUCTION
smitn,as provided for by Section 3700 of the Labor Code,for the performance a the -
w+�mkforwhichthk,ximitkissaed. - FIXTURES-PER TRAP
91 have and will maintain Worker's Compensation Insurance,as required by Section -
37W tithe Labor Code,for the performance ofthe work for which this permit is issued. GAS-Ep.SYSTEM-IINC.4OUTLETS OCC GROUP PN
My Werk cion ance a ierand Policy nu er GA,S-EA.SYSTEM-OVER 4(EA)
Currier: - ��1_ Policy No.:
CERTIFICATE OF EIC• ION FROM
WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRLWASTEINTERCEPTOR
(f his section need not becompleted ifthe permit is foronc hundred dollars(SI W) BUILDING DIVISION 65
or less.) GREASETRAP PLANCHECK FEE Q
I certify that in the performance of the work far which this peimit is issued,I shall SEWER-SANITARY-STORM EA. FT
not emer
ploy any pson in any manner so as to become subjectCourtier-the Workers'Courtier- . .
en- ENERGY FEE
Z patio.Laws of California.Date
WATER HEATER WNENT/ELECfR
O Applicant - GRADING FEE
rA NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
a become subject to the Worker's Compensation WATER SYSTEM/TREATING
p provisions shat of the Labor Coked. mus[ SOILS PF.E
W
forthwith comply with such provisions or this pemsit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.Pr. PAID
U 0 I hereby affirm Nat there is a construction lending agency forte performance of Receipt#
O wa the work for which this permit is issued(Sec.3097,Civ.C.) .
U Lender's No
TOTAL:
Lsener
tlAddress TOTAL:
I / .A—
�a�r1
informationFE
rtify that 1 have read This application and state that the above information is BUILDING E
UJ correct.I agree to comply with all city and comely ordinances and state laws relaingm QTY. MECHANICAL PERMIT FEE �yI
Ubuilding construction,and hereby numeric representatives orthis city to elnermpon the SEISMIC FEE / a
above-mentioned property for inspection purposes. PERMIT ISSUANCE /bf 4S"
(We)agree m sure,indemnify and keep harmless the City of Cupertino against / ELECTRIC FEE f GJF 7
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. 1
in consequence of the graving of this permit. - - PLUMBING FEE tLS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCERF///A)LATIONS. non MECHANICALF E
i.LA AIR HANDLING UNIT(OVER IO,IMII)CFM) CONSTRUCTIO TAX -36r
SignSign r�nt/Cmmose r Date EXHAUST HOOD GYMUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGA EE
Will the applicant or future building occupant store or handle hazardous matenal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLERESID)' PAID
Das Receipt#
Willtheair contaminor aurents
as handing occupby
nt use Day Area
Air Qualitnt or y
Managees ment
BOILER-COMP(JHP OR 100.(X10 BTU)
emit hazallous air conmminana as.clined by the Bey Area Air Quality Mnnogement TWA D.
Dlsmn7El Yes F1 No .BOILER-COMP(OVER 100.000 BTU)
have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSU
famia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if da NEW RESIDENTIAL MECH. SQ.PC
building does mulremI have ato,at,that it is my responsibility to notify the occupant
ofthere te7k, themtMorloissuanmofa ❑ca tYOc y.
Own rmammumdagent Date ?OTAL: ISSUED BY:
OFFICE