28725 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY
BUILDING DIVISION APPLICATION/PERMIT 1OLUUMIIINNCI:.MRCIIIANIC 1. PHRMI'T NO, w
B1111•DING PRO.IECT IDFINTIF'ICA•IION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
D Zi 9-A. 3 DS8/8 2 �.
OW R'SNAME: PHONE: CONTRA 101'5 NA 0:
Zi S 3 G'7 1 WoCN/C CONTROL#
•ARCHITECT/ENGINEER: LIC NO: AD R 5: ❑
CO - PHONE: BUILDING PERMIT INF
,a Q ❑ Consultant Feas Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�(7 / 7 ❑ ❑ ❑
LICENSE)CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby eRnm that 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
COZ with Section 71X0)of Division 3ofthe Busincsxand Professions Code,and my license is
F�0 in full fore end Gcn.L Lf� 3 n Sa PH MIT ISSUANCE ❑KITCHEN REMODEL
U U License Cla Lic.a
F�u] Dam Conavdor APPLIANCES—RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
F7>m> ARCHI'I'IiCI'S I3ECLARATION ❑MULTLUNIT C1 STRUCTURAL
Z c G 1 understand my plans shall he used m public records PANELS MODIFICATION
OZ—, _ UPTO200AMPS [I INTERIOR ❑CHIMNEY REPAIR
Licensed Pmfesxin°o1 20MR)O AMPS IMPROVEMENT
�` OWNER-BUR.DER DECLARATION OVER IIIIMIAMI'S ❑BATH RE REPAIR ❑DEMDL TI N
NU 1 herehy nm'n Thal 1 sen exempt from the C.rome or's License Law for the /
a6 following reason.ISectina 703 1.5,Business and Penfossions Code:Any oily u County ❑OTHER
LL which requires a per num cnn.amc6 glom improve,demolish,or repair any suumure SIGNS ELECTRICAL.
X70 priorminissuunce.also rcyuimx 0c applicant lar such permino file sm,emstatement SPF.CI AL Cl NCUI'1'/MISC. /
Q� thus he is licensed,ursuanl 1.the provisionsof the Common,a License Law(Chapter 9
OOq wommencingwilh Section TMNry o1'Ulvisinn3 ofthc Businessand Professions Code)., TEMP.MET ER OR MOLE INST. COMMERCIAL:
m and
a n 4 that he is exempt therefrothe basis(or the alleged exemption.Any vialalmm of ❑NEW BLDG/ADDITION ❑DEMOLITION
{i Section]OJ LS by any opplicvm furu permit suhjecu the npplicam lovcivil pcnahy of POWER DEVICES
❑TENANT ❑FOOD SERVICE
t mase thanff,hundsed Dollars($SW), IMPROVEMENT
L
Cl
pmpeny,or myemployees with wagesastheir(Sec.compensation, SWIMMING POOL F.LfCI'RIC
d_ and do the work,end e-The vase is not intended Licese La does id apply
y.o an owBusner
of ❑OTHER
m and arty whob Cod e:The Comthereo License Law d«snorapplymlf owner of OUTL1i1'S—SWITCIJES—FI%TURPS
6 3^ progeny who builds or improves thereon,and who dace such work himself or Nrough
his awn employees,provided rhot such improvemem i arc not intended ne offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,0e building or improvement is sold solaria one yearof completion,the SQ.ff.FLOOR AREA LSQ.Pf.
ser-builder will have the burden of proving that he did not build m improve far Wr-
pose of sale.).
❑1,as owner of the ogcontractingy,am exclusively contracting with licensed contractors to TOTAL:
pr
nsoum the project(Sec.70,14.Business and Professions Code,The Conuanors Li-
censeLawdoesnotapplymanownerofpropenywhobuiids or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for suchprojects with v commcmgq licensed pursuant to the Contmcmrx /
License law. PERMIT ISSUANCIi
E3 I am enempt under Sec. ,B&P C fonhis reason
Owner DateALTER—DRAIN&VENT—WATER(ITA) - VALUATION
WORKER'S COMPHNSAI']ON DECLARATION BACK FLOW PRO'T'ECT.DEVICE
1 hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain v Certificate of Consent to se)(Ansure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
sation,as provided far by Section 3701 of the Labor Coda,for the performance of the
work for which this Permit is issued. ITXTURES—PER TRAP
and will anal stain Worker's Comin nxaslon Insurance,as required by Section -
37Mo(the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worker'r nmpens I a b set ace enrtienmd Policy number aa�� p
Caner:
Policy No:
dDb p f0D7 GAS—EA,SYSTEM.OVER 4(EA)
'RTEgCATEOFHXIiMPfION FROM WORKERS' T.
COMPENSATION INSURANCE OREASWINDUSTRI.WARITI INTERCEPTOR
(This section need not becomplered if the permit is fa une hundreidollars(SIM) BUILDING DIVISION FEES
or less.) GREASEI'RAP PLANCHECK FEF.
(cenify that inthe saydoome,onmance of shcwmkfie which this the W rkera'W,lshxll SEWER—SANITARY—STORM EA.20o FT.
nm employ any person in any manner m as m become subjecua the Workers'Compen. ENERGY FEF. N
Z smirnlawrof Cnlifomia,Date
O Applicant WATER HEATER WNENT/IiLLCfR DD GRADING FEE
y
NOT ICE'L'G APPLICANT.ILaflcr making this Certificate of Exemption,you should WATERSYSTHNUTREATING
a ^ baome mbjcct ro the Workers Cmir aamms provisions of the Latin,Code,you most SOILS FEE
G (anhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE pp
Q 9
CONSTRUCTION LENDING AGENCY NEW RFSIDF.NTIAI.PLMB. SQ.FT. PAID
V 0 (hereby affirm ohm them is a construction lending agency fame Performance of Receip M
ILF the work for which this Permit is issued(Sec.3097,Civ.C.)
U Lenders Name AL:
Lenders Address IOTA ,�,
C 1 cenify shut I have rend this application and swat that aby.
above information is BUILD( atopy/.
w+ V) sated.lua.to comply with and all city county ordinances and some laws telmingm QTY. MECI IANICAL PERM IT FEE
L) building construction,and hereby authorize reen
Prexwtives of this city to enter upon the SEISMIC FEE
ab
ove-merahmed progeny for inspection purposes. PERMITISSUANCE
(We)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC FEE
Iiabililies,judgmenls,ems and espenxes which may in any way accrue against said Cil, ALTER OR ADD TO M HCH.
in consequence of the granfirg of this permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. AIR HANDLING UNITNIT(to 111,(NOI'M
C )
MECHANICAL FEE
AIR HANDLINGUNIT(OVER Won)CPM) CONSTRULTIONTA%
Signature of Applicant/Contrncmr Date EXHAUST t100,(W/DUC'1) - HOUSING MITIGATION PE
HAZARDOUS MAI CRIALS DISCLOSURE
Will the applicant or future building occupant store or handle humormas material HEA'TI NO UNIT T 0106.0f0 B'I'U)
as defined by the Cupenin,Municipal Code,Chapter 9.12,and rhe Health and Safety
Code,Section 25532(0)! HEATING UNIT(OVER I(H),011 BTU)
❑Yes ❑Nn VENTIIA'1']ON PAN(S INGLE RE.SI D) PAID
Will the applicant in future building recapped use egnjpmeet or deviccS whitDate Receipt p
emit hararrim,air contaminants as defnml by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,0010 BTU)
(� Disria? TOTAL:
E) nNo 1BOILER—COMP(OVER 0,000 BTU)
I have rend the hmardous mmeduls requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
(oris Health&Safety Cade,Sections M505,25533 and 2554.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. is r/�
Wiidingdbe std cowardly have a tenant.that it is my responsibility to booty eoccupant / //` J
of oho raga cora hi n ssua ala Ced ficma o cupSnc.
Ow ora zed agent 'UaLmD • TOTAL: ISSUED BY:
OFFICE