28485 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 28485
UI k BUILDING PROJECT IDEM IMCATION
BUILDI GAD �SS ^ . W SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: 1 .[ORS NAME: Y LIC NO: 08 AIA-q<
NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: / �� ❑
340
CONTACT PHONE.: -1F BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG L PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
04 Z 1 horchy ufyms that Ion licensed under provisinne of Chapter 9(commencing• ' JO DESCRIPTION
wit Section 7000)of Division J of the Business and Professions Code,andanI ncis
I-WO ym"s PERMIT ISSUANCE RESIDENTIAL•
F in full Elemental atter.
a7� ❑SFDWL ❑KITCHEN REMODEL
UZ U License Class. Lin.g
Date Contractor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RF.-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
E.. PANELS[zE !/O!/��Z 1 understand my Plana shall be used as public records MODIFICATION
pz:1^ uP TO 3al1AMI'S
uqi Licensed Professional ❑INTERIOR CHIMNEY REPAIR
.1 .3111-II1fq AMPS IMPROVEMENT
OWNER-BUILDER exempt
DECe ContrION OVER IOOn AMPS
0 6 1 herby affirm that I am exempt from the Cnntrvcmrs License Law for the ❑PATH REMODF.IJRE?PAIR (]DEMOLITION
3 04 U following reason.(Section]031.5,Business and Professions Code:Any city county SIGN$ELECTRICAL []OTHER
C,vFa't which requires a permit to construct.cher,improve,demolish,or repair any mr clPre
Oi.] prior to in issuance,also requires the applicant for such Permit as file a signed statement SPECIAL CIRCUIT/MISC.
a� But he is lioensed,metee to the provielons of the Canlracmrs License Lim,(Chapter 9
00 fcommancing wit Section]tl'10)o1'DivisionJ.f the Business and Ra(essions Code)., TEMP.METER OR POLE INST. COMMERCIAL
:
a e' that he is exempt therefrom and the basis for to alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
6•
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVIC
^rA ❑TENANT ❑FOOD SERVICE
zy not mare than live ihundredty,or yempl
0 ❑Lo the work.the progeny,remyemntended with wages ed for sale(See ota.B ones SWIMMI OL ELECTRIC IMPROVEMENT
will do to work,vul to stnmctnie is trot intenJW or offered for sale(See]IIa4.Bmincss [)OTHER
L and Professions Cue:The Contractor's License Law docs not apply to an owner of OUTLETS S -FIXTURES
^ progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvemenis arc not intended or offered for NEW Rf .NTIAI. .. SQ FT.
sale.If,however,the building,,,improvement is said within one yc..of con.pletinn,the SQ.PI'.FLOOR AREA fISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put,
mic of
❑1,as owner of the progeny.an exclusively contracting with licensed contractors to TOTAL:
construct the project(See.7( ,Business and Professions Code:)The Contractor's Li.
cense Law does not apply in an owner of property who builds or improves thereon,and QTY, PLUMBI G P• FEE
who contorts far such projects wit.oteractorfs)licenvd pursuanno One Contrecmra
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. .B&PC for tis reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of pe jury one of the following declarations:
❑Ihave and will maintain aCcelficam of Consent to self-insure fm Worker's Contain. DRAINS-FLOOR,ROOF,ARIA,COND,
amion,as provided far by Section 37M of the Labor Cade,far the perr
fomance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. NXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Inmexpen,as required by Section
3700.1'the Labor Cade,forte performanceof the work for which this panni,is issued, GAS-PA.SYSTHM-1 INC.4 OUTLETS
My Workers Compensation Insurance carrier and Policy number are: OCC,GROUP APN
Cartier Policy No.: GAS-EA.SYSTEM-OVER 4 E;A) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASfJINDUS'I'RL WASTE INTERCEPTOR
BUILDING DIVISION R?[S
(Thissectinnnxd nm becamgletW ifthe peemit is farone hundreddullers(fI W)
m Ices) GREASE TRAP PLANCHECK FEE
I certify that in the performance ofte work for which tis permit is issued,l shall SEWER-SANITARY-STORM EA200IT
not employ any person in any manner so as to become subjecrto the Warkera . .Camper. ENERGY FEE
7. video haws of California.Mw WATER HEATER WNENT/EI.ECTR
O Applicant - GRADING FEE
yNOTICE TO APPLICAN'P.IL after making this Cenifieme of Exemption,you should WATER SYSTEINTREATING
abecome subject to the Workers Compensation provisions of the Labor Code,you mus, SOILS FEE
{1'7 fuMwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
�z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB, SQ.IIT. PAID
V O I herehyaffinn But them iso conswedi lendingugency for the gepunanceof Dam Receipt#
W f'•' to work far which tis pe.air Is Issued(Sec.3.97,Civ.C.)
O U Lendcr'a Name L:
Lenders Address TOTAL:
yI Certify tat I have read tis application and sate that the above information is BUILDING FEE
h CmmvC.l agree to comply withall city and county orodinancesandsamelawsreamingto QTY. MECHANICAL PERMIT FEE Of
construction. o
V 7 building construction.and hereby suthsize mpoesentatives of this city to enter upon the SEISM1'
above-mentioned progeny fur inspection pmpayes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless,he City of Cupertino against ELECTftI
liabilities,judgments,casts and expenses which may in any way accrue against said City gLTI?R OR ADD ID MHCH.
in consequence of the stenting of this peoph, PLUMBING FE
APPLIC UNDERSTANDS AN WII COMPLY WIT LHON-P INT AIR HANDLING UNIT 10,W CFM)
SOURC:Rf 3ULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA%
Signal ofApplic /C.mrctgr Dao IXIIAUST HOOD(W/UUCI')
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION
Will lh pplicam or fuame building occupant sire'handle baznrdoua material HEA[ UNIT(TO 10(LOBO BTU)
as defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 25532(x)1 HEATING UNIT(OVER LOB WO BTU)
E]Ya, 0 N VENTILATION FAN(SINGLE RFSID) PAID
Will the applicant or future building occupant use equipment or devices which Dale Receipt N
unit harardaus itkommminanls as defined by the Bay Area Air Quality Management BOILER-COMP GHP OR 100,000 BTU)Lluildi,
TOTAL:
s ❑No BOILER-COMP(OVER 100,OOII BTU)
e remlthe hazallom materials requimmems under Congerfi95of the Cab- AIR CONDITIONER ISSUANCE DATE
&Safety Cale,Sections 25505,25573 aM 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. e5)s not currently have.tenant,tw i,is any resptmsibiin,to notify the occupum {{!C/J//�j//menlr which must b,met prior to issuance of a Ccnifrcam of Occupancy.
tmiled.geat Date TOTAL: ISSUED BY'
OFFICE