28797APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING DIVISION APPLICATION/PERMIT PLUMnING MF.CI[ANiCAL / }� 9 7
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECTPLUpM�B/ MECH
El 1:1 ❑
' LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section V0A of Divisi J.fthe Busimessand Pmfessim Cf�j dm I c
in full force and eta[( a ''\\ S l7 ` P y me nm ms
s GeC 6 CSS V
License fl Lica p
Uate Comracmr
ARCHITECTS DECLARATION
I understand my Plans shall he used., public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑K CHEN REMODEL
❑ADDITION MBINO RP, -PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
D BATH REMODEUREPAIR El DEMOLITION
Cl OTHER
PERMIT ISSUANCE•m
APPLIANCES - RESIUGNTIAL
PANELS
.,
UPT0200AMPS
Licensed Professional
OWNER -BUILDER DECLARATION CmuION
1 herchy uffrm onnl I ran exempt Gam the Cssions o License Law for the
land Professions h, or any city or county
following (Section ]071.5, t, alter.
which
which requires a permit nitrites t et alter, improve, demolish, fi repair any sswcrem
gaedmammcm
for Contracsuch tor's
prmheislcense pursu tothe previsions
that bees licensed pursuant 70th) Pmvivisio of the Conusiness nd Professions
(commencing with Section ]gX)of DivisinnJof The Business and lk.fessionsCode)nr
ode) r
that he is exmnpi therefrom and the basis for the alleged exemption. Any violation of
Section 71170 by any aPPlicam forapertni7 subjems7he ePPlicam 7o a civil penally of
not more than Eve hundred dollars ISSfM)).
work. and propery,rmycmplendedwithfined astheirsm. 70,44, Business
will dothework. Cedr: no structure Livens Lav, does
and Pr.fexsinns Code: The Cummmors License Lav, does nm apply toll owner nl
apply 1. am
his o ny who builds or improves thereon, and who does wch tinte himself or through
his own employees, provided that such improvements are not intended t nr offered for
rnprovenrcnt is at he did ro ild o completion, Ne
sale. IL howeveo the have
owner -builder will have the buN<n of Proving that he did not bui1J or improve for pm
th burden
pose oro mwne
1, es owner of The See 70y, am exclusively contracting with licensed contmno7s m
construct the project (gee. ](W4, Business unJ Professions Cale:)'IIs. Contractor's i—
ceme Law does not apply to an owner of property who builds or improves thereon. and
who contracts for such pmjems with a coutrucmrts) licensed pursuant to the Continua.
License Law.
I am exempt under See ,B&PC for this mason
201.1000AMPS
OYER IfgOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
-
TEMP. METER OR POLE INST, _
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
(]OTHER
POWER I)EVICGS
SWIMMING POOL ELECTRIC
OIITLITS- SWITCIiliS- FIXTURES
NIiW RPSIU[NTIAh ELECTR SQ PIT.
SQ, F1'. FLOOR AREA
�����
SEP 0� 1g97
&SQ. FT.
TOTAL:
QTY. PLUM B ING PE RM IT FEE
PERMIT ISSUANCE
ALTER - DRAIN&VENT - WATER TEA)
Owner Dme
--v IATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
Ihaveaod will mainminn CerificamofCansenuoself-imam for Workers Compen-
inion, as Provided for by Section 37W of the Labor Code, fur the Perfomwae ofdhe
work for which this Permit is issued.
nd will maintain Workers Compensation Insurance, as required by Section
700 of thanLn bar Cale, for the limformance.fthe some for which this Permit is issued
My Work e'Compenjpti�o�n lnj¢ace exam"and Policy ^j��u T
Carol 4!!I� Policy No.:0L'b L6 V
BACK FLOW PROTECT, DEVICE
DRAINS- FLOOR, ROOP, AREA, COND,
STORKS ir
OCC. GROUP
TYPE CONSTRUCTION
APN
FIXTURES -PER TRAP
OAS-EA.SYSTEM-I INC.40UTLF.TS
GAS- EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
e Permit is unions, hundred doll.(, 1 00)
(Orris soclion need nm he completed if rh(5
or less.)
I certify 7hinam the feointanam.fthe work fur which Nis permit is issued, i shall
not employ any person in any marmer so as to become subject to the Workers' Compere
sation Laws ofCalifomia. Dam
Applicant
GRFASrANDUMI, WASTE INTERCEPTOR
BUILDING DIV 1910th FI3ES
GREASE TRAP
YLANCHECK FHP.
SEWER -SANITARY -STORM FA. 200 FT.
ENERGY FELT
WATER HEATER WNENUELECTR D
GRADING FEE
NOTICE TO APPLICANT. If, utter making mix Cerif7cme of ilsemption, you should
become .subject to the Worker's Compensation provisions of the Labor Code, you mull
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ierc
hby affirm That there is aconswai0n lending agency fnnhe Performance of
theworkforwhich this permit is issued(See3097, Ci, C.)
Lender's Name
WATER SYSTEM/TREATING
SOILS FEE
PAID
Dam Rec p
WATER SERVICE
NEW RESIDENTIAL PCMB. SQ. FL
() TAL:
Lenders Address
TGTA
BUILDING FEE Ul
I molly that 1 have read this application and state that the above information is
eormc7. l agree to comply with all city and county ordinances and state laws relating to
building construction, and herchy amounts represeensoves ofthis city 7o enter upon the
abovemnnioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Cupertino again,
liabilities.judgments.costioul,sperses which,,,., in any wayacemeagainm said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
'
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT
PERMIT ISSUANCE
PBE
ALTER OR ADD'TO MECH.
PLUMBING
AIR HANDLING UNIT (TO IQgp CFM)
MECHANICA FEE
AIR 14ANDLING UNIT (OVER 10,TA CPM)
CONSTRUCTI TAX
Sigrume.&ApplicanVConwssor Dale
NATi1RDOUS MATERIALS DISCLOSURE.
Will the applicant or future building secupan7 store orhandle hazarrous material
as defined Etyma, Catarina. Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)]HEATING
C Yes ,M No
which
Will the air verantnrfumrc building by the nt Bay Am
air conmminann as defined by The Bay Area Air Quality Management
Qualint or ty Management
District?
F1 Yet I] No
I have read the hazardous materials requirements under Chapter 6.95 of the Cull.
mama Hcel & Safety Code, Section 5505, 25577 mrd 25534. I understand that dine
of then sten correctly haute¢neat. drat itismymaof aCoitymnatify disincentive,
of the m t poor issuance of n CeniOcem f P
�
EXHAUSTHOOD(WIDUCT)
HOUSING MITIGATION ME
HEATING UNIT (TO 100,000 BTU)
UNIT (OVER 100,00) BTU)
PAID
Date
Date Receipt is
TOTAL:
VENTILATION FAN (SINGLE RE,SIO)
BOILER -COMPORT OR IOO,fXq BTU)
BOILER - COMP (OVER 100,001 BTU)
AIRCONDITIONER
- ISSUANCE DATE/
/j- L f 7
7 7 /
ISSUED BY:
NBW RESIDENTIAL MECH. SQ. FT.
-
wneroruurhonzed )gem Y1, Via
TOTAL:
OFFICE