28515APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
. BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT' IDFNTIF'ICATION
PERMIT NO.
V
28515
515
BUILDING ADDRESS:
/ i IV c
SANITARY NO.
APPLICATION SUBMITTAL DATE
S
OWNER'S NAME: PHONE:
CONTR;lg;SNAME:O LIC NO:
NIC
CONTROLM
I
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:❑
cILlo rooselloe <41
CONTACT: �f P�Nk:S_�bb�
,.eon 2
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PF,RMITINI`0
BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DF.CI RATION
1 hercb- f min Ilial I am IicenseJ under c of Chapter 9 (commencing
ya provnh p g
with llfindn]II(1t0 of Division 3 o0he Husiness and l'rolbsxionc Creditor] mylicense ie
I. full force end eReCCt
Liccmc Class GZQ Lica 6233ff f
Dem Cnnvumor..(r�e�_
Sr A CI3ITECTS UECLARA'110N
I understand my plans shall he used as public records Z L.1�
QTY ELECTRIC PERMIT FEE
'JOB DESCRIPTION
RESIDENTIAL:
'
❑SFDWI. ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑ MUIIPI-UNIT ❑ STRUCTURAL
�Iy�MODIFICATION
❑INTERIOR puCHIMNP.Y REPAIR
IMPROVEMENT
❑ BATH REMODI?UREPAIR [I DEMOLITION
❑OTHER
PERMITISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPT0210 AMP$
Licensed Professional
OWNER -BUILDER DECLARATION Contractors
1 hereby reade .(item (hal um exempt from the Canons Co Licence Law for the
whichfollowCode: Any city or county
guiresa Permit
which requires n P, also re cumwe, alley, improve, demolish, or repair any structure
]onstru t, Business add improve.
that hor oslicenudpursantt.,es the isions nt of be C untelm's License Lewd statement
Cinema Law [C ode) 9
that licensed pursuant Section
(commencing with Sceion 7(N0)of Division3 of the Business end Professions Code) or
)ofD sof thehe Business
that he is exempt therefrom amt the basis for Ne alleged exemption. Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of
out more than Ban hundred dollars ($50(h
❑ Las owner of the prrpcny,'or my employees with wages as their sole compensation,
will do the work add the structure is not intended mattered forsxle (Sec. ]OWI, Business
and Professions Code: The Contmetoes License law docs not apply to an owner of
property who builds or improves (hereon, and who does such work himself or domigh
his Own employees, provided that such improvements arc not intruded or offered for
sale. If. however the building or improvement is sold within one yearofcompletion.the
owner -builder will have One burden of proving Nat he did not build or improve for put,
pose of sale.).
❑ 1, as owner of We property, am excluslycly contracting wi(b licensed contractors to
construct the project (Sec. 7044, Business and Pfofceaions Cade:) The Cmdowalsrr Li -
ase law does not apply manownerofpropcny who builds or improves theteon,aM
who contrecn for such pmjeen with a rma.cmd,) licensed pumuan1 Jo the Comractols
License 1. w.
6 1 .,it exempt under Sec. , B & P C for (his reason
2BLI W AMPS
OVER 10011AMPS
SIGNS ELECIRICAI.
SPECIAL,CIRCUIT/MIS❑.
TEMP. METER OR POLE (NST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
I
SWIMMINGPDOI. ELECTRIC
OUTLETfS- SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ FT,
SQ. FT. FLOOR AREA
'
$/SQ. FT.
-
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
_
BACK FLOW PROTECT. DEVICE/V
Ownv Dam
VALUATION -
O V
(� OU
whom Ju COMPENSATION DECLARATION
1 hereby unn underder penAperjury one of perjuone Ofthe following Aeeam
ltitmr:
I have and will maintalnaConificareof Consent to self -insure for W.l Condom-
ration, as provided for by Section 37M of the labor Codd, far the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Ins..nmce, as required by Section
3700 of die labor Code, for the performance of the work for which this permit is issued
My Worke'sfora matin urn a caniervnd Policy nye
Corti --- No,J-- ��9
CERT OCATIi OF EXEM (TION FROM WORKERS'
COMPENSATION INSURANCE
flbisseemmm need not he completed if the Permit is forone hundred dollars (S 1001
or less.)
I certify(hm in the perfmmmncc oflhe work forwM1ichthisparmi(isissual,Ishull
not employ any person in any manner so as to become subject Workers Cnmpgn3.
sation Lawsof Califende. Date - r•^•'•••'^^\�^!,^^"''•"
Applicant
DRAINS- FLOOR, ROOF. AREA, COND.
STORfus
TYPE. CONSTRUCTION
FIXTURES -PER TRAP
GAS- FA, SYSTEM. INC. 4 OUTLETS
OCC. GROUP
APN
GAS -EA. SYSTEM -OVER 4(HA)
GREASEIINDUSTRI, WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWIiR-SANITABY-STORM FA. 2W FT.
-^^-•
ENERGY FEE
'
WATER HEATE WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If er making (his Cenificare of Excumham, you should
becnJne auhj<cl (o the Worker', Cnmp �min$RW W yp �((h uhrf CoJ s
foMwith comply with such pritnsionslnnhi:plmlil a16111�di cJFwoku
CONSTRUCTION LI? DINGAGFN ,Y T}} EE�,i gg11
Iherebyaffrm (hal them inaamsuuct I,F"dingageg yfr}(IE perfoMs ce n�
Ne work for which this. is issued (Sec. 3IN1, Civ; C.) '
Lendees Name
p ER SYS'1'EnvTIdEATING
p ERSERVICE
_
SOILS FEIi
PAID
R HSIDENTIAL ('LMB. SQ, IT,
Date Receipt#
TOTAL:
Censures Address t
TOTAL:
I certify that I have read tits up icalion and stoic 11u1 the ....ve:..forma(..... is
corer. I agree to cmmply wish Lcitya county oNinvnccs and entre lows relatingm
building construction, and hereb Ihodze mpmsematives at this Fuy.mYataiiL IM;
above-mentioned propmy for inspastft"Ia ee
(We) agree to save, indemnify and keep harmless the City of Cupenlno against
Imbilides,judgments,coms and oapeves which Jury !rally way accrue againstsaid City-
in consequence of the Scenting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
OURCH REGULATI NS..
\ E_ Zr_
.
QTY. Ml: WIANICAL PERMIT FEE
'L-�+••�"^'k'y'-"'
PP.RMI'1'ISSUANCC
BUILDING FEE
�g•• (%�
SEISMIC FEE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING ME
AIR HANDLING UNIT (TO lOdgO CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 107810 CPM)
CONSTRUCTION TAX
Signature of AppheaMCnantcmr Dnte
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or boom building occupant store oT handle hazardous material
as definai by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code. Section 25532(x)?
pYes ❑No
tr future holding by the B use equipment or devices which
401 the air concentrations
emit hazaMous air conmminann mdefined by the Bay Arca Air Quality Management
District?
❑ Yes C] NO
I have read the hazmdous mutorials rt,,obdents under Chapter, 6.95 of the C.H.
Taenia Heal@ & So(ety Code, Seetions 25505, 25573 end 8SJ4.1 undermod Lha( i(Ihe
buildingdoerad ieu dy have mnam. fludais my resgmcihHity to notify the Occupant
oIo
raryir, a wJhm met prior I'll... of a Ce ((^m (i(,Osgypa
ell, d [
EXHAUST 1400D(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.000 BT LO
HEATING UNIT (OVER 110,000 BTU)
py`��gsp�(f•�5�� R
PAID
Date Receipt
VENTILATION FAN (SINGLE RESID),
BOILER -COMP (JHP OR 100.000 BTU)
1995 TOTAL:
BOILER - COMP (OVP.R 100," (ITU)
-
AIR CONDITIONER
I, N EDATE///'•••••.���
T/�
ISSUED BY: S lM�•
NEW RESIDENTIAL MECH. SQ. FT.
-104K
Owner or malwr red agent Date
TOTAL:
OFFICE