28978 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECfRICAL' PERMIT NO, ^ ^ w w
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL k9y8
L k8
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
OWNERS A E: 1' O E: C RACIOR'SNA Ii. LIC NO:
17a A NIC CONTROL#•
ARCHI s /ENGINEER51W: LIC NO: uwpr
AD R S: ❑
CON'T'ACT: PHONE: BUILDING PERMIT INFO
00*445 976 - g2 ❑ Consultant Fees Paid by Applieant(Initial) BLDG ELECT PLUMB MECH
a7 ❑ ID ❑ ❑
" LICENSED CONTRACTOR'S DECLARATION Qpy ELECTRIC PERMIT FEE
I hereby ..p that I me licenxed under,movi,ml of Chart r 9(commencing JOB DESCRIPTION
�oaZ with Section 7")ofoivision J ofthe Business and Erodes ons Ca .andm I'emu is
00 itell force and effect. y PERMT UANCE - RESIDENTIAL:
aVFL� License Class Lica ❑SFDWL ❑KITCHEN REMODEL
Dme = Commnnr APPI-IANCGS- FSIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
ZO�N THECT'SDECLAR N ❑MULTI-UNIT ❑STRUCTURAL
PANEIS
Z I understand my plant shall be used u public raoNs MODIFICATION
OZ—, UP'I0200 AMPS
ee�� A ❑INTERIOR 13 CHIMNEY REPAIR
P, { Licensed Professional 201-I(NOAMPS IMPROVEMENT
ra-) OWNER-BUILDER DECLARATION pyEI1 1000 AMPS ❑BATH REMODEUREPAIR 'C3 DEMOLITION
1 hereby affirm that 1 um exempt from the Centra lx License Law for the
3O S V following mason.(Station 7071.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
1y F which requires a permit m construct,alter,improve,demolish,or repair any sticture I/KKK///1 IItiNN-1 rl�i
0 prinnnits is xuancq.lsomliiresthe applicant forsuch permit...fileasigncastinement SPECIAL CIRCUIT/MISC. -
I.-
that he is licensed puauanuo the previsions of the Contractor's license Lew lChapmr9
GAO (commencin6 with Section7tID0)of Divisicn 3m the Bisioew.ad Profession.CodiTEMP.METER OR POLE INS'T'. COMMERCIAL:
G a n�' that he is exempt thcrefmm and me basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Section 70]1.5 by any applicant for o permit subjects the applicant a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE,
Y
am more than five hundred dollars D50p. IMPROVEMENT.,
O ❑ 1,us owner of the progeny,or my emPlnyecswith 01h1.1�1'avaOmnprmy.Imn.ion, SWIMMING I'OOLIiLF,CT'RICwill dothe work.unJ theswdum isn.,intended..rofIk4,Businea ❑OTHER
d Professions Codc:The Contme Littnu laIanowner d OUTLETS-SWITCIprogeny who builds or improves there.. d w m ohis own emm,orx.providedthmsac tar nt``11 d for NEW RESIDENTIAL BLECTR SQ FT.
sale.IL however,the huilJing orintpnry a .sol]withinoa m.fo'p nu,the SQ.IT FLOOR AREA $/SQ.ET,
owner budder
will have the burden of pro ire that he did b
On we for pur-
poseofmle.). I
F1 1,a owner ofthe progeny,am exclusively enmmetimg hh licensed comructhrs to TOTAL:
onmrun the project(Seo.]044,Itusiness nnJ Rnfcssions Codeq The C..mractnr's Li-
censeLawdoesnot apply to anownerofproperty who builds orimPmvesthano.,and QTY. PLUMBING PERMIT FEE . DEC Od 19
whocotnmas for such projects with a contmctoi licensed pursuant India Contractor's C
License law. I PERMIT ISSUANCE QO J
❑Tum exempt under Sec. ,B&PCimmis reason
Owner Ume AUFHR-DRAIN&VENT-WA'I'ERHiA) O
VA•
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
•FlIhuveend will maintain.Cenificamof Consenuosel(-insure for Workels Cnmren- DRAINS-FLOOR,ROOF,AREA,COND.
sotion,'as provided for by Section 37110 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP g
3Vave and will maintain Wmkcri Corroammion Inmtance,M required by Sutton
In3 lofthe LahrCode,fortheporairmanceofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work e:sC a an rn dPolicy a GAS-HA:SYSTBM-OVER 4(HA)
Cwricr: Policy No
E T IPICC OF DON I N FROM WOR ERS'
COoolmde TIONINSURANCE GREASPIINDUSTRL WASTE.INTERCEPTOR
(This section need nor MnnnpinWifthe permit is Tanana hundred dollars(slW) - BUILDING DIVISION FEES
or lesa0GREASETRAP PLANCHECK FER
(certify the in the penornance ofthe work for which this permit is issued,I shall SEWBR-SANITARY-STORM RA.2W FT.
not employ any person in any ream ,so as to becomnn
e sobjecthe Workers'Compere- ENERGY FEE
N
Z section Laws of California.Date LL
700 Applicant WATER HEATER W/VENT/ELELTR GRADING FEE
G VJ NOTICE TO APPLICANT.If,inter mmking this Ccnifieme of Exemption,you should WATER SYSTEMn R17ATING
a �^ become subject o the Worker's Compensation provisions of the Labor Cole,you most SOILS FEE
W (� forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
D
Oz CONS DO is a YONLENDING AGENCY NEW RCSIDLNTIAI.PLMB. SQ.FC PAID
GO work
by which rte thanhemissued(Sueti097. .)agency for the performmme of Data Receipt
D+ L� me work for which this permit is issued(Sec.715],Co,Civ.CJ
{UiI Name Lendels N - TOTAL:
Index Name TOTAL: '07, 9
L4 1 cenify that 1 have read this application and state that me above information is BUILDING FEE
N correct/I agree to comply with all city and county ordinances mut state laws relating to QTY. MECHANICAL PERMIT FBI,
V Z building construction,and hemhy authorize representatives of this city to enter upon the SEISMIC FEE
above-memioned property for inspection purposes. RMIT ISSUANCE(We)agree mand to ve,indemnify keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilinim,judgmenta,toms and expenses which may in any way accrue agaimuaid City timing AL',R Olt ADD TO MECH. U7��0
in consequence of the ting of this permit PLUMBINGFEB• '•
APPLICANT UNDERSTANDS AND WILL,COMPLY WITH ALL NON-POINT AIR HA UNIT(TO 10.000 FM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING ON(OVER 10.000 CFM) CONSTRUCTIONTAX
Signature of Applicata/Contractor: Due EXHAUST GOOD(WI UGI) HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Willdm.milicuntor flnam building oceupmtnireor handle limadroo tri HEATINGUNITOOI0MBTU)
as definal by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Sermon 25572(0)7 HEATING UNIT(OVER 00,00)BTU)
❑Yes FIN. VENTILATION PAN(SINGLE RESID) PAID
Will the applicant m future building occupant use equipment or devices which Data Receipt#
emit haaardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 100,0009TU)
District? , t TOTAL:
DY El No BOILER-COMP(OVER 1011,(011 BTU)
Ila creat the vmdous me rials p AIR CONDITIONER ISSUANCE DATE
requirrnmnts undo Chapter h95 of the Cali-
Hall &Smay ode,Scaiuns 25505.25577 and 25574.1 understand that if the NEW RESIDENTIAL MECH. SQ.Irl'.
buil0i eck'a not cure by have.to mm,mal it ismy responsibility trilmidy the occupant
ofthe ul. min w ch mnmle etpdormost anceofa Cenificia of(kt nry. ee
Owne oti etc TOTAL: ISSUED BY: V
OFFICE