28680 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH DING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUN;B NG-MECHANICAL 28680
BUILDING PROJECT IDENTIFICATION
LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL GATT
0 o woL.�t Ro �1_07.gS
O N 'S NAME: PHONE: ACTORS NAME: LIC NO
<fltA/I✓a'fL yi1. )j /1st
NIC CONTROL IT
ARCHTTECTIENGINEER: LIC NO: Eli >
CONTACT: TIPHONE: '1ZZ1 BUILDING PERMIT INFO
!-� Consultant Fees Paid by Applicant(Initial) BLD li PLUMB MOH
LICENS13D CONTRACT'OR'S DECLARATION �TY. ELECTRIC PERMIT FEE
p
1 hereby anion that I sm licensed under provilams of Chapter 9(conn t.cing JOB DESCRIPTION
Z with Section FKKllof Division 3.f the If igessand Pndesslons CWO,and my licence is RESIDENTIAL:
�IO
in full force mJ effect. PERMIT ISSUANCE t. 0 SFDWL 0 KITCHEN REMODEL
�F_u Ucensc Lic h
Class
NG0. Dae Contractor APPLIANCES-RESIDENTIAL EIADDITION GPLUMBING RE-PIPE
T. ARCHITECTS DECLARATION PANELS [I MULTI-UNIT CI STRUCTURAL
z b a 4 l ondernand my pl....bull be used as public records MODIFICATION
OZ-C UPTO200AMPS 0INTERIOR ❑CHIMNEY REPAIR
p.4F"J Licensed Profcssi...I 201-HON)AMPS IMPROVEMENT
�d ...41 OWNEWBUILDER DECLARATION OVER I(XX)AMPS OBATH REMODEDREPAIR El DEMOLITION
6'w 6 1 hereby air..n that 1 um exempt front the Contractor's Licen,c Law for the
X 3 d O following....(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL 0OTHER
-LL OLLa.which requires a prennd to construct,alter,impmve,Or Inh,or repair my moiclarc { _J
J prior in its issuance,also reNuims The applicant for such Permit In file a signed statement SPECIAL CIRCUIT/MISC.
Fy,ray that he is licensed pursuant to the provisions of the Cmnmctoes license Law(Chapter 9
a1�G0 (commencing with Section J(IDU)of Division 3 of the Business and Pmfesaons Crude) TEMP.METER OR POLE INST.
le COMMERCIAL:
1 oa that he is exempt therefrom and the Thom
for the alleged exemption Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
W^N Section 7031.5byanyapplicant fora permit subject,me applicant to.civil penahy of POWER DEVICES GTENAN'r ElFOOD SERVICE
>, ,more than five hundred delta.($500), IMPROVEMENT
FMa 1.as owner ufthe norm In ces with wages as their sole compensation, SWIMMING POOL 17LECI'RIG
_. ❑ Prosect my iP Y 6 pemu
p, will do the work,and the structure is not intended ornlfemdforsal apply to a, woe,of GGTHER
allm and Professions Code:The Contractor's License Law does not apply m un owner of CUTLET S-SWITCHES-FIXTURES
property who builds or improves therm,and who does such work himself or through
his own employees,provided[list such improvements are not intended or offered for NI?W RESIDENTIAL ELECTR SQ FT.
sale.If,however.the building or improvennt issold within one year ofcomple5on,me SQ,FL FLOOR AREA S/SQ.lel'.
c
owner-builder will have the burden of proving that he did not build or improve for par,
pursue ofmle.). TO
- -
❑ I,m awn[r of he propert,an,esOlm ively camn[ting with licensed contractors to h
construct the project(Sec.7044.Business and Professions Cale:)The Contractor's Li- ��
cense l.uw docs not apply to an owner ofpropeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE V Fs,
who commas for such promjee,sfwithaContnemr(s)Iicensedputsuuntto NCContracmr.s V r �nak
Licena . ��//J//_�� PERMIT ISSUANCE 's s7 kV
❑lame cit lunderS .It&1'C 6r this reason �)/r L/N r .
ALTER
R HA)
No "s VALUATIONwner a I --" V
WORKERS COMPENSATION DECARAIONBACK FLOW PROTECE DEVICE7 by af6numader
penillyoflemnyoneuf the following do,cra oat-
0 l have and will maintain a Cenifica¢of Consent to self-insure for Worker's Cotnpsn- DRAINS-FLOOR,ROOK AREA.COND. STORIES TYPE CONST RUCTION
ration,as provided for by Section 3700 of the Lubar Code,for the performmec of the
work for which this permit is issued. PIXTU RES-PER TRAP
I have and will owin cin Workers Compensation Inmrame us re ircJ by Sen
3700of1hclabor Cvd,,j dugcrformatce,f NC wmkfmwhichN permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLET S OCC.GROUP APN
My Workers Compensation Insurance canner and Policy namhr a
Carrier. Policy No, AS-EA.SYSTEM-OVER 4 0A)
CERTIFICATE OF EXEMPTION FROM WORK S' GRE dINDUSTRL WAS TE.INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthe Permit is forone In admeddallars($100) GREASET
or lues) PLANCHECK FEE
Toy that performance Nework)berom which Nis cWorers Co pershat SEWE SANITA STORM FA.300IT.
not employ any person in any manner so us m Monate subject to e Workers Compere ENERGY FEE
Z samin.Law,.f C.Iifmia,Date 10 W E Tf WNENT/ELECTR
ZQ Applicant I GRADING FEE
NOTICE TO APPLICANT:If,one making this Cert can. Eslatin...you• W S - )TREATING SOILS FEE
I•' N become mbject to the Worker's Compcmonem P risin,fm of c L.Nor Code, n st
�- forthwith comply with such provisions or this Permit shall dcentedrevoked u ' TERSE ICE
0
ns CONSTRUCTION LGNDINGA'ENCY Or NEW RLS ENTIAL PCMB. SQ.PI'. PAID
G O Thereby affirm that is a conswction lending encyf mmance of [-)are[-)are Receipt Or
tt
the work for which this permit is issued(Sec.307,Co,
I--' Lenders Name TOTAL:
J" W lenders Address TOTAL:
I candy that I have read This application and state that -shove informaian is BUILDING PEE
rycomect.l agree,.comply with all Fly and county mlimences an :ne Iowa rclwin6to QTY. MECHANICAL PERMIT FEE
U z building<nnswction.and hereby aulbume mprtscmamives.f this city eruponthe SEISMICFEE
`+ above-romiuned property for inspection purposes. PER ITT ISSUANCE
(We)agrm to save,indemnify and keep h0omless the City of Capering,aged ELECT RIC PEE
habili,ies,judgmenH.costs and expenses which may in any way accrue against said Lily AjVfER OR ADD TO MECL PLUMBING PEE
in consequence of the granting of this Permit.
ALICANT )ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0k000 CFM)
MECHANICAL FEE
S( .ERP
/1/7/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gnuture of Applicaut:ontrunor Dae EXHAUST HOOD(WMUCO 14OUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplic.he or future building oceupanutrue or handle hazardous..,coal HEATING UNIT(TO 110,11110 BTU)
as defincd by the Cupertino Municipal Care,Chapter 9.12,and the Health and Safety
Code,Section 25532(017 HEATING UNIT(OVER 100.010 BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Date ReeeiplM
Will the applicant or firume holding occupanl not equipment or dr,"es which I;OILER-COMP(?HP OR I W.UW BTU)
emit hmaomr,air mai miters as defined by the Bay Area Air Quality Management TOTAL
District! BOILER-COMP(OVIiR 100.000 BTU)
❑Yes ONO,
I have read the havalloms materialsryuireuCarl uader 1,95 of the Cali. AIR CONDO HONER ISSUANCEDATE
fomix glow no Safety Calc,Sections 21505.25533 my and 25534.1 undemond thus If the NEW RESIDENTIAL MECH. SQ.Ff.
ofit
building does um currently which havew our .Nat.morre spumibility m notify Ncscup.occupant
of Ilene requiremen[.s which most be mel prim In issuance of a Certificate of Ocaluncy.
Owner or au[h nimd agent Dam TOTAL: ISSUED BY:
OFFICE