28537 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELRCTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
.28537
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:, • - - SANITARYNO. APPLICATION SUBMITTAL DATE
111911 57 . �o�uc� 17r. C �0�a 9
OW
R'S AME: ONE: CONTRALTO 'S NAME: LIC NO:
�s T� 7y NIC CONTROLM
ARCHITECTB3NG1 EER: EIC �pRO� �
CONTACT PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
❑. ❑ ❑
.;
LICENSED I a CDNTRd under s DECLARATION QTY. ELECTRIC PERMIT FEE
Q I heresy affirm mat I am hennaed ander provisions of chapter 9(commencing JOB DESCRIPTION
with Sectme7000)of Division 3oftheBnslaessand Professions Cannionmylicense is TERMLY ISSUANCE RESIDENTIAL
-
F in full frce and e ve 63z
U Licenseos Lie.W - ''[ISFDWL, ❑KITCHEN REMODEL
•'�-g Gate Comractmo e" _ APPLIANCES ❑ADDITION ❑PLUMBING RE-PIPE
p.,pin ARCHITECT'S DECLARATIONPANELS ❑MULTIANIT ❑STRUCTURAL
.t O q 1 understand my plans shall be used as public records " i I ' MODIFICATION
CZ P UPT02W AMPS ❑INTERIOR [I CHIMNEY REPAIR
F. Licensed Professional - 201-IfNU AMPS IMPROVEMENT -'
fq$
OWNER-BUILDER DECLARATION C'm ION OVER IOW AMPS ❑BATH REMODEUREPAIR El DEMOLITION
I max. amrm that 1 am exempt atm the Contractor's License Law for the
pe 06 U following reason(Section]03L5,Business and Professions Code:Any city or county ❑OTHER WW B a,F SIGNS ELECTRICAL O which acquires n permit re construct,aper,improve,for ss,demolish,or repair any twmure
ypriorto its issuance.also requires the applicant for such Permit fileesigned statement SPECIAL CIRCUIT/MISC. �•
?J ai that he is licensed pursuant to the provisions ofth,Contractors License Low(Chapter9
(commencing with Section7")of Division 3 time Business and Professions Code)or
Q O TEMP.METER OR POLE INST. COMMERCIAL:
F y m fg that io is exempt merefmm and or basis for me alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
fiat] W
Section 7031.5 by any applicant fnwpermit subjects the eppllcanuoacivil Penalty of POWER DEVICES
��'„ not mote man five hundred dollars($SW). ❑TENANT ❑FOOD SERVICE
OLas owner of me properly,or my employees with wagc,.s their sole compensation• SWIMMING POOL ELECTRIC IMPR ENT
will do me wmkand the structure is not intendedoroffind forsale(Sec.914L Business ❑OYER
and Professions Code:The Contractors License Law docs not apply to an owner of OUTLETS—SWITCHES—FIXTURES _
property who builds or improves thereon,and who does such work himself or through -
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
' sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA g .FT
caner-builder will have the burden of proving that he did not build or improve for pur-
poss of sale.).
EJ I,as owner m the property,am exclusively commcting with licensed contractors to TOTAL: r
construct the project(Sec.7044,Business and Professions Cole:)The Contractors Li-
Genu Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT E
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ I an exempt under Sec. ,B&P C fur this reason
Owner I- Date ALTER—DRAIN&VENT—WATER(EA) VAL
0 WW
WORKER'S COMPENSATION DECLARATION
,
I hereby y aunder penally of perjury one of me following declarations:
FLOW PROTECT DEVICE
ons: '
I have and will maintains CertEemo fConsent to self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND.Pinion,es provided m
for by Section 3]00 of the Labor Cade,for performance of the ST TYPEC NSTRUCTION
work for which this permit is issued. FIXTURES—PER TRAP
❑I have and will maintain Worker's ComPeiisation Insurance,as required by Section -
3700 ofthe labor Cale,for the performance of the work for which mu lis issued. GAS—EA.SYSTEM-I INC.4OUTLETS - ACC. OUP Aped
My Worker's Compensation Insurance c mer end
Cartier: ��i ' GAS—EA.SYSTEM-OVER 4(EA) r
CERTIFICATE OF E� ON FROM WORKER ` '
COMPENS TION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the Permit is for one hundred dollars IS W) HllILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
(certify that inshe perany macro ortheiek1 work for which this thepeorditWisies'Compeall SEWER—SANITARY—STORM EA.200 FT.
not employ any persod in any manna t become jam to me Workers Compem, ENERGY FEE
.Oz cation Laws of Qa�fyrnia.]late 'f"�� WATER HEATER WNENTMLECTR GRATING FEE
yy O ApplicLa s: / 7 -
q NOTICE MAPPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
f-1 become subject to me Workers Compensation provisions of the labor Grade,you must SOILS FEE '
forthwith comply with such previsions or this permiishall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT. PAID .+
U 2 -(hereby of en that there is a construction lending agency forthe Performance of Datil � 'R ipeis
'the wor
{lJ h k for which this permit is issued(Seo.319],Civ,C.)
O U .Lender's Name L.
Lender's Address TOTAL:
1 certify that 1 have read this application and state that the above intermmion is BUILDIN 1 -
1.w In correct.I agree to comply with all city and county nominates end state laws relating to QTY. MECHANICAL PERMIT FEE
U ,7a. buildingconswetion,andherebyaudemixerepostarmtivesofthiscitytoenterupunme SEISMIC FEE_.
abFiIINU
above-mentioned property for inspection purposes. PERMIT ISSUANCE a '
(We)agree m save,indemnify and keep harmless the City of Capenim against FEE
lisbilities,judgmerns,costs and expenses which may in any way metas againstsaid City ALTER OR ADD TO METH.
t in consequence of the granting of this Permit, PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) 1
SOURC .GULAT NS. t MECHANICAL FEE
// n9 AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Sign orefAp canHC tor `. Dam EXHAUST HOOD UVMUCI') HOUSING MITIGATION FEE
RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupied store or handle hazardous material HEATING UNIT(TO 110,000 BTU) '
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)V HEATING UNIT(OVER 100,"BTU)
Yes \ VENTILATION FAN(SINGLE R_ESIDJ PAID
Will me'applicant or future building xcupant use equipment Or devices which - Date Receipt I .
emit hazardousaircontamin♦snnisaas defined by the Bay Area Air Qwlity Management BOILER—COMP OHP OR 100,0110 BTU)
ietrictO Yes /x�CNn BOILER—COMP(OVER I(q,000 BTU)
I have reatl me hazardous thamrials AIR CONDITIONER ISSUANCE E
requlremetns and Gapier 6.95 of me Co'
Hesmdj
&a dthe Code.Sections 25505,25533 and 25534.1 understand met if the NEW RESIDENTIAL METH. SQ.IT.
�huildieg does not currently have a temnL mat it is my responsibility to notify the occupant
fe"
tf the requirements canal curd be met prior to issuanre of d Cenificam of Occupancy.
Owner or aumtnzedagem Date TOTAL: t
' ISSUED Y.
OFFICE