28996 (2) ArYUGfUN I I U FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMITPLUMBING MECHANICAL.
BUILDING PROJECT IDENTIFICATION 28996
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAG
O NER' AME: r PHONE: SNA O: q_1—IL
NIC CONTROL#
• —ARCHITECT/ENGINEER: `l LIC NO: A S: &I_3 ❑ ,
CONTACT: PHONE: - BUILDI IT INFO
❑ COnsultant Fees Paid by Applicant(Initial) BLDGLECI' PLUMB - MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby atrmn that Tara licensed under provisions of Chapter,9(commencing JOB DESCRIPTION
Op with Section? )of DivisionJufthe Basin Prmfesio C dmylicenceB PERMIT ISSUANCE RESIDENTIAL:
m full force ENc a.d 6 LElSFDWL ❑KITCHEN REMODEL
I�I.. icense lass Lic.
fnzw Date Contmc aA APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
RCHITECTS DECCiDSIRM PANELS ❑MULTI-UNIT ❑STRUCTURAL.
ZO I understand my plans shall he used os public tecnrds��, QW/1./ MODI ION
OZ-, / 'OPTO200AMPS
D ❑INTERIOR NEY REPAIR
gi1" Licensed Professional 2UI.1(0)(IAMPS IMPROVEMENT
pp OWNER-BUILDERexemptfmm theARATION
ommom OVER 10M AMPS
Q 1 hereby affimt thus 1 em exempt from the Comracmr'x License Law for the [I BATH REMODEVREPAIR [I DEMOLITION
a0.UE
following..arm (Section 7031,5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
C.] which requires a Permit to construct.alter improve,demolish,or repair any structure
prior to its ismance,alsorequires theapplicant for such Permit to file.signed statement SPECIAL CIRCUIT/MISC.
y�y} that he is licensed pumu.at to the previsions of the Contractor's License Law(Chapter 9
000 (commencing with Section 7")of U vision J of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt tltcofimm and the basis for Ne alleged emmlaimn.Any simian..of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5byany applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
❑TENANT ❑FOODSERVICE
a more than five hundred dollars($500).
F6 0 1,as owner ofthe Property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
CCCG will do the work,and the structure is not intended.r.ffered formic(See.]tWa,Business ❑OTHER
and Professions Cale:The Contractors License Low does not apply to on owner of OUTLETS-SWITCHES-FIXTURES
4i 3 progeny who huilds or improves thereon,and who does such work himself or through
his own employees,Provided Nat such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR IV
SQ -
aide.If,however,the building orimprovemem is sold within one year.(completion,the SQ(F WORAREA $/SQ.pT.
owner-builder will have Ne burden of proving that he did not build or improve for pur- �//��
post of sale.). 199
C]1,as owner of the property,am exclusively contracting with licensed c.nmactom to TQ � rI
construct the project(Sec](144.Business and Professions Code:)TheComrucmr's Li- z 1,•r
cense law does not apply to an owner of property who builds or improves thereon.and QTY, PLUMBING PERMIT I'rC
who contracts for such projects with a comracue(s)licensed porm ntto the Contractor's,
'License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C forthis mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dele
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Ihcreby afEEl antler penalty of perjury one of the following dederetinns: ��
[have and maintain a Certificate of Comsento self-imine for Worker's Com,rn- DRAINS-FLOOR,ROOK AREA,CONU. STORIES TYPE CONSTRUCTIONcation,as vided for by Section 37M of the Labor Code,for the performance of the
work which this permit is issued. FIXTURES-PER TRAP "
has,
anted will maintain Workers Compensation Insurance.os required by Section
Cam ofh;Qsa Policy Nuk for which th ��is'sw GAS-EA.SYSTEM-OVER 4 IA)LETS OCC.GROUP APN
MyW rape b andy N.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not he completed if the permit is forooe hundred dollars(SIM) BUILDING DIVISION FEES
orless.) GREASETRAP
PLANCHECK FEC
Loy mythatothe performance ,the bacork for subjectch to Perthe it Wisissued,I'Comhull SEWER-SANITARY-STORM EA. FT.
not employ any person in any manner m az to become subject m the W.dem'Compen- ENERGY FEE
Q z sation Laws of California.Date WATER HEATER WNENT/ELECfR
Applicant - GRADING FEE
4 NOTICE TO APPLICANT.If,after making this Codifies.of Exemption,you should WATER SYSTEM/IREATING
a ' become mbject to the Weaken C.mpensadon provisions.(the Labor Code,y.a must SOILS FEE
fy forthwith comply with such previsions or this permit shall lm deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U rs Ihereby which,IN that there isacanswe.i0n lending agency for the perf.tmance of Dam Receipt at
� [air... the work for which Nis permit is issued(Sec.3097,Civ.CJ
O U Lender's Name TOTAL:
Lender's Address
-k, TOTAL: t
f}�t I certify that 1 have read this applimado it state thot the above information is BUILDING ME
f-r
In correct.l agree to comply with all city and county ordinances and state laws mlating to QTg MECHANICAL PERMIT FEF.
U buildimgcnnstmction,and herebya.thaiserepresentatives of this citym enter.,.the SEISMIC FEE
above-mentioned progeny for inspection purposes.
(We)agree in save,indemnify and keep harmless the City of Culwrtimu against PERMIT ISS DANCE - ELECTRIC FEE
liibilitie nm'costs and expenses which may in any way acame against said City ALTER OR ADD TO MECH. PLUMBING FEE
Inc equence fNes.orgofthis ermit.
A LI AN NDsR TAN , WILL COMPLY WITHIW.NON-POINT AIR HANDLING UNIT(TO IOM00 CFM) - MECHANICAL FEE
S OR( : -GO IiIn.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Slitsidure of Applicet nuuct Date EXHAUST HOOD(W/DUC)
HAZAR SMATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the applicant orf buddn cupam score or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Mume ode,Chepmr 9.12,and the Haalsh cad Safety
Code,Section 25532(x)? oe" 11CATING UNIT(OVER ROSIN BTU) -
❑Yes Nn
VENTILATION FAN(SINGLE RPSID) PAID '
Will the opplicent or future bull occupant use equipment or devices which Date - Receipt N
• emit haanNous air coomminams a used by the Buy Area Air Qualify Management BOILER-COMP(JHP OR IM,(D0 BTU),
TOTAL:
District? BOILER-COMP(OVER I(D,000 BTU)
❑Yes No
]have read the haaatdnus materials re uircurents under Chapter 6.95 of the Coli- AIR CONDITIONER
9 u ISSUANCE ATE
f.oia Health&Safety Code,Sections 2550.5.25533 and 255]4.1 uMerataM thus if the NEW RESIDENTIAL MECH. SQ.FT,
building does not currently have a mount,that it is my responsibility o notify the occupant
of the requirements which must he met prior to issuance of a Ccnificom of Occuperwy.
Owner.,outhorisd,orn - Data TOTAL: - ISSUED BY:
OFFICE