28611 (2) APPLICANTTO FILL IN INFORMATION WITHINRED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING-MECHANICAL. 28611
BUILDING PROJECT IDENTIFICATION
BUILDING/ADDDRESS: f11�G L L SANITARY NO. APPLICATION SUBMITTAL DATE
7 3L-1 L V�
OWN' ' ME: _ I'�NG: CONTRACTOR'SNAf.IE IVB LIC NO:
Z •Z TL go N/C CONTROL
ARCHITL'CDENGINEER: LIC NO: ADDRESS: ' ❑ ,
O.
CONTACD PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) DG ELECT PLUMB MECH
6 U 311•Z`i76 ❑ ❑ Cl
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT` FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing LOB DESCRIPTION
QWZ with Section]000)ofDlvisinn]ofthe Business end Profession Code,aadmylicenscis RFg1DF.NTIA1.
�0 0 PERMIT ISSUANCE
1y full force and cRecf. ❑SFDWL ❑KITCHEN REMODEL
WQUtC' License Cl x Lich APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F+7aa Date Carleton.
g�0y ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O�� 1 understand my plans shall he used a public records MODIFICATION
OZ—Q UPTO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
q4�; Licensed Prnfesxional - 201-101KAMPS IMPROVEMENT,
aj OWNER-BUILDER DECLARATION
Commences
OVER I"AMPS ❑BATH REMQDHL/R IES R O UEM TION
1 hereby.(Siect that 1 12 exempt fain the Coni ns Ca License Law for the `��[Fl\�!-'lPv\
ip5,06 U following reason.(Section 10313,Business and Professions Cade:Any city or ucand SIGNS ELECTRICAL' ❑OTHER
which Made..pera it to cmduarl,alma improve,demolish,m repuir day swcmrc
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Nat he is licensed pursuad 1.daprovisimecefthe Contractor',License Luw(Chapaer9
Q0 (commencing wird head.7")of Division 3 offhe Busidessand Profesxions Code)or TEMTE
P.MER OR POLE INST. COMMERCIAL:,
Q,y a that he is exempt therefrom and the basis for the alleged'exemption.Any violation of [3 NEW BLDG/ADDRION ❑DEMOLITION
% an Section]831.5 by any applicant fee.permit subjects lhe.pplicsal Ind civil penalty of POWER DEVICES
WF. . f mom Nan five ladled dollars(S508). ❑TENANT FOOD SERVICE
W.
G I,as owner of the norm employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT '
2222 Q ❑ property, Y emP Y B pe t '
y Il do the work,and the strucmmume.intended License Law noes not applyt an Business El OTHER -
W .mlRaf<viob Code:The Commaon License Law does notapplyhimself
owner of OUTLETS-SWITCHES-FIX'fIJRPS
63� property who huildx arimprovn lM1erc.n,end who dues such work himself nr through
his own employees,provided that such improvements an,am intended m offered far NEW RLSIDBNTIAL ELECfR SQ FT. "
sale.If,however,Ne building.,improvement ix Ind withinoneyem.f completion,the SQ.FT FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build of improve far par-
❑L as ownerofthe Sec 7 Business
connecting with licensed cuntmelom In TOT consumer Lthe es not (Sec.o un Rosiness and Professions Cede:)The C.nvecaor's Li
ccnu law does not apply m un owner of pmpeny whobuilds
or improves themun,end QTY. PLUMBING PERMIT
who commets for such projects with acumracmr(s)licensed pursuanuo the Contmeus. ,
License Law. PERMIT ISSUANCE.
ElIsm exempt under Sec. .B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER IEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby union under penalty of perjury one of the following declarations
Ihaveandwillnum.m.CenfficuteefCansemt to self-inure far Wmker's Camper- DRAINS-FLOOR,ROOF.AREA,COND.
seated,m provided far by Section 37 W of the Label Code,far the performance of theSTORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
AI have and will maintain WmIa,ex Compensation Insurance,v recanted by Section
31004thc Labnr Cade.far the pe nnnuncemf Ne work for which flux permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS (KC.GROUP APN
My Wrrkiex rep esu Inset <e canter and Policy -
C.rtier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION RIPS
(ThissafionnceJ not becempleted if thepemtif is Lorene M1undreJ dollars(1100) GREASE TRAP
or IcssJ PLANCHECK FEE
I cemythal in theperformarecaffhe work fir-which this permit is issued,l shall SEWER-SANITARY-STORM F.A.2W Fr.
not employ any person m any manner so as to become subject m the Workers'Co.,... ENERGY FEE
Qz sation Laws of California.Date _ WATI7R HEATER WNENT/ELECTR
Applicant GRADING PEE
O '
NOTICE TO APPLICANT.IL after making this Cer ifieme of Exemption, ..should WATER SYSTEMITREATING
I"! become subject to Ne Workers Compensation provisions of the labor Ctdc,you must SOILS FEE
(W� forthwith comply with such provisions or this permit xholl he dermad revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
L)Ol herebywhich thi that there isacd(See.onlending agency for The performance of _ Date ReceipfN
the work for which this permit is issued(Seca 31197.Civ.CJ
0 F Lender's Nerve TOTAL:
[Q. Lender's Address TOTAL:
y 1 certify that I hove read this application dad cram that the above Information is BUILDING FEE
If) correct.l agree tocomply with all city and coumy ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U 4 building construction,and hereby mundane representatives ofthis city to enter upon the SEISMIC FEE
above-memdonul property for inspection purpues. PERMIT ISSUANCE:
(We)agree to save,indemnify and keep hamdess the City of Cupertino against ELECTRIC FEE
liabilities,judgments,cents and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ID."CFM) MECHANICAL FEE
SOU ON
9 Z ZS AIR HANDLING UNIT(OVER Ht"CFM) CONSTRUCTION TAA
Sigma reef Applicun om.tor,. Date EXHAUST HOOD(W/DUCT) HOUSIN NME
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hmardous material HEATING UNIT(TO I00,000 BTU))
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sufery A
Code,Section 25532(a)'! HEATING UNIT(OVER 1x).000 BTU)
❑Yes ❑Na VENTILATION FAN(SINGLE RESID) PAID VP LVl"[Ll,f
Date R p Y ,
Willfhe applicant or farm building occupant um equipment or devices which
ema mnomA. BOILER-COMP OHP OR 100,000100,000 BTU)
it hazed us air c nnmin.s defined by the Bay AAir Quality Management
DisWnL:
0 Yes ❑Nn BOILER-COMP(OVER 100,00000 BTU)
I have read the hazardous meteridx requirements under Chapter 6.95 of the Cdi- AIR CONDITIONER 1, ISSUANCE DATE
humid Health&Safety Code.Saunas 25505.25533 and 25531.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
Wilding doex matauca my have a meant.Nut n is my responsihiliry t.notify the rucupam
of the requirements which must be mel prior to issuance.(.Certificate.f 0ccuper,
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE