28795 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
'CITY OF CUP FRTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PFRMIT PLHMBINc.MEcMNICAL 28795
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW EX'S NA E: HO CONTp(,Gfp@'g IC NO:
�LJVeLXh> NIC CONTROLN
•ARCHITECT/ENGINEM: LIC NO: DDDR `: �� / ❑ ,
CONTACT: PHONE: 1I BUILDING PERMIT INFO
•s ❑ Consultant Ftts Paid by Applicant(Initial) BLDG ELECT B MECH
U '❑ ❑ LUM ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 and licensed under Provisions of Chapter 9(commencing JOB DES IPTION
�Z with Section?0H(E.f Dtvisi .3 fthe Business and Professions Cede,and my li=case is RESIDENTIAL:
in full fomc and e c*k. PBRMIT ISSUANCE
U❑�❑ License C u I< T SSS Lic,X D�'O ❑SFDWL [I KITCHEN REMODEL
�<y Data Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITES DECLARATION PANELSOw ❑MULTI-UNIT ❑STRUCTURAL
Zpyya l understand my Into shall beusedos publicrecords I MODIFICATION
UPT0200AMPS C1 INTERIOR ❑CHIMNEY REPAIR
Licensed Professional201-I000AMPS IMPROVEMENT '
OWNER-BUILDER DECLARATION OVER IM)AMPS ❑BATHREMODELI EP IR 11 DEMOLITION
'
I hereby affirm that 1 1. exempt from the Coolmsmrs License Law for the
4iy5O U which followingreason.pSection]rmametusine,land improve,
demolish,
Co de:Any city or county SIGNS ELECTRICAL []OTHER s� U I"' which its issuance,
s permit re canswch altar,improve,demolish, fi repair any slmcmre
that hor oiunsedalsnrequiree pousim omflant for esuch Permit micensle ae Law
(Chapter
SPECIAL GIRGGIT/MI
that he is licensed purstion 7 N)provisiom of the Commas License Law lChapsr9
00 he i`Z IrwingwiNSeetioon it In.basis far ofthe Business prion.Any vi Code?of TEMP.MEfERO INST. Comm
that he Irwin b any applicant
p li and toe basis far Ne alleged exemption.Any violation of ❑NEW BLDG/AD(ITION ❑DEMOLITION
aC ty4
not
]in.. by hundred
dollararapertnh subJeme the opplicunnnacivil penalty of POWER DIiVI []TENANT ❑FOODSERVICE
41 nm more than five hundred dollar(g500). GO
C] SWIMMING Ne pmperty,.r mydinuences withwred fixtlei(See.compenmaon. SWIMMING POOL ELfGfRI IMPROVEMENT
O will do the work,and the structure is not intended or offend forwk($ec.7044,Business []OTHER
and Professions Code:The Contravenes License Law does not apply to an owner of OUTLETS-SWIT 9- UR _
.r property,who builds or improves there..,and who does such work himself m through
his own'empleyea,provided that such improvements are not intended or offered for NEW RESIDENTIAL EL SQ PT.
sale.If.however.the building or improvement is sold within one year.(completion,the SQ.FT.FLOORAREA VSQ.FT.
mer-builder will have the burden of proving that he did not build or improve for put.
pose of sale.).
❑1,m owner of the property,am exclusively contracting with licensed contractors to TAL:
construct the protect(Sec.704q Business and Professions Code:)The Contractor's Li-
cameLawdoesnotapplymanownerofpropsrtywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
whormanicts forsuch projects with a commands)licensedrsu
puuan .the Commcmrs
License Law. - PERMIT ISSUANCE
Owner Date (E
E] 1 am exempt under See. B&P C for this reason
ALTER-DRAIN&VONT-WATER A) VALUATION
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTEGE DEVICE
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent m self-imam for Workees Causes- DRAINS-FLUOR.ROOF,AREA,GOND,
satiun,m Provided for by Section 37110 of the Labor Code,for the Performance of the I STORIES TYPE CONSTRUCTION
workfoe hi ch this pamsit is issued. FIXTURES-PER TRAP
end will maintain Worker's Compensation Insurance,as squired by Secdon
37W ofthe Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS DEC.GRU10P 14 APN
My Worker Compen tion
Crean canter and Policy nymegerq
Gurnee Policy N.
O'D ^) GAS-EA.SYSTEM-OVER4(EA) '
ERTIFICATEXFMPHON FROM WORKERS' Air, pi
COME OF PENSATION INSURANCE GREASERNDUSfRL WASTE INTERCEPTORi ES
an In..This section..it not be Completed if the permit is for one hundred dollars GRPASETRAP - PLAN yy T1.
Iramify that in the performance ofthe work fm which Nis Permit is issued,1 shall W 4
m to en SEWER-SANITARY-STORM EA. FT.
nolc -
p y y Califon in any mrtmner so az m become subject India Workers Cooper. ENERGY PEC
Z Applicant
Laws of California,Dem
O7-. O pplicuns � WATER HEATER WNP.NT/ELECTR O V GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
abecome subject to the Workers Compensation provisions of the Labor Cale,you must _ SOILS FEE
W forthwith comply with such provisions or this permit shall he dcemeJrcvoked WATER SERVICE
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
V Q i hereby a(fum that there is sued(Se.constriction0 lending agency for the of Data ReVisa`
0
'he andee,for which this permit is issued(Sec. Civ.C.)
Q Lenders Name TOTAL:
V Lenders Address IOTA
0. I certify that I have read this application and state that than above ws testing is BUILDING TEF.
ti comrca.l agree m
eComply with all city and county ordinances add stem laws relatingm QTY. MECHANICAL PERMIT FEE
plane-gconswctionn,andheeebyouthonzprposes. tivea.(thiscitymenterrupon Ne V.
SEISMIC FEL
above-mentioned 1.case forimpecyioapurposes. PERMITISSUANCE
- (We)agree m save,indemnify end keep hermleu toe City of Cupeninn against ELECTRIC FC
liabillties,judgments,costs and expenses which may in any way acme against said City ALI'ERORADDTOMECH. PLUMBING FEE
m consequenceof the gmnting of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1EM)CFM)
SOURCE REGULATIONS. MECHANICAL FE
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTIONTAX
Signature of Applicant/Conerector Date EXHAUST HOOD OVMUCf) HOUSING MITIGATION FEF. '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantorfuture building occupant storeorhandle limitations material HEATING UNIT(TO 1011,000 BTU)
es
refusal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,00(0 BTU)
El Yes Fl No
VENTILATION PAN(SINGLE RESID) PAID
Will thea applicant or future building occupant use t or devices which Date Raeipt X
pp g« p ea Aird, BOILER-COMP IMP OR IOGOW BTD
emit hazardous air c0nmminams ax defined by the Bay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes FIN.
I have tend the hallotation.mmerials reyuircmems ender Chapter 6.95 of the Cali- AIR CONDITIONER - � ISSUANCE DATE
fomia Health&Safety Coal,Sov ions 25505,5533 and 25534.I diamond that if arae NEW RESIDENTIAL MECH. SQ.FT.
building nacurte yhaveat t.thatitismy=WnsibilirytonWfytheoccupant
of Ne P ormjssygcq.f.cedificas upancy. �)('' A
or authorized ager �J11''VV�v1 14 to TOTAL: ISSUEDBY: `��-
OFFICE