28481 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO BUILDING-ELECTRICAL PERMITNO. l
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL- 2848
1
BUILDING PROJECT IDENTIFICATION
BUZR SANITARY NO. APPLICATION SUBMITTAL DATE
2 6—7�\SAS
OWN 'S ME: PHONE: CONTg1C1'OR'S NAME LIC NO.
(7 �� NIC CONTROL#
A HE 'CT/P.NGINEER: LIC NO: ADDRESS: ❑
CONTAw PHONE: BUILDING PERMIT INFO
�//.Q / ❑ Consultant Fees Paid.by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION o 6 QT. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under previsions of Chapter 9(commencing
Matzwith Section 7lKKBof Division3ofthe Business and n PrdbepsiansCode,and myliccnse is RESIDENTIAL:
{s�D O . PERMIT ISSUANCE
F WE t full force and effort. ❑SFDWL ❑KITCHEN REMODEL
�UI' License Class Contractor
APPLIANCES-RESIDENTIAL []ADDITION C1 PLUMBING RE-PIPE
F t0. Date GOmtDECL
Z8=N ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT s El STRUCTURAL
y1 Z 1 understand my plans shall be used as public records MODIFICATION
0 G UPTO ZOO AMPS ❑INTERIOR [I CHIMNEY REPAIR
�'3u,] Licensed Professional - 201-1I00AMPS IMPROVEMENT.
OWNER-BUILDER DECLARATION CmuraON OVER 1000 AMPS ❑BATH REAJQQ _�PA`R�DEMOLI'PION
W 1 hereby amore that I R-exempt from the LRATI Oars License Law for the I��7�.g
O 6 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER Ta
F O which requires a permit.to construct,alter,improve,demolish,or repair any saucmre
poor mits imuance,also requires the applicant for uch permit mfileasigned statement SPECIALCIRCUIT/MISC. VI -A3 V43�
<�
that he islicensWpursuant to the provisionsofthe Convectors License Low(Chapter9
OD mommencingwith Section 7000),(Division3ofthe Business and Professions Crefil TEMP.METER OR POLE INST. COMMERCIAL'
q�5o eu' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDRION ❑DEMOLITION
W to Section 7031.5 by any applicant for u permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT FOOD SERVICE
fF...
WE more than five hundred dollars 1S5 W).
CZQ
[:1 1,as owner of Bre pmperly,or my employees with wages as Nairsole compommicn, SWIMMING POOL ELECTRIC IMPROVEMENT
X255 will do the work,and the structure is not intended oroffered for sad,(See 7W,Business ❑OTHER
ail i a and Profexaiom Code:The Contmcmrs License Law does not apply to an owner of OUTI.E'I:S-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 oRered for NEW RESIDENTIAL ELECIR SQ pT.
sale.If.howcventhe building or improvement,,sold within one year of cmmpletiaathe SQ.FT.FLOOR AREA $/$Q.FT.
ownerhuilder will have the burden of provingthat he did not build or improve for put-
of sale.).
1,ea owner of the pmpeny,am exclusively contracting with licensed,,streams 1. TOTAL:
stmct the project(Sec.70,14,nosiness and Professions Code:)The Contractor's Li.
cense Law does not apply.an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE t
whocomracts(arsuchprojects withacom s)licemosipur roomme Comrenors
License Law. PERMIT ISSUANCE
❑Ian n race, .Zff B&P C for this meson
Own Date ALTER-DRAIN&VENT-WATER(BA) ' VALUATION
WOR' R C PENSATIONDE .ARATION - BACK FLOW PROTECL DEVICE
i herehy alto.under penalty ofterjory one of ,following declarations:
❑I have and will mainminv CenifmamofCcnsem t sal6insure for Worker',Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPECONSTRUCDON
.tion,as provided far by Section 37M of the Labj Code,for the perfortrence of the
wool,far which Nis permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the LaborCode.fur the poll romance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE,INTERCEPTOR BUILDING DIVISION MRS
(This rection used not he completed time permit is boon,hundred dollars(5[ad) GREASETRAP
or less.) PLANCFIECK FEE
I comfy that in the Performance ofthe work for which this permit is issued,Ishill SEWER-SANITARY-STORM EA.2(0 ff.
not employ any person in any manner so as to become subject the Workers'Compe t- - ENERGY FEE
z Applicant
of California.Data WATP.R HEA'ILR_W/VENTA1LECR
Q 0 Applicant - GRADING FEE
y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you sipWd1 .'WATER SYSTEM/IREATING ,}
a ? become subject m the Worker's Compensation pmvisans of he Labor Crude,440 must SOILS FEF.
{Zar
forthwith comply with such provisions or this permit shall be'deemed revokW� q EI�R CI� •+'
Q ka
CONSTRUCTION LENDING AGENCY y; .N'RFSIDENTIAL PL. t '�S PAID
U rht R Date Receiptp
I hereby affirm mamore isaconstrunion leading ugcncy for the perfo once of
the work for which this permit is issued(Sec.3097,Civ.C.) ,
lenders Name ,5 TOTAL:
V Lenders Address - srr is -
Yr W0. BUILDING FEE
[y I comfy that I have reed this application and state that the shove information is s.
N correct.I agree to comply with ell city and county mdame,s and sate laws rela�Ihg to QTY. MECHANICAL PERMIT ,,:.%:FF!�
U 4a buildingconstruttion,aadherebyauNoize"p ntativesmfthiscitytoenterupb the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,mdmnnify and keep harmlos the City of Cupertino ugdIts,, MI]`'I$SIIAfICM.^ ELECTRIC FEE
liabilities,judgmems.costs and expemes which may in anyway accone ag' stmid City ALTERORADDTOMECH.-
in consequence of the inau this permit PLUMBING FEE
APPI ANT ,D ND WILL PLY WITH At ON-POINT AIR HANDLING UNIT(0l0,000 CFM)
MECHANICAL FEE
5 R GULATI -
AIRHANDLING UNIT(OVER 10.0,N)CFM) CONSTRUCTION TAX
Si...bacof ApplicanVL nuaaor Date EXHAUST HOOD(W/DUCI) H LNG MITIGATION FEE
HAZARDODS MATERIALS DISCLOSU
Will the applicant or future building occupant store or nd,e haxardaus material HEATING UNIT(TO I00,000 BTU)
as defined by Ne Cupertino Municipal Code.Chapter 9.12, d the Health and Safely
Cede,Section 25531(47 IEA'T1NG UNIT(OVER 100,000 BTU)
❑Yes Clam VENTILATION FAN(SINGLE!RESID) PAID "
Dart
Will the applicant in ams a building by the Bt y A equipment m deal,,which BOILER-COMP(3HP OR 100,1100 BTU) s
emit hamNous air contaminants as defined by the Bay Area Air Quality Mnmtgcmenl
Dlsmd? Visa
❑Yes ❑Na BOILER-COMP(OVER I00.000 BTU) 1
AIR CONDITIONER
I have read the hautdems materials requirements under Chapter 6.95 of the Cali- Nae_. ISSUANCE ATE
forma Health&Safety Code.Sections 255115.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FT. /1�a
Wilding docs not currently have a mount.that it is my responsibility m notify the occupant W/
of the requirements which must be met proton issuance of a Cmificate of Ihcupuay.-
Owner or mmoiaed agent Dam TOTAL: ISSUED BY:
OFFICE