28994 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /1 f1 (�/N /I
BUILDING DIVISION APPI.ICA•I'ION/PERMIT PLUMB N;-MECHANICAL 2 8 9 9.1 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Dee lws oni
OWNER'S NAME: PHONE: CON" CI' JG LIC NO.
O®ANCHIT[CfIENGINEIiR: LIC NO: ADDRESS: N/C CONTROL#❑ ..
CONTACT: PHONE:
// / BUILDING PERMIT INFO
Y.C� _/�`SC� ❑ Consultant Fees Paid by Applicant(Initial) B,L,D_,G/ [CECT' PLUMB MECH
�!`�'1). 777 U V R2 ❑ ❑ ❑
LICENSED COST RACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE
1 hereby error,that].at Eccnad ander pow,f,e..of chapter 9(cammencmg JOB DESCRIPTION
wOZ withlical r70W) fDivision 3 0111 liusinus and ProfessinnsC ,nnJ my license es E D I
�uu1-u u in full force nn ae I'IiNMIT ISSUANCE. FDWI. ❑KITCHEN REMODEL
.19 . o2Gs3a
P z w License I' p ❑ADDITION ❑PLUMBING RE-PIPE
FZ41 Uatc swCanvacto APPLIANCES-RESIDENTIAL
IN,apy ARCfIITECPS DEC RATION t /nla an PANELS El MULTI-UNIT ❑STRUCTURAL
Z p h Z I understand my plans shall be used az public records MODIFICATION
O Z- UPTO 200 AMPS ,�
F 4 f'w Licensed Professional ❑INTERIOR jrpi HIMNEY REPAIR
aia: OWNER-BUILDER DECLARATION 201-IIX11)AMPS IMPROVEMENT
6 I hereby affirm that 1 am exempt from the Commanr's License Law for the OVER I000AMPS ❑BATH REMODEL/REPAIR DEMOLITION
3 LLF following reason.(Statin.7031.5,13almaol and Pndessions CMc:Any city or county SIGNS ELECTRICAL ❑OTHER
which regmms a permit m ainsfruet,alive impmvc,demolish,or repair any structure
���� pnorro its Alone,al xo relaias the applad,fnrcuch permiun file asigneal statement SPECIAL CIRCUIT/M1SC.
ppgg rLL1�i1�Y than he is licensed......intame pro,....Ovofthe Contmemrs Licence Law(Chapter 9
(yC�� (commencing with Section 9(KKI)ot'Division 3 ofthe Business and Professions Codt)m TENURMEfERORPOLEINST. OMM RCI
E E:c m that he is exempt therefrom and the basis for the allege)exemption.Any violation of ❑NEW BLDG/ADDITION
tea• Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑DEMOLITION
at more than Five hundred dollari S500j. ❑TENANT ❑FOOD SERVICE
�Sp ❑ Las ownerofrhe property,tem myemployces arm wagesar their.decompensaion SWIMMING POOL ELECTRIC IMPROVEMENT
tl•p.o will dothework,and mestmcma is not intended oroffered for sale(Sec.THO,Business ❑OTHER
Wand Professions Code:'File Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
IL properly 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 ELEC'IR SQ LT.
,.Its If.however,he buildingnr improvement issold witbin o.nyetraf mmplcuon,the SQ.FT.FLOOR AREA $/SQ.FF,
cr-builder will have flit harden of proving that he did not indoor improve fuaar-
p
ons
samawe.) . -
❑1,as owner of the progeny,am exclusively contracting with licensed contractors to TOTAL: AI�p 2 2 1996
amnhual rhe project(Sec.70,14. Professions
14.Business and Cale:)The Cantrettnr's Li- APR cease law does not apply to an ons of property who builds or improvesrhemon.and QTY. PLUMBING PERMI PE
wn
who<onhazufor such pmjecss wimamnuacmrts)licensed pursuant to the Cnntmctors
License Law. C'N1 of uu iCnIIIs`V
\
1
C]1 am exempt under Sec. ,R&P C for oris reason RMIT ISSUANCE
Owner Dec ALTER-DRAIN&VENT-WIT
E (FA VALUATION
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICIi � ('% -�
I hereby alBnn under pmarlty of perjury one of the fallowing drularmiod.s J LJ
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compact- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONS'I'RUCI'ION
satioo,as provided for by Section 371X1 of the Labor Gds for the Performance of the
work far Lh this permit is issued. IEX'I'URES-PER TRAP
I o e lord will moiaminWorker's Compensation Insurance,as required by Section
fthe Labor Code,far t'he�jo6rownce of rhe work for which this pemtitgis issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My---xrkf111prtlppaiat�pr ncc carrier and Policy Mmhetnd33/a�
Carrier:' O Policyolicy k•�xe GAS-EA.SYSTEM-OVER 4(Eq)
CERTIFICATE OP EXEMPTION MGM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION LTi&S
(This section need not be can.Orlard inhe permif is ounce hundred dollars S1NP -
orlese:) GREASE TRAP
PLANCIIECK PEE
Loy mymntinthe perfonnne,an t bework became subject
bjech thiI Permitisissuca, per- SEWER-SANITARY-STORM EA.NX)FT.
nm employ any person in any senses m m m become subject m the Workers Comped- ENERGY FEE
Z sation laws of California.Dec
Z O A licant WATER HEATER WNFiNT/ELECfR
PP GRADING FEE
NOTICE TO APPLICANT.
rvatommaking this Certificate of Exemption,yen should WATER SYSTEMlIREATING
becomes comp y the worker's Compton this provisions of the lafvt Gde,you must SOILS FEE
forthwith comply with such provisions or permit shall he JeenaJ rcvokcd. WATER SERVICE
as
Q
CONS'I'RUCI]ON LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.ET PAID
U 0 thereby alEnn that there is a consouetian landing agency far the pedimnance of Date Receipt#
the work It,,which his permit Ix moral(Sea 3091,Civ.C.)
'] Lender's Name TOTAL:
LJ Lando,Addcss TOTAL:
I}" a 1 certify has 1 have read this application and eta¢that he above information is BUILDING FEE
Z? correct.I agree to comply with all city and county andinances and state laws relating to QTY. MECHANICAL PERMIT FEE ZZ0
L) Z building information.and hereby authorize represcounives ofthis city to contraband the SEISMIC FEE
aboveomemiand property for inspection purposes.
a)
Wc
( goes to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FF;F.
liah#IR
Igmena,costs and expenses which may in anyway acerae againslood City ALTERORADDTOMECIF r
in cfrhe gramingo this permit. PLUMBING FEE
A I' T ON
.1' A W OMP LTH ALi,NON-POINT
AIR HANDLING UNIT(TO IONX)CFM)
SO T�,A'T S MECHANICAL Fiil$
/-.??-76 AIR HANDLING UNIT(OVER 10,M)CFM) CONSTRUCTION TAX
Signature of Applican/Contwtor / Dam EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant sore or handle hinumbus material HEATING UNIT CFO 100,000 BTU)
as defined by he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532FIF1HEATING UNIT(OVER 1100.1000 BTU)
❑Yes kevd/ PAID
VENTILATION FAN(SINGLE RESID) Data Receipt It
Will he an comm Or ratan h.ifi 1, he B use equipment tem devices which
Di"n"mrtlnm'air mmaminanlx ax Jctinnl by slit Hay Acott Air Onulhy Management BOILER-COME(JHP OR I(X),fXXI IF]GO
DistricYl
TOTAL'.
❑Vas NO' BOILER-COME(OVER IWJNI)BTU)
1 have read he hazudous materials requiamems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Heal 4 Safety Calc,Sanious 25505.25533 mJ SSR.1 undermad Onto if me NEW RESIDENTIAL MECH. SQ.ET.
brig nm curtendy havcarcwnt,than. ponsibilisymnmifyheoccuital
of he nus w) u�lur (pm/mi- sofa Ccrtiftc •y[( upaagv�
Owner or nuhnntad agent // 77 dd Dam// TOTAL: ISSUED BY:
OFFICE