28723 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI"T"Y OF CUPERTINO BUILDING-ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL •. - 28723 Q 7 2 3
BUILDING PROdEGT IDENTIFICATION L�J
BUILDING AD RESS: - - , SANITARY NO. APPLICATION SUBMITTAL DATE
11 3�O 3
OWNER INA E: - PHONE:/' )'/ CONT R' \1E: LI O: t
"L'J 3 3yS GV NIC - CONTROL N
RCHITB NGINEER: LIC NO: A R S$: q ❑
'CONTACT PHONE:lye VA �/��J BUILDING PERMIT INFO
�� /��U ❑ Consultant Fees Paid by Applicant(Initial BLDG ELECT "PLUMB MECH
V ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
GKz with Section WIFE)of Division 3 of the Business and Professions Code,and my license is - 'RESIDENTIAL:
u�00 in full force and effec)). PERMIT ISSUANCE
�FWrr C-y(� CSS D D / ❑SFDWL [I KITCHEN REMODEL
UyU LicenseC ass Li0.M APPLIANCES ❑ADDITION r❑PLUMBING RE-PIPE
h6a] DatehContreawr - -
4 ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRGCTURAL
E7rn PANELS
Z O t/a I understand my plans shall be used as public records - MODIFICATION
02,.h. UP TO 200 AMPS
�.
Live nseit Professional C1 INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201=1000 AMPS IMPROVEMENT a
I hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1000 AMPS r -❑BATH REMODEUREPAIR ❑DEM (TION
ip5�O y U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
w F" which requires a permit to construct,alter,improve,demolish,or repair any structure f
priorto its iesuence,also requires the applicant for such Permian file a signed statement SPECIAL CIRCUIT/MISC.
>r at he is licensed pursoatnmthe provons of the Contractor,License Law(Chapter9
GOthisi
(commencing with Section7(YJII)of Division 3 of the Business and Professions Codi TEMP.METER OR POLE INST. 'COMMERCIAL:
a Oo N that he is exempt therefrom and the basis for He alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Cyd IL Section 7031.5 by any applicanw pe
t for a permit subjects the applicam a civil nalty of POWER DEVICES
ul^y - []TENANT [I FOOD SERVICE
not mora than five hundred dollars y employees
' F > IMPROVEMENT ,
0 ❑Lo the woo ofthe properly,or rmyemployeeswithwred for sale
compensation, 'SWIMMING POOL ELECTRIC t
will dothework,and the he Contisnots LicenseLaw do for salepply too an Business ,0OTHER
and Professions Cole:The Contractors License Law dcea not apply m an owner of OUTLETS—SWITCHES—FIXTURES
r: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 ELECIR SQ ET.
sale.If,however the building or improvement is sold within one yearofcompledomme -. SQ.FT.FLOOR AREA $/SQ.FI.
mer-builder will have the burden of proving that he did not build or improve for pur-
pese of sale.). I -
❑ I,as owner o0 the P.Peny,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7014,Bus and Presidents Cale)Tan CaThe Contractor's Li-
m
_ cee Law does not apply[.an owner of properly who builds or improves N,amm and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a eontractar(s)licensed pursuant to the Contractor's fin
License Lew. PERMIT ISSUANCE,
grinexempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(EEM
Owner Data VALUATION
re ..
y WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty ofperjury one of the following declarations - 1 '
❑I have and will maintain a Certificate of Consent toself-insure for Workers Co.,.- DRAINS-FLOOR.ROOF.AREA,COND.
_
station,as provided for by Section 37W of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
�w,m'k fm✓which this permit is isseed, FfXTURES-PER TRAP
ave and will maintain Worker's Compensation Insurance,as required by Section
M afthe labor Code,forthe performance ofthe work for which
rthis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
•,} M Workers Come a4R b3sn lHumnce carrierPOG YNo Policy i) d I / GAS-EA.SYSTEM-OVER 4(EA)
Cm
COMPENSATION
EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
f! BUILDING DIVISION FEES
I(This sediaa need not he completed ifthe permit is Forane hundred dollars($I00)
GREASETRAP
ar lessb �,/ PLANCHECK PEE ®"
I certify last inthe performance ofthe work for which this permit is issued,)shut[ SEWER-SANITARY-STORM EA.200 FT.
not employ say person in say manner so as to become subject w the Workers'Campen- ENERGY FEE +
Z, selion L.mwe of Celifomia.Dam WATER HEATER WNENT/ELECTR.
0 A"PPIicaM `- - GRADING FEE NSI
'—' NOTICE TO APPLICANT`.If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING
became subject to the Workers Compensation provisions of the Labor Code,you must SOILS ME
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE II t
I Y Ur U f .
Or CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U z (hereby aBirm tha,them e,aconcoction lending agency for the performance of Dates R tp
V the work forfinThis permit is issued(Sec.3IF Civ.C)
0 f~ Lender s Nan. - IAL:
W Lenders Address TOTAL. -
1 cenify that I have read this application and state that the above information is BUILDING FEE
L41 correct.I agree in comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U ,7a. building construction,and hereby anthanse representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection Professes. PERMITISSUANCE
(We)agree w save,indemnify and keep harmless the City of Cuperlino against - ELECTRIC FEE
Iiabilidi ,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. - '
in consequence of the granting of this permit " PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOW-POINT AIR HANDLING UNIT CEO 10,000 CFM) - '
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IQ000 CFM) CONSTRUCTIONT
Signature of ApplicanUContracwr Date EXHAUST HOOD MMUCT) ' HOUSING MITIGATIOPTME
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle lecarmaus material HEATING UNIT(TO I OgWO BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532bd? HEATING UNIT(OVER 100,000 BTU) ,
-y• ❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dam RecelPtM
Will the COMP Li HE OR I W(Ind BTU)air warn ro
or fure building occupant use equipment or devices which -
emit haurdous air contaminants as defined by the Bay Area Air Quality Management BOILER— - �TOTAL:
Disuim7 . 1 e BOILER—COMP(OVER 100,000 BTU)
[I Yes ❑No
-
AIR CONDITIONER
I have read the hazardous materials requirements under Chapter 6.95 of the Cali. - IS$}jANCF.,AA'1jL�
fomia Health&Safety Code,Sections 25505,25533 and 25534.I understand Nat if the t 3��{lJ 6y�
buildingdoes not curren0 have nanp Nal it'am hilar to notify the one"ant NEW RESIDENTIAL MECH. SQ.FT.
Y Y rc of. Y Y y
of Ne reg me est et primmts.uance of.CM ,�cpupa cy.
Own oaemoted agent 'me i, NOTAL: ISSUED BY:
OFFICE