28757 (2) APP.LICANTTO FILL,IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I '
CITY OF CUPERTINO BUILDING,-ELECTRICAL PERMIT NO.
BUILDING DIVISION " APPLICATION/PERMIT PLUMBING-MECHANICAL. r 28757
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x BUILDING PROJECT IDENTIFICATION
s BUILDING ADDRESS: - - SANITARY NO. AP/PPPL.ICATIONSUBMITTALDATI
Oct Ity
ER'g NA E: - THONG'. '
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C A. - PHONE: BUILDING PERMIT INFO
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L , :3 (�O� ❑ Consultant Fees Paid by Applicant(Initial) , I B '•. ELECT PLUMB MECH
I NO o ❑ ' o
LICENSED CORACTORS DECLARATION QTY - ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O a+� with Section 700E of Dt' for 3 offle Bust d Professions Code,anemylicensers RESIDENTIAL:
p IOy O in full fume vnd off PERMIT ISSUANCE s.
gapF:U U incense critC11111 i Lia#: D� ❑SFDWL :'D KITCHEN REMODEL
rr�zW Date w (, Con[racro APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
[�•++Don ARCHITBC IS DECLARATION PANELS ❑MULTI-UNIT" " STRUCTURAL
X p 2 I urger,"a�M�)•pl' hull y�blie7�Ns ,, MODIFICATION
OO Zc�g,+,CgGCCG��� �✓ional—w1(0�,��,/'+ I/N.a40— 'UP?0200AMPS INTERIOR [_1 CHIMNEY REPAIR
F.�., Lmensed Professional / v( 201-1"AMPS' MPROVEMENT
4yd OWNER-BUILDER DECLARATION OVER 10W AMPS El BATH REMODEUREPAIR El DEMOLITION
P W 1 hereby affmn that I am exempt from the Contractors Lic case Law for the
aO y U following reason(Section 7031.5,Business and Professions Code:Any city or cromY SIGNS ELECTRICAL HER
O which.requires a permit io construct,alter,improve,demolish,or repair any structure
prior to its Issuance.also requires thevpplicant for such permit o the a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuunun the provisions of the Contraco is Licenae Law(Chapter 9
Ci00 (commencing with Section]000)uf Division 3ofthe Braids.ind Professions Code)., TEMP.METER OR POLE INST. 'COMMERCIAL:
y m y that he is exempt therefrom and the basis for theallegedexemption.Any violation of - [_1 NEW BLDG/ADDITION ❑DEMOLITION
Y%l ti'
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
> t more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
TQ.E]1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOLELECTRIC IMPROVEMENT
GC will dothe work,amd the structure isinflatendedoruffered forsaI ISec.]044,Business ❑OTHER -
and Professions Code:'-TTe union
Lice a Law cines not apply m an owner of OUTLETS-SWITCHES-FIXTURES" �`
�'3.. progeny who builds or improves th eon,en ho does such w r m through his own employees,provided that s h ro cuts are not 1 ��T[offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.It,however,the buildingo ' f e old'within onelt a�itfc yli+ ple[ioq the SQ.IT.FLOOR AREA - SISQ.Cr.
ow ner-builder wit ave t d o Ing the nt Ido prove for par- 1.�
pose of saµe^). ,�/ Q
❑L m er e p rt ma e I elp co me mg with licensed wnhecam to TOTAL: -
onswn the proj ec.]044,Bus Esq\a,Td Professions Cadn)The Commetor's Li- -
come Law rices no a ly to nn owned Fropeny who builds or improves thereon,and QTY PLUMBING PERMIT THE
who contracts fors th rejects with v contraetorod licensed pursuantto the Contractor's '
Licemel.uw. + - PERMIT ISSUANCE - +
❑I am exempt under Sec. B&P C for this reason'
ALTER-DRAIN&VENT-WATER IFA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION - BACK FLOW PROTECT.DEVICE .
I hereby affirm under penalty of p ujin,one of the fallowing doclamtinm: -
❑ I have and will numbion a Certificate of Consearto self-insure far Workers Conifer- DRAINS-FLOOR,ROOF,AREA,COND.' STO IES TYPE CONSTRUCTION
action,as provided for by Section 3]00 of the Labor Cade,for the performance of the ` -
work for which this permit isissued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as regoired by Section `
3700 nf[he Labor Code,for the fertrrmance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCOGROUPAPN -
My Worker's Compensation Insurance currier and Policy number are:'
Carrier: - Policy No.. GAS-EA:SYSTEM-OVER 4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ' GREASEJINDUSTRLWASTEINTERCEPTOR .
BUILDING DIVISION FEES
(This section need not hecrmpleted ifthepeimii is fnronc hundred dollars($100) GREASE TRAP
or less.) PLANCHECKFEE '
I certify that in the performanceofthe work for which this pnrmii is issued,I shot[ SEWER-SANITARY-STORM EA.200 IT.
rot employ any penor m any ma ner so a m become subject to the Wu r of pen- ENERGY FEE
z nation Lv shr ia.Dal WATER HEATER WNENT/ELECI'R
Applicont�' ry.�lr ' GRADING FEE
z h NOTICE APPLICANT:1 'afar making this Cerift ee of Exemption,you should WATER SYSTEM(fREATING
�^ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS 17EE
W {'y forthwith comply with such previsions or this permit Shull be deemed revoked. WATER SERVICE
�
,Z
CONSTRUCTION LENDING AGENCY "' NEW RESIDENTIAL PLMB. SQ.FT. PAID Date .Receipt#
.V I for
rwhichithi thatdrail i isaed(Sced30 lending agency for the performance of -
the work fpr which this permh is issued(Sec 3099,Civ.CJ '
0(--� Lender's Name TOTAL:
I3I, lender's Address. TOTAL:
Ty 1 certify that)have read this application and ,are that the above information is BUILDING FEE
V) cores.l agree to comply withal]city and county ordinances and store laws reforms to QTY. MECHANICAL PERMIT PEE
building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
elf—woommned property for inspection purposes.
(Wc)agree to save,indemnify and keep numbers the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE D ( #
liabilities,judgments,costs and expenses which may in anyway accrue against said City ALTERORADDTOMECG - -
in onse,fo ce of the granting of this permiu PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM) MECHANICAL PEE
` SOURCEjEG CATION s' n .. �'
�I:`�r �Q' • ..7/ZV AIR HANDLING UisIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature ofAppfFa Co for to EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE "
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicentnr future building occupant store orhandle haznNous material HEATING UNIT(TO 100,000 BTU)
es defined by the Caperton Municipal Code;Chapter 9.12,vad the Health and Safety
Code,Section 25532E)] a HEATING UNIT(OVER I W,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) . PAID
Dam �Recei
" Will the applicant or future building occupant vee eqm' mens or devices which -- ,
` •vark hazardous air contaminants m defined by the Bay Area Air Quality Mamagcment BOILER-COMP GHP OR 100,(100 BTU) TOTAL
District'
❑Yes [IN. Is
- - BOILER-COMP(OVERI IL000 BTU)
I have tend the hazardous mnterials AIR CONDITIONER
requirements ender Chapter understand
of the Calle ISSUANCE DAT
fomin Healthes&Safety Code,Sections 25505:25533 and 25534.I undersivnd thw if the NEW RESIDENTIAL MECH. SQ.PT.
as boildinysdoes nmcren"Ryhave atenani,that i+ismy respnnsiM1iliry to notify Ne occupant (,I L( of UW'CT111NU+
o ereq'rca=ra!a ins a,to imuvn ofa Certificate Oc uponey.
Own or,itudarifIalajerit, Dae TOTAL: "r ISSUED BY.
- t
OFFICE