28844 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. /�^ /A a� /1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L XV VX 4 4
BUILDLING PROJECT IUEXTIFICA'1'ION
BUILDING ADDRESS: SANDARYNO. APPLICATION SUBMITTAL DATE
OY6
OWNERS NAME: PHONE: CO RACfOR'S NAME: LIC NO:
VNO ,-1 I /� e�._C �.O Nis r- NIC CONTROI.p
z 99
ARCHITECT/ENGINEER: LIC NO: ADDRESS El i ❑
Cr
CONTACT. PHONE: BUILDING PERMIT INFO
McZs 2 s3 ^g33Z ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELO PLUM MECH
Dtie ID
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I nerebr anirm mm I am eeenam under promxh,nx ar chanter 9(=ommearmg JOB DESC IP"CION
OC2 (h Sec(iun?000)of Divinioni of the Buslocxs unJ PmRssions Csrle,and my license is RESIDENTIAL,
F�•OO I.full force and effect. PERMIT ISSUANCC
W� ❑SPDWI- ❑KITCHEN REMODEL
�UV License Clens Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUh1RING RE-PIPE
F�[R Dmc TSDECLARATION
VVF1IOw
ARCHITECTS UF:CLARATION PANELS [:1 MULTI-UNIT ❑STRUCTURAL
Z O rn Z I understand my plans shall be used as public peards MODIFICATION
OZ-O UP TO 200 AMPS ❑INTERIOR C1 CHIMNEY REPAIR
r4f"W Licensed Professional 201-10X10AMPS PROVEMENT
�y$� OWNER-BUILDER DECLARATION OVER 10011AMPg THBEMODEU"PAUt ❑DEMOLITION
W C Q I hereby affirm that 1 um exempt from the Contrucmr's License Law,for th<
f 3 L F following reason.(Section 01131 5,Business and Professions Code:Any city nr county SIGNS ELECTRICAL ❑OT ER
41 a y which requires a permit to construct.ober,improve,demolish,or repair any swaure
prior it)its issuance,also requires the applicant for such permit on file a signed statement SPECIAL CIRCUI'rIMISC.
ythat he is Iren.wd pursuant)the pmvi cions of the Contractor's License Law(Chapter 9
W 20 (commencing with Section Than of Division 3 nrlhe Business and Preresslon.s Code)or 'L'EMPMMERORPOLEINS, COMMERCIAL:
6 a e Y Nat he is exempt thcrtmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�w
section 7031,5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE.
t mom than Ove hundred dollars($5ot0.
F Z Y IMPROVEMENT
ca wi Lo the work.IM1e pro peny,mmyemployncs with wages for sale
SWIMMING P(N)I.ELECTRIC
FO will do rework.Code:
That oiitisnoC%Liecow Law
for catalpa.0814,Business DOTTER
3m and Pny who b Code:Thc Commnors.and sc Law docs or apply toanowner of OUTLETS-SWITCHES-FIXTURES
a' his o ny who builds or improves thereon,and who fleas such work himself m through
his own employees,provided that such mens is sold
are not intended of m oRered for NEW RESIDEMIAL ELECIA SQ FT.
sale If.however.the building or improvement is sold within one year of<ompleion,the SQ.FT.FLOOR AREA LSV.FT.
wn
n-huilder will have the burZnh.,d,that he did m IJ or improve for pur-
pose of sale.
I,as owner of the ProfKny, con tin8 with lien ed contractors(o TOTAL:
mnetmm IM1e pmjem(Sec.7044. fessions Code:)Thc onwewrs Li- S�� 2 �(]��
nw Law does not apply m an fy who builds orimpros ,thedun,and QTY. PLUMBING PERMIT FEE a7
whocontrai for such Francis rts)licensed pursuant to Commerols /s �yLicense Luw, PERM1 I'ISSUANC17 Gr VI' �VI�G�I1 am exempt under Sec. .u&P C h this reason INU
ALTER-DRAIN&VENT-WATER FFA) VALUATION
WORKHSC
Owner Cre
1 rebY.E.under pc ally of OT fOte rag amiona: HACK PLOW PROTICLT.DEVICE /�r�yO
•Dlhavc dwill mVImmerse
untnog orkcrs Compcn- DRAINS-II.pOR,ROOF,AREA.GOND. ST J VV TYYIiCONSTRUCTION
lion,as p vidcJ do L �raCCld s r the pcmframer or the
whir Chissitu FIXTURES-PER 9'RAP
and ill orks 'om a nwmttce,as mquirtd ny Senium3700 of the Wtx Cperfn ante of work for which this permit is issued. GAS-PA.SYSTEM-1 INC.40UTLEfS OCC.GROUP APN
My Wnrkcrs Cnn carie and Policy number are
Cartier. PnInv No.: GAS-HA.SYSTHM OVHR 4(PA)
CE gCATEOF MPTION FROM WORKERS'
COMP SATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This senior recd BUILDING DIVISION FEESomple(ed ifum Permit is fortune hundred dollars($I00)
or less.) GRFA$F:'TRAP PLANCHECK FEE
I certify that in the performance of the work for which this Fermi is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
notemPloy env ymunnenyp (o cjLone suhicy1 m lite Workeri ComPen. ENERGY FEE
Z
r'l- O NO3'ICE —� � y9S WATER HEATER WNErELET
ApPlicam
GRADNG ME
TO cPPUCAM:
If,after making this Cenifca¢of Exemption,you.should WATER SYSTEMOTEATING SOILS FEJT
become subject to the Worker's Compensation Provisions of me labor Code,you mus(
� '.
forthwith comply with such Provisions mthis Permit shall be deemed revoked. WATER SERVICE
0
]z CONSTRUCTION LENDING AGENCY NEW RISIDENTIAL PLh10. SQ.ET. PAID Dmc
V G l hereby effort that mere is a construction lending agency forthe performance of
H the work for which this permit isissa.it(Sec.3r97.Civ.C.)
OI Name 1 O"fAL:
r IULI Lenders Address
y 1 certify that 1 have read this application and stale mat the above information is BUILDING
rF. h cores(.I agree it,comply with all city and county ordinances and state laws mlating nt QTY. MECHANICAL PERMIT FEE
U z building construction.ant)hereby aulhmrice representatives oTlhiwp
hy to enter upon the SEISM
above-meriinned Property for inspection puHtoxs. PERMIT ISSUANCE Q
WO agree to save,indemnify and keep hasnless the City of Cupertino against ELE I
liabilities.judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
consequence ofthe. ) granting of .Mali PIAMB ,PE
APPLICA ' ERSND
TAS WILL JMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.00d CFM) MECHANICAL FEE
SOUNC F.GUI ATIONS,
AIR HANDLING UNIT(OVER I O,(glO CFM) CONSTRUCTIONTA
0 6
Si m •u Appllcam/Contuc(or Dae EXHAUST HOOD(WMUCI) HOUSING MITIGA ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous material HEATING UNIT(TO 100.1100 BTU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'I HEATING UNIT(OVER I00.(100 BTU)
❑Yes F1 No VENTILATION FAN(SINGLE RESID) PAID
Dale Receipt a
Will the applicant infuture building occupant use ea Air mor devices which
ist huznMous air comeminanls as Defined by the Noy Arca Ar Quality Management BOILER-COMP(1HP OR IW.(g0 BTU) T09'AI.
Distrix?
❑Yes ❑No BOILER-COMP(OVER 100.000 BTU)
I have read me harandous macrial.• AIR CONDITIONER
reyviremenls under Chapter 695 0l the Colt- ISSUANCE DATE
(aria Health&Safety Code.Sections 25505,25533 wd 25534.1 understand ma if use NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a¢natty,that it is my mspmsibility to notify the occupant
of the"doememu which must be oat prior It,issuance of a Cenilicide of Mrupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE