28908 (2) 'APPOCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL ,PERMIT NO. 0 "
BUILDING DIVISION APPLICATIONIPERMPF PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
/
OV�R'S PHONE: C TRACfOR'S NAME: LIC NO:
- �k 4e N/C ��!!"^''���� CONTROLM ,
A CHITECT/ENGI E LIC NO: ADDRESS: /Q2
CONTACT: PHONE: - - BUILDING`PERMITINFO
aS3�l2Sb ❑ Consultant Fees Paid by Applicant(Initial) BLD E PLUM MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing AID DESCRIPTION
-❑0Z with Section]000)of Division J of the Business end Professions Cade,and my licenm is RESIDENTIAL:
❑p in full force enJ effe PERMITISSUANCE
OF ❑SFDWL ❑Kll'CHEN REMODEL
f�r...'U U Liit. Class Lic.M
Va<4 Date Canwaor APPLIANCES-RESIDENTIAL DITION [I PLUMBING RP.-PIPE
F• ARCHIT'ECT'S DECLARATION PANELS ❑M LUNIT ❑STRUCTURAL.
Z p I understand my plans&hall be used as public records MODIFICATION
O Z-a UPT0 2M AMPS
❑ 1 ❑INTERIOR [I CHIMNEY REPAIR
I•S4t:[�i Licensed Profesaionel; 201-Iqp AMPS IMPROVEMENT
J OWNER-BUILDER DECLARATION - OV ER IOOIIAMPS O BATH RERIDEUREPAIR El DEMOLITION
C Q I hereby affirm That I am exempt from the Contractors License law for the
improve,demolish,m repair any
3 a.F laze I
0 following reason(Section 1031.5.Holmes,end Profession,Code:Any city nr county SIGNS ELECTRICAL []OTHER
which malaise,a pewit m coma ryes, he, suueture
prioruiuiamance,six.requires theapplicant for such pewit,,flea signed stmement SPECIAL CIRCUURMIS
} Net he is licensed punuanuo the provisions of the Contmcmr's license Law(Chapter 9
ra po (commencing with Section 7")of Division J of the Business and Professions Cale)or TEMP.METER OR POLE.TN COMMERCIAL:
a se E that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
tL Section]011.56y any applicwt fore pewit subjects the epPlienm toacivil penalty of POWERDEVICES ?
W ❑TENANT ❑FOOD SERVICE
y t more N.IT.hundred it.]].. IMPROVEMENT
�6❑ pl,a cowna of Ne pmpeny,army employees with wages as heir compensation, SWIMMING POOL ELECTRIC ' _
vert do the work,and the swdum is oat imendeJ or offered for sale(Sec,]044,Business ❑OTHER
and Professions Code:The Contractnr'c License Law does am apply m an owner of OUTLETS-SWITCHES-FIXTURES -
a 3-s Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however,the building or improvement is sold within one year of completion the SQ.FT.FLOOR AREA VSQ.IT.
owner-builder will have the burden of proving that he did not build or improve for put
po _
se of sale.).- C
- E]1,as owner of the property,um exclusively contracting with licensed convectors to - - TOTAL: �s b, g 1!
construct the pmjact(Sec.]f144;Business unit Professions Code:)The ContmCone's Li- - - U
cense Law does not apply tom owner of property who builds m improves thercun,and QTY, PL G PE IT FEE �p•r ,.. ,
who contracts projects with a contatmnr(s)licensed Perxaantto the Contractors - OV I 26
License Lew. PERMIT ISSUANCE" 0 b. 1995- "
❑ I am exempt under Sec ,H&P C for this reason -
ALTER'-DRAIN&Vb - (EA) is 1 I Ur (,UHj"i^f VA UA'HON
Owner Dam 14,
WORKER'SCOMPHISSAT10NDECLARA)ION ' sr BACK FLOW PROTECT.DEVICE" + IIOyD
I hereby of ren under penalty of perjury one of the following dedarmtna,:
❑ I bnvemal will mairem..Cenificdte of Consent to wit-insure for Worker's Compen. DRAINS-FLOOILROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
satim.re provided for by Section 3]1X1 of the Labor Code,for the performance of the -
warkfar which this pbwitisismed. I FIXTURES-PER TRAP _ - -
❑1 have and will maintain Workers Compensation Insurance,va required by Section r
3700af the Labor Code,for the perfawonceUf thcworle for which this pewit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETSOCC.GROUP, APN
My Workers Compensation Insurance carrier and Policy number am: ' GAS-
Caniec Policy No.: EA.SYSTEM-OVER 4 EPA)
CERTIFICATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE GREASPJINDUSTRL WASTE INTERCEPTOR
(This acetion need nor be completed tf the pewit ie Tonins hundred dNlurs($1007 BUILDING DIVISION TTFS
car less.) GREASE TRAP PLANCHECK FEE
I certify that in the perfowanceof the work for which thispermt,is issued, SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner baso e e jam m Ne Worker'Co.,.. ENERGY FEE
z ,Z sation laws of Celifomin tit
O Applicant - WATER HEATER WNENDELECTR GRADING ME
sty NOTICE TO APPLICANT,TE ,'making this Certificate of Exemption,you should WATER SYSTEM/IREATING
become subject to The Worker's Compensation provisions of the Labor Cak,you must SOILS FEE
Wforthwith comply with such provisions or this pewit shall be reamed revokW. WATER SERVICE li
CONSTRUCTIONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ. PAID
I)Q work
hichwthemittiiuconswc.construction agency fm me pcdowantt of Receipt
P. � The,work for which this pewit is issued(Sm.709],Civ.CJ
Olender's Name TOTAL:
WLenders Addren TOTAL:
1 unify that I have read this application and state that me above momention is BUILDIN
W correct.I egme to comply with all city and county oNinances and stns laws miming N QTV MECHANICALPERMIT FEE
V Z building construction'
and hereby marodm representatives of this city to enter upon the SEISMIC FEE
ti above mentioned property fm inspection puryosas. PERMIT ISSUANCE
(We)agree m save,indemnify and keep howlcas the City of Cupertino agaimt ELECTRIC FEE
liabilities,judgmenn,costs end expenses which may in any way&serve agvnn said City uenALTER OR ADE MECIL -
in coneeqce of thw
due of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO IQOODCFM)
SOURCE REGULATIONS,". MECHA AL FEE
AIR HANDLING UNIT(OVER 10,00)CFM) CONS ULTION TAX
Signature of Applicam/Contrzcmr Data EXHAUST HOOD(W/DUCO HO LNG MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
-Will the applicant or future building meupantnoreur handle Tarakous material HEATING UNIT TO 100,0013 BTU) - s
I NO
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)'!' HEATING UNIT(OVER IIXI,000BN) - `
❑Yes -
[:1 No VENTILATION FAN(SINGLE RESIDE PAID
R
Will the applicant or eceipt g orfuture building occupant use equipment or devices which BOILER-
emit hernNuus sir conmminoms us definW by the Any Arcn Air Quality Mvnagemem COMP(JHP OR 1(10,000 BTU) .
District?] - BOILER-COMP(OVER 100.000 BTU) TOTAL:
, ❑Yes nNo '
I have rem!the hoommis materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCED
fomia Health&Safety Coale,Sections 2.5505,2,5573 and 25594,1 nndentmuf that if the NEW RESIDENTIAL METH. SQ.PT.
building doe est cu all It ten. Mn it is illy responsibility to notify rbc occupont
ofinereq ' m tsw must a ionnissuvnce nfv CeniOcme rosea ny.� + -
Ow nr euthorizal n®em lute _TOTAL: ISSUEDBY:
OFFICE'