28968 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, L is 8
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BUILDING DIVISION APPIACATION/PF,RNHT PLUMBING-MECHANICAL �XJ�lJl lhJ VX
IIIIILDI1,6 PROJF,CT IDENTIFICATION
BUILDING ADDRESS:i
Pv SAN]FARY NO, APPLICAHO SUBMITTALDATE
Saq
ZNF SNA" : M la PION _ CONT C )IT:S ,VSI"AMC:LIC NO: /�*
�IVV1l ILVrgP NIC CONTROL#
ARCHITECDEN INVER: LIC KO: AD }tFSS: A I ❑
CONTACT: PHONE: 3 L, BUILDING PERMIT INFO
estez5 _y ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LUM If MECH
I ❑ ❑ ❑
LICENSED CONTRACTOR'S DEC RATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QUO nme5utlnn 9gHp nfDivision3ofum'11d1n#ess and Protexsiuns Cale mdmylicclmu is pI;BMI'1'ISSUANCE RESIDENTIAL
CZ)
F fn 11 force and off r/ ❑SPDWL 0 KITCHEN REMODEL
FU u APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
N 6 W D , Commaor
ARCHITECTS DECLA PANELS ❑MULTI-UNIT GSTRUCTURAI.
F
z 0g zK I understand my,l..,,h.il be used.,public records MODIFICATION
oz—, IIP TO PID AMPS ' El INTERIOR El CHIMNEY REPAIR
F�2 t:41 Licensed Prnfes,mmal 201-I1ggIAMPS IMPROVEMENT
44 7-1 OWNER C Q I hereby affirm aha 1 em wimp ERomENe CommCLARAI �ors License law for the OVER 10IDAMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
X
E00 U followinglim,. (Section)1131.5. t,atm r. andProfessions
vex d do li Cale Any city as county SIGNS ELECTRICAL ❑OT=F_ ;R
W W LL F which rcyussu n permit re einswm,ppar,improve,dourest, file
repair any structure g/(/ 1(I_W_ L^�•.�^��tlI
��0� prionoir,isnu.nce,also requires the applicant for such perminofleusigneJ smtemem SPECIAL CIRCUI'TIMISC. V-T
that he is licensed pursu.nl to the provisiomaftbe Contncior's License Ltw(Chuluer9
W C0 (commencing with Section'l000)of Divioun 3 craft,Business and Professions Codd)or TEMP.METER OR POLE INST. COMMERCIAL
d 6 c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
Ir• Section 71131.5 by any applicant for a permit%objects the applicant to o civil penalty of POWER DEVICES
t mord than rive hundred dollars l$100) GTCNANT GFQQD SERVICE
IMPROVEMENT
=6 ❑Lmowner k.Nepfestruc or my employees wiNwages es Nei(See 7 CLBuaios, SWIMMING POOL ELECTRIC
will do Ne work.antl the mmcmreis nal intended or u((ertdfor sale l8ec.]DW.Business OTHER
I�i1 m and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—PIXTUktS
6'; pmpeny who fuilds or improves thereon,and who does such work himself or through _
his own employees,provided that such Ir;,rovemcnts are nor intended ar oflired for NEW RESIDENTIAL ELECTR $Q ff f.
sale.IL howeverthe building orimprovcmcat is sold within one year ofeumpleum.the SQ,FT FLOOR AREA $/SQ.IT.
owner-builder add have the harden of proving That he did not build or improve for pus
pose of sAe.).
E]L m m owner of the property,aexclusively contracting with licensed contractors to TOTAL:
ciarmin Ne project X.,90lq Busime„and Pmfdssinn,Gen)The Contractor's Li- /!n6 s
eerie Low dues nor apply to an owner of property who molds or improves lhefam.and QTY. PLUMBING PERMIT PEE APR d1. Lt 1996
whocontncus frsuch pmjecuwithacomracmgs)licensed pnsnan urhe Contrncmrs V y
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&PC for chis main Ur VUrr
Owner
ALTER—DRAIN&VENT—WATER(EA) VALUATION'
Wm under'S COMPENSATION Iofa1e following
BACK FLOW PROTECT.DEVICE Q
1 handyafoulunderpenahy lcperjuryaneofthefollowing declarations:
❑inner,
as and will foi by Section
37an of the Labor
Code.for are
Worker's ce of the
DRAINS—FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
,.dons as provided for by is i..n J]ql of the Labor Cwld,for Ne performance of the
work for which this permit is i oo,ce FIXTURES—PER TRAP
3I have and will maintain Workers Compensation Insurance,kfowhich r%Peri by Section
PllU of th�IrMr Cal for the erfo not at,oflhewnrk for whichod.+penniars issued GAS—fiA.SYSTEM-I INC.<011'I'LETS OCC.GROUP APN
My W kir' 1 d Policy u /
CarrieA..l I ePolicy No.: % VS GAS—EA.SYSTEM OVER 4 RA)
CERTIFI ATE OF EXEMPT ION FRONT WORKERS'
COMPENS A I'ION I NSURANCE GRF:ASUINDUS'1'kL WASTE INTERCEPTOR
BUILDING DIVISION FHES
(This,ecaion..W not becomplelediflhepermil is kaorchrodreddidirs($ton) GREASETRAP
or lust PLANCHECK FEE
Toy any Nainthe Taffarrany
as
Thermalork far which this the dit is Workers'
d.I,hdlCamped-
$EWER—SANITARY—STORM EA. FT.
nm employ any person in any manner mr m m hecame subject the Workers'Compel- ENERGY FEE
ZZ ,anon Lew,of California.Date WATER HEATER W/VENTA LECI'R
Q Applicant GRADING PER
N NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/1'REATING
become subject to the Workers Compensation provisions of the Labor Cale, no most SOUS FEE
Wfathavolcomplywithsuch pmvisionsurthispamitshallbcdecmedmyoked. WATER SERVICE
P� z CONSTRUCTION LENDING AGENCY NEW RIiSIDENTIAhPLMB SQ.F . PAID Date Receipt#
V 0 Thereby off rn that there is o constmetion lending agency for the performance of
0s f" the work for which this .it is issued Sat 3097,Civ.C.)
Lenders Name TOTAL:
ULenders Address TOTAL:
0. BUILDING FEE
1 cillme aria 1 have read 11 cry ad
and situ that the above information i.
to bonding 1 agree ct comply hue AI city and county ordinances and comm Iowa r.TFmi t e QTY. MECHANICAL PERMIT FEE
C.Jz building construction.and hereby auNerine nprescnmaivuof Nis city menmrupon the SEISMIC FEE
above-nu mired property for impeclam purpeus. PERMIT ISSUANCE
(Wed agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabil ities.judgments,costs and expenses which may in any way oceme against said City ALTER OR ADD TO M ECH.
in conscymuct,of the grunting of Int,pcnnll. PLUMBING FEE
APPLICANT UNDER S'1' NDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT TO 10.000 CFM) MECHANICAL FEE
SOURC RP ULATIO
DA AIR HANDLING UNIT(OVER 10,011)CFM) CONSTRUCIONTAX
Signature of App' trod. Dom EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PBE
HA. S AI'ERIALS DISCLOSURE
Willtheapplicamorfrom,building oecupammore or handle ImuNws material HEATING UNIT(TO 100.000 BTU)
az defined by the Cupertino Municipal Gale.Chapter 9.12,and the Health and Safer,
Code,Section 25532(.)! HEATING UNIT(OVER 100.000 BTU)
[3Yes ❑No RNEWR�IDEN71ATC
PAIDAN(SINGLE RBSIDI pate Itwtipl#
Will the applicant or future building occupant use equipment or davieds whichemir ha¢ardo s air contaminants us defined by the Buy Ana Air Quality Management OFF Oft 100.000 BTU) TOTALDistric?❑Yes FlNo (OVEft 100.000 N]'U)
I have read Ne harardous rn i.Is rcquiremcros under Ctnpmr 6.95 of the Cali- ER ISSUANCE DATE
Tomlin Health&Safety Code.Sections 25505,25533 and 2553].1 understood Nae if the1AL MECH. SQ.Er
building snot curt dyhavcatcnan.derouts yeespnnsibildym ifythc upmI
of them ch muss ce oft Cenif an d(hxu
Owner on tork"'ry, agent Tinue T(YTAL: ISSUP ''�
OFFICE