28802 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PERMITNO, 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SSUUUBBMMIII17A�L DATE
ERS 1.A ' O PHONE: C(IM O '. N I. - LIC NO: C A^/
e. NICCONTROL
-Zpr
I ARCHITECDENGINHER: LIC NO: ADDRESS: ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MESH
❑ ❑ ❑ llko
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby anon that 1 am licensed under provisions of Chap=r 9(commencing JOB DESCRIPTION
�z with Sa11on70Q0)of Division3 ofthe Businessem Professions Codgnndm Himmel, PERMIT ISSUANCE
00 y RESIDENTIAL:
full force and effat.
OF n. ❑SFDWL [I KITCHEN REMODEL
��UU License Class Contract
W Ua¢ Cnmm�or APPLIANCES-RESIDENT'[AL ❑ADDITION ❑PIAMBING RE-PIPE
pF..Dams ARCHITECTS DECLARATION PANELS ❑MULTI-UNE ❑STRUCTURAL
ZpVJ IunderstanJ my plans shell be uuJ as public records . MODIFICATION
O,Z�(D UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F41-; Licensed Professional 201-IOWAMPS IMPROVEMENT
�h P - that I a exempt
m Ce Conte ON OVER INXI AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
44'' 1 heathy.(firm on 71 1. exempt from the Cosigns C s License Law for the
02U following reas�n.(Sarinn 70JL5,Business Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
I 10 F which requires a permit to construct,Ohm improve,demolish,or repair any Reunion, '
��� primmilsiss...eiRidor moss On...linen,mrsuch permiuo file.signed satemcntt LA
SPECIAL CIRCUIT/MISE.
} thm he is licensed pursuantto the provisions of the Connectors Licelue Law(Chapter 9
00 (commencing with Section 7000)of Division Sof the Bminessand professions Code)or TEMP METER OR POLE INST COMMERCIAL
4 c that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
^-,0 Section 7031.5 by yap.an applicant fora ❑NF:W BLDG/ADDITION ❑DEMOLITION
permit suhjsu Ne applicant to Penalty of POWER DEVICES []TENANT ❑FOODSERVICE
1F..., y not mom than Eve hundred dollars($500).
Cy�'Q ❑ Lo the worof the pro perly,mmyemployas wi owagesran(m.aompemmion, SWIMMING POOL ELECTRIC IMPROVEMENT
will Profework.ands: he cture Contractors
tended License offered(°rota(ply town Business ❑OTHER
a
and Professions Code:The Ces theme's License do dike not apply s if owner of OUTLETS-SWITCHES-IIIXNRES
properly who builds or aided to thereon,and who Jens such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR $Q IT. ,
Rule.If,however,Ne building orimprovemem is nuW withinnne yen,of completioglhe SQ.PT.MOOR AREA S/SQ.IT,
owner-builder will have the burden of proving that M did not build or improve for pur-
pose of sale).
El L as owner of the properly,nm exclusively contracting with licensed em ar m ons o. - TOTAL:
construct the pmjee9(Sec.70k .nosiness and Professions CMe:)The Comracars Li-
mass
i- I i
c ss Law does not apply to an owner of properly who builds or improves therw°.and QTY. PLUMBIN FEE Ar
who contracts for such projects with a conumcmr(s)licensed pursuant to the Contrem
cr's Q{{II
License low.
❑Ism exempt under See ,B&P C for this..Ron PERMIT ISSUAE CHS ( ' 41995
ALTER-qA[N&VEVT-WATER(HA)
Owner - Date V(jj,VALUATION
WORKER'S COMPENSATION DECLARATION BA LOW PROTECT.DEVICE `F71bL•V
I hereby affirm under penally of perjury ane of the following declarations:
❑ L have and will maintain a Certificate of Ccamenuo.sel6asum far Warker's Compen- DRAINS-FLOOR.ROOF,AREA,COND.
cation,as provided for by Series 37W of On labor Code,for the perfom.nce of fee STORIES TYPE CONSTRUCTION
workforwhichthispemitisissued. t FIXTURES-PERT P
❑1 have and will maintain Worker's Compensation Insumncq as required by tion
37W ofthe LaborCMgforlhe performance ofthe work for which d.spemi siuued, GAS-ISA,SYSTEM CiOUTL S
OCC.GROUP AI'N
My Worker's Compensation Insurance artier and Policy number are: r
Carrico Policy Nn: GAS-EA.SYS VE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF,ASM 1 RL WA#T. TERCE R
(This section need not be composed if the Permit is for a=humored Pollan 91W) BUILDING DIVISION FEES
or less) C 5 T \P
PLANCHECK FEE
Ittrtify Nminthe any mannceaDhe work
mewhichNis no Wokis em'Col, ell -SANIT Y-STORMEA. Ip FT.
not employ any person in any mannerso m m become subject m the Woders'Camp - ENERGY FFP '
0 z notion Laws of Califumi..Date WATER EATER WNENT/ELEC
ZR Applicam GRADING FEE
Iti NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEMUREATING
a ' hecomc subject m the W°rkm's Compensation provisions°fthe Lahr Cede,you must SOILS AEE
f31 forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
M A
t'7 :Z CONSTRUCTION LENDING AGENCY NC•WRESIDENTIAL PL SQ.ITT, PAID
V I for which
that there issedSee,i0nlending agency fur the performnnne of Dae RtteipN
D-t F the work for which this permit is issued(See.3097,Civ.C)
0 Lenders Name 'TOTAL:
GU] 1<nder' Address TOTAL:
I comfy that 1 have read this application and Hare Nat no above information is BUILDING FEC
%) comm.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
G F7 building construction,and hereby authorize representative ofthis city to enterupon the SEISMIC FEE
.bnswinamionM property for inspection puryoses. PERMIT ISSUANCE.
(We)agree resmml
ave,indeni fy and keep beraethe City of Columuaagati o aaaaaaa ELECTRIC FEE
liabilities,judgm,ms,costs and expenses which may in any way summe against said City ALTER OR ADDTO MECH.
in cousel a a(the granting of 0 it. PLUMBING FEE
APPLIC N1 UNDERSTAND. :NO IL CO PLY WITH ALI,N N-P INT AIR HANDLINGUNI'T(TO RI.000CFM)
SOUR IREGULATION. �� MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0110 CEM) CONSTRUCTIONTAX
gmalmard ApplicantlCon tar Uat EXHAUST HOOD(W/DUCI)
HAZARDOUS MATERIALS DISCLOSUREHOUSING MITIGATION FEE
Will the applicantor made,building occupant store or handle hnxurdons mahout HEATING UNIT(T(3100.0011(ITU)
as defined by the Cupertino Municipal Cade.Chapter 9,12,and the Health and Safety
Code,Section 25532(x)? 1 HEATING UNI'I(OVER I00,000 BTU) ,
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or turn=building t use t or devices which Data Receipt p
rr dby the
ea Air n BOILER-COMP(3HP OR I(I(k1gID B'TU)
emit hmunlnus air cantaminanu as defined by Ne Iluy Area Air Quality Management TOTAL:
District?
❑Yes 0N BOILER-COMP(OVER 10)[1,000 BTU)
I have rail the bazmdoua matchalsuiremenu under Chapter 6.95 of the Cali. AIR CONDITIONER
req ape ISSUANCE DATE
fomia HUBS&Safety Code,have
tins 255(15,25533 umd 25534,1 undersand that if the NEW RESIDENTIAL.MECH. SQ.PT.
building does not iswhincurrently have a tenant,that o is my ce of a Cagines notify the sx;c.pam
of the rtquimmenu which must ed met poor m issuance of a Ccnificn=n(Occupxncy.
Owner m umforized agent Data O ISSUED BY:
OFFICE