28516 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
RUII.DING DIVISION APPLICATIOWPERMIT PLUMBING-MECHANICAL 28516
BUILDING PROJFCT IDRN'1'IFICATION
BUILDINGADDRESS: AT
SANITARY NO. APPLICATION SUBMITTAL DE
S fir-z5-
O NER'S NAME: i'HONE: C RACTOR'S N LIC NO:
ZZ NC CONTROL# -
?RIMIT /ENGINEI?Ii: LI NO: ADDRS:
�—
CONTACT,. PHONE: 3MIc 2k&&4k 1 BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QT y ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(cnmme erg JOB DESCRIPTION
�aZ with Semon]")of Division 3 of the Business and Pommuinna Code,and my license is
O O rCRMn'f$suANce RESIDENTIAL:
Li full font vnJ of
I-UU Z SFDWI. ❑KITCHI3N REMODEI.
U U Licen: Lic.N _
b-�ul Dam Comrador APPLIANCES-RPSIUI3NTIAL ADDITION LUMPING REPIPE
0Ihp.rn Dy , ARCHITECT'S DECLARATION PANELS [I MULTI-UNIT TRUCI'URAL
Z I understand my plans shall he uxd as public Iccoks MODIFICATION
.!nZa UPTO 2W AMPS. ❑INTERIOR C1 CHIMNEY REPAIR
5s4. LL1 Licensed Professional 201.100IAMPS IMPROVEMENT
J OWNER-BUILDER DECLARATION
Contractors
ON OVER EXRAMPS ❑BATH REMODELREPAIR El DEMOLITION
L x 6 I hereby affirm on 70 am exempt from the Cononaors License Law o fou the
kd0aO Yoliowingrcasoaermii to
Business andve.deionsh,or realAny airy or county SIGNS BLECfRICAI. ❑OTNEN
which requires a pewit m ennswa,altar improve,demolish,or repair any swcture
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECI AL Cl RCU I'UM I SC.
<� Thal he is licensed punuam la the provisions of the Contractor's License Law(Chapter 9 - -
�� (commencing with Section]000)ofpivision 3 ofthe Business and Professions Cade)or TEME METER OR POLE INST. COMMERCIAL:
Q.t>c T& that he is exempt members,and the basis for the alkged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
2 not mole than Ove hundred dollars($5010.
Rd Las owner of the norm In res with wn SWIMMING POOLELCCTRIC IMPROVEMENT
1 O ❑ props y yeti# y yfroade(Sri.7mFL B sines,
will do the work,and the swctureisnot intended o Law
far sale(Sec.]M4,Business ❑OTHER
G3�^ and Professions Code:The Conrmwer's Litems do does not apply self owner of OUTLETS-SWITCHES-IIXTURI!S
his o ny who boils,or improves thereon.and who sax such work himself or through
his own employees,e provided that such mentis merm arc not intended or offered dor NEW RESIDENTIAL CLECfR SQ FT.
owner-builder
-Mwer .will have flue burng orden of proving
is at hedidwithin t haild or improve
.the pay, ,SQ.FT.FLOOR AREA -USQ.Ff.
ownerhuilder will have the burden of proving that he tllal not toils or improve for pur-
❑Las ownerof the prope0y,am exclusively contractingwilt litanies ll.— m TOTAL:
mnswct the project(Sec.](114,Business and Professionss Code:)The Cnnuazmrs—
ase Law does not apply to an owner of property who builds or improves thereon,and Orly. PLUMBING PERMIT FEE
who common for such pricers with u ennlrealm(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
El I on exempt under Sec. ,B&P C for this ream, _
Owner pate ALTER-DRAIN&VENT-WATER IRA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
I harcbyvlfirm under Penalty of perjury one of[tic lbllowing declwasions: V y
❑I have and will maintain a Certificom of Cousentto self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,GOND. q'OHIES TYPO CONSTRUCTION
sedan,o rvided for by Section 3]1X1 of the Labor Calc,for the perfnmlence of Ne
wor rwhich this pc.is is issued. FIXTURES-PER TRAP ..
hove sand will maintain Workers Compensation Insurance,as required by Section
My eche Labor Code,for pranonnanceafthe work for which this pcnni`islasu GAS-F.A.SYSTEM OVER 4_(P.A)OUTLETS OCC.GROUP AI'N
My Worye�}.C� ,Iia ier,nd Policy nm fJ 92r5L/
Catricr(�BI /tyre Policy Nov
CERTIFICATECOMPENSATION
EXEMPTIONFROMWORKERS' -
COMPENSATION INSURANCE. GREASI'IINDUSTRL WASTE INTERCEPTOR
(Thi,watian need net becnmpleted iOhepermi,is for one hundred dnllwa($I(K)l BUILDING DIVISION FEES
or less.) GREASETR&Pp, PLANCHECK fg3L•
I cenifythalin theperformanceef the workfmwhiclvhispermit is issued,l shall, C"SP.s . SANITARY-
not employany person in an manner seas w hecbme sub ect to the Worker'Cc n-j STORM EA.list PT.
a 1 ENERGY FF:C ,
oration anwe of Ca ifo ia.Date — A
O Applicant �.�— \ WATER NEATEN w/vPMI'/ELECIH GRADING FEE '
zN ff//rw NOTICE TO APPLICANT:If,after making this Cer ilicme of Exemption,.%%X%%X,,,o,,,u¢¢Iauld - s WATI!'.yST ,ATING
a [' becomasuhjecl to the Worker's Compemanory provisions of the Labor C 1Je,Nnft must SOILS FEC
G fanhwith comply with such provisions or this pewit mill he rcsTOs$ge�� P SigVIGE
aQ
� Z CONSTRUCTION LENDING AGENCY ('�P�E�. NEW RESIDENTIAL PLM B. SQ.FT. PAID
L) r1 Ihereby affirm that them is a construction lending agency for the entrance of Date Receipt#
O Ip-yy the work for which this permit is issued(Sec.3197,Civ.C.)
Lender's Nome TOTAL:
ULenders Address " TOTAL:
I!-y' I certify Ihm I have read this application and smm that the above information is '# v BUILDING FEB
h correcn l agree to comply with all city and county ordinances and state laws refining to QTy, MECHANICAL PERMIT FEE
V 4 buildingconsuunion,and hereby authorize representatives oflhiscity master upon On SEISMIC FEE
abve-Inentioned pmpeny for inspection proposes._ PERMIT ISSUANCE
(We)agree to sive,itinerantly
and keep harmless the City of Cupenino against ELECTRIC FEE
liabilinies,judgeram,emotional expemw which may in any pmy...Sam,,said City ALTER OR ADD TO MECH.
in consequence of Ne granting of this permit. PLUMBING FEE Sal
APPL NT 'NDE S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
Sf RC[ ,ULATIO MECHANICALFEE
AIR HANDLING UNIT(OVER 10,0011 CPM) CONSTRUCTIONTAX
Signewm ofAppliran unlrncmr Date EXHAUST HOOD(W/DUCT) ROUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding mccupanfatore or handle hazardous material HEATING UNIT LTD IIXI,(MA BTU)
as defined by the Cupertino Municipal Code_,Chapter 9.12,and the I front and Safety
de,
CoSection 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
[3 Y. ❑No VENTILATION FAN(SINGLE RFSID) PAID O�o -Z)• y37
Date CA 6 IN2ceiptp
Will the it contaminants
or future building occupant use u Air ern or devices which BOILER-COMP QHP OR 100,000 BTU)
emir hazardous air conmminums as defined by the Buy Amu Air Qwdiry Management TAC: J
District? -
❑Yes ❑No BOILER-COME(OVER 100.000 BTU)
1 have read the hazardous materials rt uimmetps under Cha 6.95 of the Cali AIR CONDITIONER
9 Tee ISSUANCE DATE
Funds,Tow nt Safety Cale.Sections 25505,owit 25533 and 25534.f understand thin if the NEW RESIDENTIAL MI!CH. SQ.FT. �I I Y UI' lzUf C fit 1101-
ITV V
buildinguirenmts hi,h..,tbe,mently have e,pior oixmyrasp.Ceritytonmify thniums,um !Y
of Ne requirements whish moo be mel prior to issuance ofo CeniOcam nl'(h<upancy.
Owner nr authorized agent Date 'TOTAL: ISSUED BY'. TDC Vcce
OFFICE