28477 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO
BUILDING DIVISION APPLICATION/PERMIT- PLUMBING-MECHANICAL
BUILDING PROdhICI'IDENTIFICATION 28477
s BIIILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
OWNERNAME: PHONE CONTRACT
'S NAME: LIC NO:
g� v NIC CONTROL#
Iy CHITEC/ENG EER: LIC NO: ADDRESS: 415141 ❑
16 50 64411a
CONTACT: - PHONE: BUILDING PERMIT-INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT LU B At
LICENSED CONTRACFORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby off that L am licensed ander provisions of chapter v(commencing JOB OESCRrPTION
"Z with Scalm.7003).f Division 3.fthe Business and Profusions Code.and my license is
�00 Y PERMIT ISSUANCE RESIDENTIAL
ml all force and cf( I.
� ❑SPDWI. ❑KITCHIiN RCMODIB.
License Lic.p
FW Dem Cnmmcmr APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
ZNO"A ARCHITECT'S DECLARATION ja4G PANELS ❑MUUHbUNIT ❑STRUCTURAL
5 I understood.,,[am shall be used as public records MODIFICATION
OZrl-O UPT021NIAM1'S ❑INTERIOR C1 CHIMNEY REPAIR
� IY Licensed Professional 201-10011AMPS IMPROVEMENT
•�] O.,I an ULLDER DEthe Cmd ION OVER H")AMP5
1 hereby a(Brm mat 1 em exempt from the Conbucwr's License Low for the ❑BATH REl10DELIREPAIR 0 DEMOLITION
iGS,O y V Following reason.(Sermon 7151.5,Business and Profession.Cale:Any city or county SIGNS ELECTRICAL. ❑OTHE _
w 3 La F' which requires a permit to construct,Ther,improve,dc fish.nr repair any somehow
proem its issuance,also requires the applicant for such permit file a%ignedgncrosm SPECIALCIRCUIT/MISC.
that he is licensed porsuanuo the prosimona of the Couldewrs Licenso lxw(Chapter 9
00 (commencing with..............I Division 3 of the Business and Professions Castle)or TEMP.METER OR POLE INST. COMMPRCI
that he is exempt Therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
i�ro V. Section 7031.5 by any applicant for a pardon subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
lignm mart than five hundred dollars 13500. IMPROVEMENT
CD ❑ Las owner ofthe pruner,or my employees with wages as their sole cmnpeasahion, SWIMMING POOL ELECTRIC
(.; will do the work,and theewnare item intandedoruffered Trust].(Set.7( ,Biomass ❑OTHER
¢1 and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves down.,and who does such work himself or through
his on employees,provided that such improvements are eat intended at.ffered for NEW RESIDCNTIAL ELECfR SQ FT.
sale.IL however.the building or improvement is sold within ane yrdI complain,the SQ.FT.FLOOR AREA VSQ.FT.
owne,milder will have the burden.(proving ohm he did nm build or improve for par-
p+se of aide.). -
❑ I,as owner of me pmpeny,am exclusively contracting with licensed contractors to
consumer the project(Sec.II/f4,Bus and Professions Co d.)The C.mm........i-
censeLawdoesnotapplytoanownerofproperty who builds or improves thereon,and QTy. PLUMBING PERMIT FEE
who contracts for such projects with a connotations)licensed pursuant The Contmcmrk
License Law. PRMIT ISSUANCE
❑ I am exempt under Sec. - ,B&P C for this reaa.
ALTER-DRAIN&VENT-WATER(EA) - VALUATION
wrier Dme _ _ _ - pp��
WORKER'SCOMPENSATIONDECI:ARATION7�.. s "'/ BACK FLOW PROTECT.DEVICE s y� p�
I hereby affirm under penalty of perjury mw of the following declarations: R./
I have and will maintain Cenificme.f Consent wself-stow fur Worker,Comp o` DRAINS-F100R.ROOF AREA,( N
ami..,ns pr.viJal for M1y Section 3]110.(The Lot, Code. Terfarmanro of Thc 1 STYPO CONSTRUCTION
work for watch Ti,permit i,issue). IIXTURF.S PE,TRAl TOADS 17 19g
❑I have and will maintain Worker's Compensation Insurance as required by Section - n A99
3700.fthe Labor Cnde,handle perfirman uffie wgi.pI Tic permit is issued. GAS-EA YS'1'EM.I INC.40UfLETS f ROyP � APN
Crime, ersC.mpenaationInsurance<artierandPo roc: y A,SYSTEM.OVER4(EA) E {r1Nn
Camee Policy No,:
CERTIFICATEOFE.XEMPTIONFROM�ORKERS _ II -
COMPENSATION 1[[IISURAN 6R/INDUSTRL WASTE INTERCEPTOR 11
BUILDING DIVISION FEES
This section need not be complete)ifthdgmdt is foram hundred dollars($100) GREASETRAP,
or less.) PI.ANCHECK PPE
I cantly that inlheperformadecnfihc work forwhichthispermil isiasne_J,I sbull, ,. SEWER=SANITARY- CA.2hgIFT.
sToRM
n.temployanypersoninanymanne ism me vAs Pm the Werke ' en n- ENERGY IEE
Oz action Law fCaRt on Dem WATER IIFATER W/VENTIELECfR
z O
Apprised GRADING FEE
H FN-r NOTICE TO APPLICANT:If,afwr making Tis Cedific se o,you should WATER SYSTEM?BEATING
become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
@l fnrthwith comply with such provisions.,,his permit shall be deemed revoked. WATER SERVICE
Q
UQ CONSTRUCTION eGAGENCY NEW RPSIDCNTIAI.PLMB. SQ.lel'. PAID
IM1or which
i isned(Seat3097.dingagency for the perfnnnance of Dole h N
L4 F me work for which this permit is issued lScc.309],Ci,C.)
Q Lenders Name TOTAL:
I cert
W Lender's Astlyt
11....Ir ly costly that 1 have reed This application and state that the above information is BUILDING
Z) correct.l agree to comply with all city and county marmots and state lows relating to QTY. MECHANICAL.PERMIT FEE
(.)Z building construction,and hereby amhnrite represenutives of this city to enter upon the SEIS -C
.trove-mentioned property for impcaion Imrryrses.
(We)agree m save,indemnify and keep tuneless The City of Canadian against PERMIT ISSUANCE. ELECT sC
liabilities,judgments,costs and expenses which may in anyway acerae against sad City ALTER OR ADD TO MECH.
in mnseu fthe rantin 1 PLUMBING FEE
q g g. pcnnn.
APPLIf ]'UNDERSTAN TWILL CO IPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10,011)CFM) MECHANICAL EE
50 E GULA3'IONS
AIR HANDLING UNIT(OVER 111,1100 CPM) CONSTRUC7H NTAX
Signature of Applied .mwctar ' ;nc EXHAUST IIOOD I W/DUCT) HOUSING MI IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE 1
Will the applicant or furore building mamas store or handle h:mardnus material HEATING UN IT(TOIIq.IXNI BTU)
es defined by tM1e Copeman Municipal Cale,Chapter 9.1^_,and the Health and Safety
ode,Section 2553200? `1 HENTING UNIT(OVER IWIXIO[]TO)
❑Yes IyNn PAID X
'` VENTILATION FAN(SINGLE RB51D7 - Date - Receipt#
Will the applicant or 1'morc building ncarpnm use equipment or device.which
'toll haurdoos air enthusiasm as define)by The Bay Area Air Quality Management BOILER-COMP(3HP OR Wdgh)BTU)
TOTAL.:
District �k BOILER-COMP(OVER I(10,000 BTU)
Yes �R Nn
Ihavereodhh mLd
awrialsrequirerocrumder Chapter h95 of the Cid- AIR CONDITIONER IS. ANGARI
forma Heallry�h,m/P�gSafety Caons 25505,25 33 and 8534.I understand Tat if the NEW RESIDENTIAL MECIL SQ.F1'.
building do�glfty(itembandwnam,hhatit' my obTuddhility to notify Theoccupant
the t a=nwwhimet isRaantt.fa Ce ific�' yccupyh`y._
Uwncr.r sothonssJ agent d*j ,DoleeJ/Z L ISSUED BY.
OFFICE