28713 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 28713
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: —� SANITARY NO. APPLICATION SUBMITTAL DATE
11" !0
OWNER'S NAME: �k C v PHONE: CONTRAC 'S NAME: L1+;0:
NIC ONTROL
•ARCHITECTIENGINEBR: LIC NO'. ADDRESS: ❑
CONTACT. , PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG_ ELECT PLUMB MECH
`I1/�Y`/ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions
na'Z of Chapter 9(commencing
ani JOB DESCRIPTION
thSection 7800)of Division 3 ofthe Business and Professions Code,roti my license is PERMIT ISSUANCE RESIDENTIAL:
FWF in fail force nntl< n. �X`���me 0SMWL ❑KITCHEN REMODEL
F�U License Clans Lit.a
NQ Da¢ ` '� Contractor _ L 44 a 1, APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
7y ARCHITECTS DECLARATION OMULTFUNIT ❑STRUCTURAL
PANELS
I an�Alyy.s��_d_��rryykappinns��sM1yy11 be used us pubids ds MODIFICATION
OZ- //�TI✓x _ Icor UPTO 2W AMPS wn'
D - - [I INTERIOR pQ¢IMNEY REPAIR
��,F'.m Lusn�scdimfemon I 201-IIXIOAMPS IMPROVEMENT I
sdf„'4j OWNER-BUILDL•R DECLARATION OVER IIXOAMPS [I BATH REMODEUREPAIR [I DEMOLITION
CC tt I hereby of roar that 1 am exempt from the Commmnr's License Law for the
s3 F following reason.ISmon.7031.5,Business and Professions Core:Any city or county SIGNS EL[CTRICAL ❑OTHER
W O which minima a permit to consumer,Ober,improve,demolish,or repair any si ucture
prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC.
That heir licensed pursun d to the provisim—f the Com eacmr's license Taw(Chapter 9
(commencing with Section 7"l of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL,
a o e that he is exempt theefmm and the basin for the alleged exemption.Any violation of t BLDG/ADDITION ❑DEMOLITION
D• Smtion 0031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
h ANT ❑FOODSERVICE
t more than five hundred dollars($SIX)).
�a ❑hmoevowk, id propenyor my employees withwugesazthei(See. 0,FUBusiness
sines SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the he Concis not imcnded o Law do formle(SmABW,Bunn Of
❑OTHER
G
andportico,
Professions Cede:The oyes therein License Law does not apply hi s anmwner of OUTLCTS-SWITCHES-FIXTURES
.r puberty whooyees.or improves Hereon,and who does such work himself or through
his own oomv Me building that such improvements are not intended nr olpered for NEW RESIDENTIAL ELELTR SQ FT. �
sale.ILhower will have thinburden fpcment ithat sold hewithin one uild Oimpri ve fogthe SQ.F1'.FLOGR AREA SSQ.FT.
owner-huildcr will hove the burJen of proving the he Aid not hail.or improve for bur '
pose Ofsale.. _ 0 1996
I,ss owner 0(N<pmpeny.am exclusively mmmcting with licensed commnors a TOTAL:
onswct the project(Sec.7014,Business and Professions CNet)The Commences Li- yl 1 a a
se Law docs not apply to un owner of property who bolds or improves thereon,and QTY, PLUMBING PERMIT FEE I'rr Ur'' LurtHIINU'
who contracts for such projects with a commands)licensed pursuantto the Contannr's
1.rcenu law' PERMIT ISSUANCE
❑lam Law.
under See. ,B&PCfrr this rtason
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dete
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declamtions:
C]have and will maintain a Certificate of Concato self-insure for Worker's COmixt DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
sauon,as provided for by Section 37M of the Labor Code.for the performance of the
work for which this peed,is issued, FIXTURES-PER TRAP
0 1 have and will roinmin Workers Compensation Insurance,its required by Section
37M of the labor Code.for the performance of Ne work for which Nis permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Works s tYyt lnsnn+lle cerys[r and Policyn s9�,c
Carries o WPOlicy Nu.: �N e070Y GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION MRS
section rend not he completed if Ne permit is for ane hundred dollars(S Ran
or less. GRFASIi TRAP
PLANCHECK FEE -
Icenifythat inthe performance of the work for which this permit is issued,I Shull SEWER-SANITARY-STORM EA. IT.not employ any person in any manner so as to become subject m . .the Workers Compen- ENERGY FEE
O Z sation Laws of Calimania.Date WATER HEATER WNENT/ELEC FR
z O Applicant - GRADING FEE
r NOTICE TO APPLICANT,IL slier making this Cmificme of Exemption,you should WATER SYSTEM/TREATING
a; become subject the Wo kin's Compensation provisions of the Labor Code,you must SOILS FEE
Forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. Sqml PAID
V 0 k for which
Nemec issco (Set.3097,
agency for the pcdormastconf Data Receipt
W L~ Ne work far which this permit is issued(Scc.309],Ci,CJ
Lender's NamW e TOTAL: ..Lender's AddAMIress TOTAL:
y I certify that I have rceJ this application and sem that the above information is BUILDING FEE
(Al correct,l agree to comply with all city and county ordinances and state laws elating to QTY. MECHANICAL PERMIT FEE
V ❑ building construction,and hereby aductie representatives of this city to corer upon the SEISMIC FEE
above-mentioned propcdy for inspection purposes. PERMIT ISSUANCE
(We)Ogren to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabiiities,judgmems,consand expenses which may many way nameagaimtsaid City ALTER OR ADD TO MECH. PLUMBING FEE
'n consequence of the granting of Mspermit.
APPLICANT❑NDE TANDS AND WILL COMPLY W�}}TTTjjjf�l ALL ON-POI,NT AIR HANDLING UNIT(TO W."CFM) MECHANICAL FEE
SOURCE GIRT S. 1 �,1 /w r
L 11,1c AIR HANDLING UNIT(OVER 10,000 CFM) CONsTRUCTIONTAS
Signawm ofApplic rAZARDO Dare EXHAUST HOOD(WB)UC17 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
.Will the applicant or fumrcbrilding wcupam score or handle hazuNous mnmrinl HEATING UNIT('TU IW,(kO BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety
Code.Section 2 532(a)? HEATING UNIT(OVER 100,000 BTU)
O Yes FIN. VENTILATION FAN(SINGLE RESID) - PAID
Date Receipta
Will thedous applicant or future building wcupart use by
Area
Air Qnt or uality devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the BOY Arca Air Quality ManaBcmcm
District? TOTAL:
C Yes. DNo TOILER-COMP(OVP.R 100,000 BTU) s ,
Ihave mail va
thehNm omaterials requirtmenu under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Sam.Health&Safety Code,Sections 25505,M533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not curen0y have a retort.that it is my responsibilitym nmify the cecopant
ofthe rtpurans as which most be met pd.,to issuance ofa Cenificamof Occupancy.
Owner or amhomed agent Date TOTAL: ISSUED BY:
OFFICE