28810 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY t
CITY OF CUPERTINO "1- BUILDING-ELECTRICAL PERMITNO. /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL- /8 Q 1 0
BUILDING PROJECT IDENTIFICATION L V 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
90 397 W& m o 4z, /an Tl
OWNER'SNAMB: PHOGN -�/./� CONTRACTOR'SNAME: LIC NO:
', a T �h 0 5/GO 11460 (�f r NIC CONT OLa
ARCHITECT/ENGINEER: LIC O: ADDRESS: "'
CONTACT: PHONE: BUILDING PERMIT INFO
4 `oe C'� e, !J s%—,6o e./ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
LICENSED a CONmed tod RS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby norm shat 1 ad.liaased under and
Pro tna of Ohopter 9 my hea ping - 70B DESCRIPTION
�pZ with genion 7000)ofDivisian3ofthe Business and Pmfesslons Code,and mylicense is
HWr in full force and effect. PERMIT ISSUANCE SFDWL �RITCHIE
td M License Class Contractor
APPLIANCES—RESIDENTIAL
W Date Conpamnr ❑ADDITION ❑PLUMBING RE-PIPE
Fy ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
Z O m 7J. I understand my plans shall he used asblie records PANELS
Pu MODIFICATION
OZ40 I1PT0200 AM PS ❑INTERIOR El CHIMNEY REPAIR
Licenttd Professional 201-I000AMPS IMPROVEMENT
..l Oat I am
DECLARATION
W 6 1 hereby affirm that t cin exempt from the Contractors License Law for the OVER Iq)pAMPS ❑BATH REMODEVREPAIR �DEMOLITION
O y U following reason(Semon]031.5,Business anJ Professions Cotle:Any city or county SIGNS ELECTRICAL C OTHER
F`�„•O F which requires a permit to conswm.aper,improve,demolish,or repair any swcmrc
Print to its issuance,aim requires the applicant for such permit to fibita,dednatement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
POO (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: ,
G Ly e that he is exempt therefrom and the basis for the alleged exemption Any violation of
)d� El NEW BLDG/ADDITION El DEMOLITION
tWil Sedion]0315by any upplicadtfor a,,($50Enron,mhjed the epplicanunacivil penalty of POWER DEVICES El TENANT 0FOOD SERVICE
FZ Py' not more than five hundred dollars(8500). - IMPROVEMENT
C ❑ Lo the workf the properly.remyemntended withwages r (Sec.
compensation, SWIMMING POOL ELECTRIC
will dothework,and thesuumontis dots Licensprofferedfor sole(Sec.70an Business ❑OTHER
R and Professions who
Cnda:Thp imp..Contractors License Law does not apply s if owner of OUTLETS—SWITCHES—FIXTURES
progeny who builds or improves thereon,and who does such tints himself ar through
his own however,
the
provided that such mentis sol dw are one intended or offered for NEW RLSIUENTIAL EI,ECI'ft SQ FT
cale.menbuiwevenll have
eburen offementisat he
noneyldorimrovetfonthe SQ.FT.FLOOR AREA $ISQ.FT.
o.,a of rte).will have Ne burden of proving that he did not build or improve for pun
❑pose of sown. s a Ver O
I, u owner of the pm.70,1 ,B exclusively contracting with licensed nnmmnors to TOTAL:
construct the protan(Sec.]044,Business and Professions Coda:)The Contractor's Li- -
c se Law does not apply to an owner ofpropeny who builds or approves thereon,and QTY. PLUMBING PER FEE
who amoreats for such patterns with o co rnmeaudi)llansed pursuant to the Contru tors
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
Owner Data
ALTER—DRAIN&VENT—WATER(EA) VALUATION
' ^
WORKER'S COMPENSATION DECLARATION'S BACK FLOW PROTECT.DEVICE �/ / I e
O��
I hereby affirm under penalty of Perjury one of the following decimations: C v
C I have and will maintain a Certificate ofConcent o self-insure for Worker's Com �pen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Cade,for the Performance of the
work for which this permit is issued. FIXTURES—PER TRAP -
C r have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the Isrfoamanceof the work for which his permit is issued. GAS—E,.SYSTEM-I reINC.4 OUTLETS ffl�y;; {{O�CC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number a : y� µq Q
Came,: No.
Policy : GAS—EA.SYSTEM-OVER 4(G)
CERTIFICATE OF EXEMPTION FROM WORKERS'
'COMPENSATION INSURANCE GREASEIINDUSTRL WASTF INTERCEPTOR BUILDING DIVISION FEES
(9akercdon need not becompleted tithe parted,is forone hundred dollen($RICO GREASETRAP - /
or less.) -- PLAN E K
I cenifythat in the performance ofthe work for which this permit is issued.Ishall SEWER—SANITARY—STORM EA.200 FT. CMI
not employ any person in any manner so bje
as to become suct m the Wnrkers'Camped- IENER�PY,FEES
,z sation Laws of California.Date - ' t.t•t 1
zO Applicant WATER HEATER WNENTRUECfR' ' I GRADING FEB
i.y ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
abecome subject to the Workers Compensation provisions of the Labor Cade,you mixt SOILS FEE
67 forthwith comply with such provisions onhis permit shallbedeemed revoked WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
L) Q .r
UI hereby affirmthat there is a construction lending agency for the performance.f Date Receipt of
the work for which this permit is issued(Sea 309],Civ.C.)
0 U Lenders Name • TOTAL: -
LkI Lenders Address TOTAL:
(y I certify that I have read this application and state that the above information is BUILDING FEE
W correct I agree m comply with all city and county ordinances and state laws nations to QTY. MECHANICAL PERMIT FEE w
U building construction,and hereby andamize representatives ofthis city to enter upon die SEISMIC FEE 6 70
above-mentioned property for inspection purposes.
(We)agreesave,to indemnify and keep harmless the City of Cupertino PERMIT ISSUANCE against ELECTRIC FEE YJJ V Q
liabilities,judgments,costs and expenses which may in anyway areas,against said City ALTER ORADD TO MECH.
conazquedceof Negrantingofthis permit PLUMBING FEE 3
APPLICANT DBRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IL000CFM) MECHANICAL FEE
SOURCBR ,ULATIONS./) /v ��
(y�,�/'�„— / _ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
�A✓V
Si tureof ApplicanVConnacame Date EXHAUSTH ODD ONMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
El Yes. ON.lei VENTILATION PAN(SINGLE RHSID) PAID
_ Doe Receip[N
- Will the applicant or Fours building occupam use equipment tor devices which BDILEkCOMP(3HP OR 100,000 BTU)
emit hazard —
hazardous air contaminants as defined by the Bay Area Air Quality Management
District? TOTAL:O{District?
❑Yes 0 N BOILER-COMP(OVER 100.000 BTU)
ZHeatffi
anthe hazardous mmenatsreuirtmems under Chapter of the Coi= AIR CONDITIONER
9 P I ISSUANCE DATE
bamfety Cae,Sections 25505,25533 and 25534.1 understand that if theNEW RESIDENTIAL MECH. SQ.FT.
builumntly hav enanl,Nat itismy msptnsib'iry tontify the oaupamof ths whit x met prior to issuatme mf m ifice O Nancy.
r authorized agent Data TOTAL: ISSUED BY:
Ila I
OFFICE