28808 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ a-S as 0 as
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 218 l87 S8
BUILDING PROJECT'IDENTIFICATION
BUILDINGADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
0 / V L ' lane -A slat dZ (6—n qS
OW R'SNAME: PHO CONTRACTOR'S��A`ME: LIC NO:
4 ,101' O S �/ .9Ss'6000 0404-7 e/' NIC CONROLa
•ARCHITECT/ENGINEER: LI•NO: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
,,,4e Is Coe s� �08s 606/ � Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
09 �a p
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FETE
1 hereby,i fiat that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section 7000)of Division 3 of the Basin sand Professions Code,and my license is RESIDENTIAL
Oall PERMIT ISSUANCE
inceneClassarai, nd effect. �Sa FOWL ❑KITCHEN REMODEL
t{.;.z{j License Class Lica APPLIANCES-RESIDENTIAL
NQpp Dme Cantracmr []ADDITION El PLUMBING RE-PIPE
F-7ym ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O Z CJ� 1 undvrsmnd my plans shot)x used as public records MODIFICATION
pp UPTO200AMPS ❑INFERIOR ❑CHIMNEY REPAIR
F'4 W Licensed Prdessiared 201-IIXp AMPS IMPROVEMENT"
�9 -'4j OWNER-BUILDER DECLARATION OVER Iqp AMPS - ❑BATH REMODFLREPAIR DEMOLITION
Q 1 hereby affirm Nat 1 am exempt linin the Contractor's License Luw far the
yU following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL []OTHER
F which rcquims a pvmds m constmct.alter,improve,demolish,or repair any structure
tho prior m its issuance,also re,tum,thespparal for such permitto file u,nocalmudemcm SPECIAL Cl RCUIT/M ISC,
tEa N that he is licensed pursuant to the provisions of the Contmcmis License Law(Chapter 9
G� (commencing with Section 7000)of Division 3 of Ne Business and Professions Cade)or '1'EMP.M ETER OR POLE INST. COMMERCIAL:
e eq that he is exempt thercfnnn and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of POWER DEVICES
❑TENANT ❑FOOD SERVICE
not mom roan Ov<hundrtd dollars(85W). IMPROVEMENT
6Q ❑1,as owner of ma praperty,army employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
C• will do the work,and the structure,is not intended oroffered for We(Sm.7044,Business []OTHER
and Professions Cash.3'he Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who dxs such work himself or through
his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
.]a.If.howaver,the buildingar improvement issald withimca,,eir ofcrmplairgtho SQ.FT.FLOOR AREA ,5/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for per.
pose of sale.).
I,as owner of me pmperty,am exclusively contracting with licensed contractors to TOTAL:
mascara,the ct Sec.7044,Business and Professions Cadet'The Court Li-
prrje ( — y
nselawdcesnotapply loan
swith aommatonywho
sed purrimproves the Connector's
onnecand QTY PLUMBINGPERMIT FEE
who se Lit .
for
such pct+Jeers whhacomracmr(s1licensed pursuam to the Commcmh
License Law. PERMIT ISSUANCE M
❑lam nempt underSm. ,H&1'C fnr Nin reason H�nkW�
Owner Dam ALTER-DRAIN&VENT-WATER(EA) �g/� AA�,yfTl-UATLON TJ
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE eoff i� 'Y 7
I hereby affirm under penalty of perjury one of the following declarations: \Y
Fl Hovermd will mainmina CertiBnamof CorsenuoaelFri forworkers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES M TYPE CONSTRUCTION
spirit,as provided for by Seen,,.37110 of ma Loss Code,far the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of the work for which thi s permit is issued, GAS-EA.SYSTEM.I IN040UTLE7S OCC.GROUP APN
My Worker's Connotation.Insurance carrier and Policy number me:
Cartier. Policy No.:• GAS-EA.SYSTEM-OVER 4(EA),
CCRTIVICATE OF EXEMPTION FROM WORKERS' GREASVINDUSTRL WASTUINERCEI'TOR (�
COMPENSATION INSURANCE
(This section need not becompleted if the pemdt is Forane hundred dollars D 1011 BUILDING DIVISION FEES
or less) GREASETRAP I certify that inearformi of the work
P K
this (.,which this permit is issued,].hall
SOWER-SANITARY-STORM EA. FT.
" 1995
not employ m
p y y person in any manner so us m he+me auhjcn to the Woderi Compen- ENERGY FEE
7-s action laws of California.Date
�O 11
Applicam WAIFS HEATER WNF,NtiLECfR - I'CRAI)ING H'FfrtHJ H p )
ti NOTICE TO APPLICANT,,If,af(ar making this Cerilicale of Exemption,you should WATER SYSTEM/rREATING
a ' becmne subject to the Worker's Compensation provisions of the Labor Cale,you must - SOILS IEE
fid foMwim comply wimsuch provisions or this permit andl be overread revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
L) ark far
thi thauhereisood(Secti0n lending7,Cs.agency fonbe performance of Dam Rettipta
i, P,
theder'.Name TOTAL thispermit is issued(Sec.3007,Cis.C.)
O U Lenders Name TOTAL:
LendersAddress
certTOTAL:
l7c 0. minify that 1 have,cad this application and state that the above information is BUILDING FEE 117 I
�rt V) correct.I agree to comply with al)city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FCC
L) Z building conswction,unit hereby mousimrepresenmtivesofthis city to enter upon the SEISMIC FEE a 7�
above-mentioned property for inspection purposes. pa
(We)ague,to save,indemnify and keep bat oder;the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
Iiabilitow.judgmencs ns wood expenses whichmaymarry way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of granting of this permit.
APPLICANT I' ERSTANUS AND WILL COMPLY WITH ALL NON-POINT Alli HANDLING UNIT(TO IO,OIXI CFM) MECHANICAL FEE ash �r.y
SOURCERE- ATIONS. O.aY O
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX 34,rs 66
Sig pplinenVCocancer a EXHAUST HOOD ONMUC17
HAZARDOUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will the applicant or future building occupant score or handle hsaadmix material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEA'T'ING UNIT(OVER 100,000 BTU)
Q Yes [:J No PAID
VENTILATION FAN(SINGLE RESID) Date Receipts
Will the air c nm or future building by the B use ea Air a or devices which
tics? mus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR IW,OOp BTU)
TOTAL: i •,
District?
Yea ❑No BOILER-COMP(OVER ionot10 BTU)
❑ � OF A
I haverev the haaurdmix materials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER IS DA
fomia Helth afery Crale.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
bui1dingd not currently h enint,dut mmoy re,lanorality moon the necupant
of rtrttenI whic vt Is,met prior to issuance ofeCe)jjlgvl c P
Owner or amhoriaed egenl a�Dac TOTAL: ISSUED
OFFICE