28591 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28591
IiUH,OING PROJECT IDENTIFICATION
BUILDINGADDRESS: t SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' NAME: In E: CO `CTOR-SN ME: L N0: I "�
NIC CONTROL 9
ARCHITECDENGINEER: LIC NO: DRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S UECons of CON QTY ELECTRIC PERMIT FEE
1 ion? affirm that 1 am limned unmet and
protons of s Code. 9(commencing JOB DESCRIPTION
with Section 7(NIe)effect,
Division l ofthe Business and Professions CNE,and my license is
�O PERMIT ISSUANCE RESIDENTIAL'
U', in Poenforceend effect.
� F ❑SI'DWL LJ KITCHEN REMODEL
UU Datc Class Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION [I PI RFPIPEW Date ContrECL
1„praJr ARCHITECTS DECLARATION [I MULTI-UNIT ❑'101CTUNAL
PANELS
Z O 'LZ 1 andemvntl my plans nhnll he used ac Public records I MODTRUIFICATION
vv�2 UP'1'0200AMP5
O Z.f D ❑INTERIOR JdCFi1MNEY REPAIR
LicenxW Professional 201-I070AMPS MPROVEMENT
OWNER-BUILDERtDECLARATION OVER WDDAMPS ❑BATH REMODELREPMR (]DEMOLITION
1 hereby affirm IbmIur am Gexempt from the Comrucmrn License Law lin the
LLO U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL -[]OTHER
O y which requtmz a permit to reactant,alma improve,demolish,or xepair any structureniss
prioo its mance,also requires the applicant for such permit to file.signed statement SPECIAL CIRCUIT/MISC.
that he is licensed purxmort m the provisions of Na Cmnmctorm License Law(Chapter 9
p Go (commencing with Section 7")of Division 3 of Ne Business and Professions Cale)or TEMP.METER OR POLE INST COMMERCIAL:
that he is attempt therefrom aM the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC fL Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES„ ❑TENANT ❑FOOD SERVICE
W -y not more Nan five hundred dollars($500).
�G ❑1,as ownerofthe property.or my employees with wages as their into compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the strocturci.s not intended ter offered for sale(Sec.7040,Business ❑OTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OIIT'LHI S-SWITCHBS-FIXTURES
a' Property who builds or improves thereon,and who macs such work himself or through
his own employees,provided and such improvements arm not intended ar offered for NEW RESIDENTIAL L'LECfR SQ Ff.
sale.IL however.the building or immoceneal is sold within one yar of completion,he SQ.FT.FLOOR AREA S/SQ.Pr.
owner-builder will have the burden of proving that he did am build or improve Doper-
potentiate.).
or per-
pose of sale.))
❑hss of the property,am exclusively comming with licensed contractors to TOTAL:
mmmmu the project(Sec.7044,Business and PrMessions Code)The Comracnr'a Lk
cense Low does and apply to an owner of Draftily who builds or lmpnwes Damon,and Q'rY. PLUMBING PERMIT FEE g�,
who contracts for such projects with a contractionO licensed pursuant to the Commctoec �� 0
License Law. PERMD'ISSUANCE
I nm exempt under Sm. ,B&P C for this reason sC
Owner• Dem ALTER-DRAINla VENTWATER(EA) � VAL A S
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE I hereby affirm under penalty of perjury one of the Inputting declarations: (x
rhr
❑ I have and will mainmin a Certificate ofConsem to set insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND.
sation,u provided far by Section 37M of the Labor Cade,far the performance of Ne STORIES E CONSTRU
CnOk
work for which this permit is issued. FIXTURES-PER TRAP11'
❑ 1 have and will maintain Workct's Campen.wion Insurance,as iuluired by Sation
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-BA.SYSTEM-)INC.40IITLEfS
OCC.GRO AP
MyrWorkers Compensation Insurance carder and Policy number oro:
Carrieler. Policy Na.: GAS-EA.SYSTEM.OVER 4(EA) �
CERTIFICATE OF 11KRMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASEDNDIISTRL WASTE IN7ERCErR _(Thissection need nm be completed ifthe permit iz Tetonhundred dollar(S ItOD) INO DIV
nr less.) GNIiASP.TRAP PLANCHE FEI modify that in the performance o0he work for which this peandt is issued,[shallSEWER-SANITARY-STORM F.A.2W Fnm employ any Nosan in any manner so as m become subject to the Workers'Compen-z union Lows of California.Date� ApplicantWATP.R HLATiat WNENT/F.LECI'RF
q vs 'NOTICE TO—APPLICANT.If,after making this Certificate of Exemption,you should WKTER SYSTEM/TREATING
become subject to the Worker's Compensation Provisions of the Lehr Cade,you must Lstm oz
Li) forthwith comply with such provisiom car this permit shall be deemed rcvaked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
UO 1 herahyaffiml that thea iia mostrunian l0M11ngagemy fnthe perfamtenaeot Oma Rcci tp
Ws �-I the work for which this permit Is issual(Sm.31197.Civ.C.)
O U Lender's Nome TOTAL:
Ikl Lendefs Address TOTAL:
91.
1 certify Nat I have read this application and stoic that the above information is BUILDING FEE
Us correct.I.,me to comply with.11 city and coumyordireemsand mute laws odmingm Q'I'Y. MECHANICAL PERMIT FEE
V building construction,and hereby authorize representatives ofthiscity,to cnterupm the SEISMIC FEE
above.mentioned property for inspection purposes.
(We)egrce m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
limbal ars,judgmift,cost,and expenses which nary i n any way recruit against said City ALTER OR ADDI( MECIL
- in consequence of the griming of this permit. PLUMBING FEE
APPLICANT UN ERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT GO 10,000 CPM)
SOURCE RE !i" MECHANICALFEE
q1 AIR HANDLING UNIT(OVER 111,1X7()CPM) CONSTRUCTION TAX
StS�of AppbcenUContm `— D, 666 EXHAUSTHOODOW/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the applicant or future huddling occupant store or handle hazardous material HEAPING UNIT 00100.00 BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and no Health and Safety
Code,Section 25532601 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Data Recci"is
Will the applicantor ifuture building by theBupoint y Area
Air Quent ality
deviceswhich
BOILER-COMPQHPOR 100,00PTU)
emit District?
us air contaminants u defined by the Bay Area Air Quality Monngemcm
OimrinT
❑Yes ❑Nit BOILI?R-COMPIOVER 11X).000 BTU)
l have rtad rhe haxoNons mamdms rcquirtmemz unmet Chapter fi.95 of the Culi- AIR CONDITIONER ISSUANCE.DATE.
fomia Hulth&Safety Cate,Sections 25505,25,113 tend 25534 1 undersmnd that it[he NEW RESIDEMf1A1.MECkI. SQ.FTI'.
buildingdces urn curtcmly hav<a tanvm,that it is my responzihility m nmify Nit acupant
of the requiremcnu which mum be mer pdono issuance of o Certificate of Occupancy.
Owner m omhorlmd.lirnt Date TOTAL: ISSUED BY:
OFFICE