28508APPLICANTTO FILL-IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING - ELECTRICAL.
PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING - MECHANICAL
O
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS:
-
SANITARY NO.
APPLICATION SUBMITTAL DATE
`15 -
O ERS NAME: PHONE:
CONTRACTORS NAME: '•. - LIC NO.
N/C
❑
CONTROL# -
.
ARCHITECVENGINEER. .I�Off_ A ADDRESS:
r
CONTACT: PHONE:
- BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG I ELECT PLUMB MECH
o ❑ D? ❑
LICENSED CONTRACTOR'S DECLARATION
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
I hereby affirm than I tan licensed under provisions of Chapter 9 (commenem,
Division3of Ne Businessand professionsCedc. and mylicenuis
withhllr
ri,71X10)of
in full force and dTect.
..
PERMIT ISSUANCE
WL ❑ KITCHEN REMODEL
License Class
Dam Contractor
Conor
APPLIANCES- RESIDENTIAL
❑ADDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION -
PANELS
I understand my plans shall he used as public records
MODIFICATION
UP TO 2#1 AMPS
C1 INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
Licensed Professional 701-I(100AETPS
' OWNER -BUILDER Ce ON
OVER ["AMPS
[:1 BATH REMODEUREPAIR (] DEMOLITION
Contractors
1 hereby affirm That 1 um exempt fromm the umracmr's License Law for the
following reason: (Section 7031.5, Business mad Professions Code: Any city m cnunty
SIGNS ELECTRICAL
[]OTHER.
which requires a permit to ennswct, alter, improve, demolish, or repair any druch re
/,ems_ r /9 -
poorto iu issuance. also requires the applicant for such perono file a signed statement
poor to
SPECIAL CIRCUIT/MISC.-
G
Thatheislicensedpursteanuothepmvisions refute Contractors License Law (Chapter 9
-
COMMERCIAL'
(commencing with Section 70kn of Division 3 ofthe Business and Pmoseions Code)or TEMP. METER OR POLE INST.
that he is dempt therefrom and the basis fin the alleged exemption. Any biolation of
❑ NEW BI.DG/ADDITION ❑ DEMOLI'TION
Section 7031.5 by any nonfiction for a permit subjects the upplicam to a civil penalty of
POWER DEVICES
❑TENANT' ❑FOODSERVICE
nm more than five hundred ddlms(S50(1).
IMPROVEMENT
❑I, as owner nates progeny, ar my employees with wages as theirsale <nmpenmtinn.
SWIMMING POOL ELECTRIC
El
willdothework, and thesuucmrconot intended menaced for sale I Sec.91W4, Business
OTHER
and Professions CMe: The Contractors License law does not apply to on owner of
OUTLETS - SWITCHES - FIXTURES
poi who build, or improves Neeson, and who does such work himself or through
his own employees, provided than such improvements arc not intended or offered for
NEW RESIDENTIAL ELECTR SQ FL
SQ. FT. FLOOR AREA
E/SQ. FT
sale. IL however, the building or impmvanem in sold within one yearofcompletion, the
monsar-builder will have the burden of proving that he did not build of improve for put -
pose of sale.).
1, as owner of the progeny, a nexclusively contracting with licensed conuacmrs to
TOTAL:
consumer the project (gee, 9144, Business and Pmfesslonu Cede:) The Cnntramndc Li-
emacLawdoesnotapplytounowner of property who builds or improves thereon,and
QTY, PLUMBING PERMIT FEE
•
who contracts for such projars witha conmechads) licensed porsuanuo the Contucmr s
License law, -
PERMIT ISSUANCE
1 ata exempt tinder Sec. . B & P C forma, Texan
I Data
owner D
ALTER - DRAIN & VENT - WATER (EA)
VALUATION
'
EN
WORKER'S COMPSATION DECLARATION - BACK FLOW PROT[Cr. DEVICE
1 hereby aRw under penalty o(perjury one of the following dedamfiom:
I have and will maintain a Cenificate ofConvenn to self -insure for Worker's Compen-
DRAINS- FLOOR, ROOF, AREA. COND,
STORIES
PECONSTRUCTION
sonata, as provided for by Section 3900 of the Labor Code, for the pmfivar mer of the
work for which This permit i, i,auad,
FIXTURES - PERT RAP
❑ 1 have and will maintain Worker's Compensation Insurance, as myuired by Section'
3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued.
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROUP
My Worker's Compensation Insurance currier and Policy number we:
,
Carrier. Policy No,
GAS=riA. SYSTEMOVER 4(EA) V
�
- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASUINDUSTRL WASTE INTERCEPTOR
2PhANQiIiCK
DINGR
O FEES
(This section need not be completed it the permit is for one hundred dollars (EI00)
CRBASE TRAP
or lest
s
I cemy That in the performance ofthewerk for which Nis permit i, issued, l shall
SEWER -SANITARY -STORM EA. 200 FT.
not employ any person in any manner so as to become mbjauo the Workers' Compen-
EN V j
Laws California. Dom
sonata of
WATER HEALER WNENT/ELECfIt
GRAD 'E
.Applicant
NOTICE TO APPLICANT: If, after making this Cenificate of Exemption, you should
WATER SYSTEM/TREATING
SOILS FEE
become subject no the Workers Compensation Provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
WATERSERVICE.
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PI -MB. SQ. FT.
PAID
I hereby affirm That hen is a construction lending agency for the performance of
_
Data Receipt#
Ne work (or which This permit is issued (Sec. 3097, Civ. C.)
-
Ladders Name
TOTAL:
Lenders Address
}/
TOTAL: J 6•'��
' HUIL G FIEF.
I rectify, that I have read this application and .dam that the atone in ..main. is
correct. l agree to comply with all city and county containers and sum laws n1mingto
QTY. MECHANICAL PERMIT FEE
building construction, and hereby authorize representatives of This city to enter upon The
SEISMICXE
aMrve-mentioned property for Inspection purposes.
PERMI'P ISSUANCE
ELECTRIC PEiss
(We) agree m save, indemnify tarso keep hurnilars the City of Cupertino u,neni t
liabilities,judgments,costs and expenses which may in any way accrucagainst said City
ALTER OR ADD TO MECH.
PLUMBING FEE
in tan quence of the growing of this permit.
of
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT TTO IO.OW CFM)
SOURCE REGULATIONS.
CONSTRUCTION TAX -
AIR HANDLING UNIT(OVER10,00D CFM)
SignamreofApplicant(Contracmr Date
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE'
Will theappliviart tar future building occupant some til handle hazmmus material HEATING UNIT (To 100,008 BTU)
u definal by the Cupertino Municipal Cede, Chapter 9.12, and the Health and Safety
G�,_p
_
Code. esmat25532(mv
100,OWBTU)FI
Ya, (]Nn
PAID O �Rf342?
VENTILATION
- VENTILATION FA N(SINGLE RESUH
Data Recnpt#
Will the applicant tar furore building occupant we egdlpeunt or devices which
min foramens air contaminants as defend by the Buy Arca Air Quality Management
BOILER - COMP (31{p OR I W.lxp BTU)
OTAL:
AUG
1District? Ya �No
BOILER- COME (OVER 100.00(1 BTU)
�- III�LI
oder Chapter 695 fth Cilie
Ih Sateh o n 1.5, re33
AIR CONDITIONER '+
VI v _•
DATE
bwni H les &t Safety Sections25505 2553) an 25531.1 understand that if Ne
NEW RF_SIDENTIAh SUCH. SR FT.
e,p notify the pane
buildingr, t currently have tenant. io t t stayce Aon.
tly
Cdnyfon
of the req 'wncnswbwh nuaMmet pont umttnfaQnf un of Occupancy.
'
_=IS�1JpACE
ISSUED BY: Cr—
O so er or euthuriud agent Date TOTAL:
OFFICE