28952 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONPERMIT PLUMBING-MECHANICAL.
. 28952
BUILDING PROJECT IDENTIFICATION
ILDINGADDRESS: _ - SANITARY NO. APPLICATION SUBMITTAL DATE
PHONE ONTRA R'S NAME: LIC 3 N
SIC CONTROL
�I�ARCHITE/NCT//ENGINEER: LI,OGNJ•O: A`Dj/R� ��ESS;
� J?b� � ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
X. ❑ ❑ ❑
LICENSED CON]RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed ander provisions of Chapter 9(commencing B DESCRIPTION
OCO with Section 7000)Bf Division 30fthe Btraimssand Porti,inm Cale,and my license is PERMIT ISSUANCE
O RESIDENTIAL:
FEW mfall forceanJ efte� / , ,. pO�y ❑SFDWL ❑KITCHEN REMODEL
Q U U License Class IS Lic.p DLJ aK5"
vFiZW ha" Contmeea APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION Ll MULTI-UNIT ❑STRUCTURAL
PANELS
Z p y Z I/'
1 understand my plans sM1ull M used us puhlic reagJs MODIFICATION
OZ�Q UI"10200 AMT'S El INTERIOR [I CHIMNEY REPAIR
FyF'W Licensed Professional - 201-IIXIO AMPS IMPROVE\FENT
�y,F; OWNER-BUILDER DE CLARATION OV[R IOBBAMPS ❑BATH REMODEL/REPAIR' ❑DEMOLITION
S.U
'I hereby.fano(hat 11. exempt from me Contractor's by cLicense An,a Law for the
113 LL F. following reason.(Section]0315,Businessmpr Pref Cala Any'city ncoumY SIGNS ELECTRICAL ❑OTHER
q which rryuims a permit m conswet,al¢q improve,demolish,or repair any structure
-1 primtoimissoance.also reyvires rife applicant for such permitmaleasigneJ smtemrnt SPECIAL CIRCUITAIISC.
P N
that he islicensed p se tt the p x ol flue C t to,.Li,c OL.w(Chatfirar)
ty y_.QO (commencing withSectio 7000)tf Division 3 ofth Business' and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL
6 6 ce C that h pt therefrom d theb f thealleged exemption.Anyviolation or ❑NEW BLDG/ADDITION �,,,rOLITION
x Y• Sectio 70315 by any applicant for a permit subjects the applt nt m a civil penalty or POWER DEVICES y'^P
1+1—m []TENANT LBFOOD SERVICE
1- >s not mom than hazswnerlive hundred nf the Pmpcny.dollars
m ($500),
mccs with wages es their sole cath _
y pcnsation. SWIMMING POOL ELF,ERIC IMPROVEMENT
will do the work,andtbesuacmre is not ithemednro(feted for sale(Site Pasineser f PS-PIXTURES
❑OTHER
W"� and Pon ersions C a1c:The Contractor's License Law does not apply m an ownoOUTLETS
propcny who builds(i"improv<x thereon,and who does malt work himself lir through his own employee.,provided that such imp ravemems arc not intended or offered for NEW RESIDE'-IAL ELECfR SQ PT.
sale.If,howevea the building or improvement is sold within one year afcompletion.the SQ.FT FLOOR AREA SISQ.FT.
ovener-hadder will have the burden of proving that he did not build or improve for Pur-
po.a of salt).
1,as owner of the property,am exclusively contracting with liknsed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- .
cense Law does not apply m on owner of property on.but Ids or improves th,nam,add QTY. PLUMBING PERMIT FEE
who convects for such Inspects with a contmetons)licensed pursuant to the Connector's
Liccnu law. PERMIT ISSUANCE
C]1 am exempt under Sec. .B&P C fur oris recon
ALTER-DRAIN&VIEST-WAFE (- VALUATION
Owner Date -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DE5EZ9 (A
_
I hereby affunr under penalty of perjury one of the following declarations:
❑Ihave omit will maintain uCenlOcatenf Consent to.eelf-insure for Wonker'x Com pen-. DRAINS-MOOR,ROOF AREA,CUsy STOIES TYPE CONSTRUCTION
,.if..,as provided for by Section 37M of the labor Code,for the pertomance of the
work for which this pewit is Issued. FIXTURES-PERT
❑I have and will maintain Workees Compensation Insurance.as required by Section
3700 ofthe Labor Code.1b,the ry:donnanaof life work lice which this permit k ulnad. GAS-PA.SYSTEM-I INC. UTLETS .00Q GROUP APN .
AtywOk tion Insurance turnerandicygryycr arc i/�
Carievr `::!; I'ad Pelf���� a�I�� aT��-• GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE GRIiASFIINDUSTRL WA. E INTER EM
BUILDING DIVISION FEES
rlElss<cd0nneednotbecompletediftbepemdtislar0nehundreddollars(5100) GRCASETRAP '
ar less.) PIANCN[CK Mk
Icertify In.,in the perfamtance ofthe work fnfwhich this p<•neit isisxued,[,hall SEWER-SANITARY-STORM PA.2
not employ any person int e any manner so as to become subject to the Workers CompenENERGY FEE,
Z vtion Laws of California.Date WATER HEATER WNENT/ELECT
Applicant . GRADING FEE
z �. NOTICE TO APPLICANT:If,after m.king this Certificate of Exemption,you should WATER SYS1'IiMIIREATING
� ' hec0me subjem a the Worlds Compe...on.provisions of the Labor Code,you must SOILS PGG
W fnMwith comply with welt provisionsmthi permit shell he dcemai invoked. WATER SERVICE -
wQ
CONSTRUCT ION LENDING AGENCY NEW RESIDEN1'[Al.PLMB, SQ,FT PAID
U O thereby of rrat that there is a construetmn lending agency forme perfom,ance of - Dam - A
the work for which this pemdt is Issued(Sec.301 civ.CJ
1,ender's Name TOTAL:
0 U [sander's Address _ TOTAL. r
t" 1 I certify that 1 have read this application and,state that the above infumw �tion is BUILDING F -'a'F' fR) correct,l agree to comply with all city and county ordinances and state law's relating to QTY. MECHANICAL PERMIT FEE
U z b 'Iding cansa e,Om,and herebyeuthinve represenmtivcsor Mis city to chuntipon the SEISMIC
-mentioned propcny fol impr'n,ur purpose, I
IT ISSUANCE
e (We)agree to save,indemnify and kee,har ark,the City of Cupertino against ELEC FRIC F17H
If. lities,judgmenm,cns,,andexpcn- Without manywayaccrueagainsuaid City OR ADD TO MECH.
In
nsequcncc of the gm n'ngaf this "mit, PLUMBING FEE
A [Y .D W .COMPLY WITH AL1,NON-POINTNDLING UNIT('1'O 10,NX)CFM) -
S U CEREGUL TI MECHANICAL PF.
Z NDLING UNIT(OVER Ia.00a CFM) CONSTRUCrIO TAX
'ignam of pplic.nV' nwctnr Dam UST GOOD(W/DUCT) HOUSING MIT )ATIBN FEE
I ZARDOUS MATERIALS DISCLOSURE
F Will the app)'ant ar future building occupant store or handle hara"dous materialNG UNIT 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cuda,Section 25532(.)? NG UNIT(OVER 100,000131'U)
C)Yes El No
ILATION FAN(SINGLE RESID) PAID
Will thea applicant or fuuue building ant use e t or devices which Dam Receipt x
PP dby the Area
cn R-COMP(3HP OR 100.E B'TU)it haavrJous uircontaminants as dclineJ ny the Ifuy Arcn Air Quallly Munagemcm TOTADistrictOYcs ❑No R-COMP(OVER 100,001)BTU)I have read the harasous materials nqulremmns corder Chapter 6.95 of the Call- ONDITIONERISSUAN ATErami.Health&Safety Code,Sections 25505,25533 vast 25534.1 underand that iftheESIDENTIAL MECH. SQ.ET DEC
building does act urrently have a tenant,that it is my responsibility to notify theoccapent
of the requirements which must he and pn0r to issuuna of a Certificate of Ocaupnncy. . /
Owner or anthorired agent Date TOTAL: I SLUED BV•CU
OFFICE