28476 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEi RTINO BUILDING-ELECTRICAL PERMIT NO. L �Vj^ ^ 47
6
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
Z23 6 aM '' X54,U
OWNER'SNAME: P NEr' CONTRACTOR'S NAME: LIC NO:
7" 00 L.p( p N/c coNTROLx
(�ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
iij
o v' 2l iJ. nal bVG
COM'wCr: PHONE: BUILDING PERMIT INFO
❑ Consultant FccS Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1hereby afr that 1amfthe Beunder it Proonxof Chapter 9(commencing JOB DESCRIPTION
�UZ with Saire 7000) Division3ofthe Business and Professions Cufn and my license is RESIDENTIAL
F full(nice and eOmi�l I'EkM11'ISSUANCE
QFUV License Cl°f�s e-' Lo.x ❑SFDWL [I KITCHEN REMODEL
NGd Dam jI I') Cunlraclor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPF,
ARCHITECTS DECLARATION W El ❑STRUCTURAL
Z p h Z 1 understand my plum shall la,used as public records PANELS MODIFICATION
O Z-+ UP TO NX)AMPS
(=�^W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
�yfW-'j OWNER-BUILDER DECLARATION 201-IOW AMPS IMPROVEMENT
6 1 hereby affnn that I.m cxampn from the Contractor's License Law for the OVER I(XX)AMPS ❑BATH REMODEVREPAIR ❑DEMOLITION
3 O a V following reason,(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
N¢ which requires a Permit to construct,alcor,improve.demolish,or repair any stricturey.] prim to itsissuance,ulso requires the applicant forsuch permit no hleasigned sta¢ment SPECIAL CIRCUIT/MISC.
Gthat he is licensed pursuanno Ne previsions of the Contnnors License
"I
9
��p0 (comoner,wird Section]BIX)of Division Jofmv Business and Profession,Gyle)or 'TI';MP.METER OR POLE INST. COMMERCIAL'
L q m C at he is exemptth
therefrom om and the basis for e alleged exemption.Any violation of El NEW [INEW BLDG/ADDDN DEMOLITION
ad 4. NSeeded]031.5 by any applicam for a puma subjects the applicant to a evil Penalty of POWER DEVICES
I�„3�. out more thin five hundred dollars($500). ❑TENANT OFOOD SERVICE
�=a0 ❑Las owner ofthe property,or my employees with wages as their role compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
CF' will do thewoek.atldthe swcture is not intended oroffered forsale(SCe.9044,Business ❑OTHER
a 3$ and Professions CWc:'ILc Cootomrs License Lw does not apply to an owner of OUTLETS-SW ITCHES-FIXTURES wrsirffl L
Property who builds or improves thereon,and who d«s such work himself tae through
his own employees,provided that such improvements are not intended or offered to,, NEW RESIDENTIAL ELECIR SQ PT.
sale.If.however,Ne building or improvement is sold within one year ofcompletion,the I SQ.FT FLOOR ARG $/SQ.PT.
owner-builder will have NC burden of proving that he did not build or improve for pur-
pox of sale.).
❑1,as owner of the property,am exclusively conweting wird licensed contractors to TO
construct the pmject(Sec.7044,Business and Professions Cale:)The Contractors Li- '
rise Law does not apply man owner ofpmpimy who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contraemthd licensed pursuant to the Conlonors -
License Law.
❑I um exempt under See ,B&P C for this maim PERMIT ISSUANCE
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DE VICE
1 hereby affnn under Penalty of perjury one of the fol '
❑I haveanJ will maintain. sc -msurefor WorkeeSCompe.- YAINSOOR,ROOF,AREA,CONUSTORIES TYPECONSTRUCTIOration,as provided fir action 3]00 of the tabor Code,fnr the performance ofthewrkforwbidithis rmitisi...ed. ERTRAPI have and wit naimmio Wrkers Compn,mlon Inwm le,as required by ScaiedSTEM-IINC.4OUTLETS OCC.GROUP APN
My Workers Co pervaded Insurance coma and Policy.am rCarrier: Policy Nu: STEM-OVER 4 TAERTIFICATEOFEXEMPTION 0 F.RS'CO PENSATION INS N USTRL WASTE INTERCEPTOR(Thisse m r.cednnt eom I i' pe C hu it s� BUILDING DIVISION PEESor les'.) PPLANCHECK FEE
I entity hat in the oftheworkforwhlc I I nit- i_ewcdlal R-SAYI'TARY-
notemploy.n peraminanyn erma Ke ble orkers'C a- STORM FA.200 FT. ENERGY FEE
,z, cation laws of aI forms.Da
O O Applicant WATER HEATER W/VENT/ELECTR>
GRADING FEE
NOTICE TO PPLICANT:IL after making this Catifcau,of opti......hould WATER SYSTEM/1REA -y p
F , become subj t m the Workers Compenstanm previsions a 'up
ra Cole,you must SOILS FEE
0.aiQ forthwith co ly with such provisions or this permit I be deemed revoked. WATER SERVIC0.
.7Z CON: 10 DINGAGENCY NEWRESIDEN'1'IAL PLMB, FT. PAID
U O Ihereb .ffiemw
nh.,if i striation lending agency for ma
he perfornce of. "^` Date ReceipnM
fY H the work for wh is issued(See JW],Civ.C.) Cyd,
Lender's Name
U Lendcr's Address �TOTAL: TOTAL'
p, I renify that I have read this application and one that the fewe information is
BUILDING HE
rp eorecl.I agree w comply with all city and county ordinances and state laws relming m QTY. MECHANICAL PERMIT a
U Z building construction,and hereby authonze representatives ofthis city to crime upon Ne FEE SEISMIC
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(we)agree msave.indemnity and keep harmless the City of Cupertinu against ELE rE
Babilities.judgmenu,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in nseyuence of the granting ofthis permit. PL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOD tR00BCFM)
REG ' AT10NS
SOU , . �^ MEC ANICALFEE '
h/s AIR HANDLING UNIT COVER I0,00)CPM) CONSTRUCTION X
Sigmo a of ApplicanVConnaaor 1[[ Date EXHAUST HOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSINGMITI ATION FEE
Will the applicant or future building occupant store or handle hassrdons material HEATING UNIT CTO I WAW BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)'! HEATING UNIT(OVER 100.000 BTU)
❑Yes Fl No
VF,NTRATION FAN(SINGLE RESID) PAID
Will the applicam or future building occupant equipment or devices which Date Receipt p
Coil hazardous air eonmminant as defined by the Bayy AArea Air Quality Management BOILER-COAfP(3HPOR 100,000BTU)
District?
Yes �No BOILER-COMP(OVER 100.000 BTU) TOTAL:
1 have read Ne hazardous materials rcquirementa under Chapter 6.95 of the Cali- AIR CONDITIONER
forma Health&Safety Code.Sections 25505.25533 and 25534.1 understand thm if the IS ANCE DATE
building dace nm curreilly have a acnam,that it is my revporobiliny mnotifythe�eculunn NEW RESIDENTIAL MF,CIL SQ.PF.
of the requirement which must tic men prior to issuance of a CertifwteofY cuZ"Zcy.
Owner nr amhnnze0 agent pate TOTAL
ISSUED BY:
OFFICE