28724 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE-BALL POINT PEN ONLY , ' -
CITY OFCUPERTINO _ I BUILDING-ELECTRICAL PERMITNO. a� �S�,.a w
BUILDING DIVISION APPLICATION/PERMITL
PLUMBING.MECHANICAL l8J -24
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: `. - SANITARY NO. APPLICATION SUBMITTAL DATE
3aca o :
OWNRR'S NAME:' yPHON�� �•' ` J ' CONTA OR'SN SIC NO:
Cr) C5r'•J ^t(I III
/' /^�j /' N/C CONTROL#
's�ARCHITECT/ENGINEER: LI f06 l� �I>RE 5� t2e -.� 7+y 'e ❑ -
CONTACT: PlllH•••O///NE: l , I BUILDING PERMIT INFO
' .. ��^ qt y q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
0 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
�oZ vrthSddirm7Ts .fDivisi�n31fihcBmicassmdProf..musCede,andneylicaleis RESIDENTIAL'
FW in full force end efft. C A� _ PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
U U I ieanse assLid.# V
.FZU'Date Cmntrnnmr vCR APPLIANCES-RP.SIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
yF`�J 9Q'j ARC ITECT'S DECLARATION PANELS E:1 ❑STRUCTURAL
z p K 1 understand my plans shall he mud as public records MODIFICATION
Ozapp UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F.y- Licensed Professional - 201-1000AMPS IMPROVEMENT
•� -
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEWREPAIR El DEMOLITION
1 hereby affirm that I am exempt from the Contractor's License Law for the
iW5 Ps U following rens...(Section 7031.5,Business and Profusions Cade:Any city.,county SIGNS ELECTRICAL ❑OTHER
W 3 f+ y¢ which requires a permit m command.alter.improve,demolish,or repair any structure
VIC priortoil,ammnca,also iegnlre.thcepplicamforsuchpermine fleasignedstatemem SPHCIAL CIRCUITIMISC.
,•� that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9
OO (commencing with Section 701Hgnf Division 3 of the Bosinessand Professions Cotle)., - TEMP.METER OR POLE INST. '
W m y that he is exempt tM1erefrom and he basis fur the alleged exunpti.n.Any violndan of .0 NEW BLDG/ADDITION El DEMOLITION
a pmit subjects me appcanto a cCE
Section 9031.5 by any applicant for erbjlit civil penalty of POWER DEVICES u+^y []TENANT ❑FOODSERVICE
z not snare man of hunzddollarsyempl. IMPROVEMENT
Cq ❑Eo the adalithe the,trucare isetinoyeeswuffeed wages assh,(See.compensations SWIMMING POOL ELECTRIC '
C^' will do the work.unde oCureictim's Ludim or nfw due,
ad Business OTHER
and Professions Code:TTe over th mrs Liceree Law dues nm apply toll owner.f OUTLETS-SWITCHES-FIXTURES Of
properly who builds or Improves thereon,and who does such work himself or through
his own nployees,provided that such improvements are not intended or offered
for NB W RF.SIUENTIAL ELECTR SQ FT.
sale.If.however the building orimprovemenr is sold within tine yearof compleliogthe .Q,FT.FLOORAREA $/SQ.FT.
cr-bandef will have the hurdle.of proving rent he did not build m improve far p.r- �S
pose of eowne e - TOTAL: 7?
-
❑1,as owner of ct property,am exclusively contracting with licensed contracture.-
use La the es nett(Sec.o an Business and Profusions Cade:i The Convenor's L.-
came
i-
orselawdaesnotapplyman ithaofpropedy who
sedprs improves Co ereemd QTY. PLUMBING PERMIT "FEE
who commas fm such projects wish v eo.tmdm(s)licensed pursuant to mo C.mracmr's
License Law. PERMIT ISSUANCE
❑I im exempt under Seo, B do l'C for his reason „
Owner
ALTER-DRAIN Su VENT=WATER(EA VALUATION
' Date '
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
I ereby aftirro under penalty of pe jm,one of the following derelsrations:
•❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-mFLOOR,ROOF,AREA,GOND. STORIES 'TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Cale,fore performance of the. ,
work for which this permit is issued. FIXTURES-PER TRAPJCJ� ,
and will maintain Worker's Compensation Insurance,as required by Section
3TIDof me Labor Code,for the performance it the work for which thispermit is issued. GAS-EA,SYSTEM-1 INC.4 OUTLETS OCG.GROUP APN
My Worker)'^ m
pens Insu cc ca d Folic ogre�¢,ppre:�`f yy -
Certiee_yp PolicyNoyOf/ '9 A CO PI ? GAS-EA.SYSTEM-OVER 4(GA)
•RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This satires need not beccmpleted if the permit is forme,hundred dollars(1100) @UILDINO,DIVfMON 1+EBS• '
of less.) 1 c GREASE TRAP - -
PLANCHECKPEE
I certify thin in the performance of the work for which this permit is issued,[shall SEWER-SANITARY-STORM EA.200 UP
not employ any person in any manner so as to become subject to the Workers Crimper- ENERGY PEE
0 ]. sation laws of California.Data WgTER HEATER W/VENT/ELECTR -
7 Applicant GRADING FEE
F7 Tory NOTICE TO APPLICANP..If,after making this Certificate of Exemption,you should WATER SYSTEM/[BEATING
abecome subject to the Worker's Cmnpensati.n prdwisimns of me Labor Code,you must SOILS PEE
W forthwith comply with such provisions nr Nis permit shall be dearmainvoked. WATER SERVICE
aQ
� z m
CONSTRUCTION LENDING AGENCY ', NEW RESIDENTIAL PLMB, SQ.FT PAID
U0 I fofibrrwhichaffithit permitthere LsedConstructioni09e.Cis.agency for the Performance of - Dem ip
w ti the work for which this permit is issued(Sec.3159.Civ.CJ '
O L~ Lender's Name TOTAL:
WLender's Address TOTAL:
Q. f certify mm 1 hove read this application and nam tbm rhe above infnrmaion is 4�0BUILDING FEE
A carted.I agree to comply with all city and county ordinances and slam laws relating to QTY. MECHANICAL PERMIT FEB -
U� building construction,and hereby,niffamiec representatives of,hisdty to enter upon the SEISMIC PEE
above-mentioned propmy for inspection purposes. PERMIT ISSUANCE,
vgre
(We) e m save,indm
enify vnd keap harmless the City of Cmadi it m against ELECTRIC FEB '
liabilities,judgments,cans and expenses which may in any wary accrue against said City ALTP.R OR ADD TO MECH. - T
onsegnence of the graining of mss pemtit. PLUM➢ING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNIT(TO I(I,tFlO CPM) MECHANICAL PEE
SOURCE REGULATIONS. -
- AIR HANDLINGUNIT(OVER 10,000 CFM) CONSTRUCTION TAX -.
Signature of ApplicanVConvactor Data - EXHAUST HOOD OGDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant r future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter,9.12,and the Health and Safety
Cale,Section 25532(x)? HEATING UNIT(OVER I(EmoBTU)
El Yee, No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the it cintatorantra building by the occupantuseAir Quality
Management
BOILER-COMP(3HPOR 100,1100BTUp
emir hazardous air contaminants as defined by the Bey Area Air Quality Management TOTAL:District?
rJ
EJ Yes ❑No BOILER-COME B3VER I00,000 BTU)
1 have mad me hazardous matcriWs ms rements under Chv to 695 0[the Cnli- AIR CONDITIONER
qui pSUAE QjATE
s fomla Health Safety Codgea Lena 25505,2s my and 25534.1 understand that if ma NEW RP.SIDENTIAL MECH. SQ.PT. ^ `�., (.Jj
"
building doe not cunenlly haveatennnk that it is myresponsibilirymmtify me occupant ' v of the aqu'sine ,w stir ren prion issuance of a Ceelfcme of scups ey
wor m �� rr
Oumaed agent iZ Date 'TOTAL: ISSUEDBY:
OFFICE ,