28769 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.I.ECTRICAL - PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT26 A
PLUMBING-MECHANICAL 8 7
RUILDING PROJECT'IDKNTIFICATIO.4 O 1 9
HUILDINGADDRP_SS: SANITARY NO. APPLICATION SUHMI'1'1'AL DATI
a ylz yr
�AWR�ILOINCER
- 'HONE: 'O I'RAC'IOR:S NAMIP glaLIC NO, O
O N/C CONTROL#
LIC NO: ADDRESS:
3 / 6 3 El
CONTACC PHONE: BUILDING PERMIT INFO
❑ COnsRltant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
- ,(eZ
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEB
1 hereby effrm thafl wh licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
yy�� Z with Section 7000)of Division 3 of the Business and Professions CWe,and my license is RESIDENTIAL
F1O in full force and cffeet. PERMIT ISSUANCE R
Ad fy� ❑SFDWL ❑KITCHEN REMODEL
Ku Lt...Class Lic.# APPLIANCES-RESIDENTIAL
�<LL Date Contractor ❑ADDITION [I PLUMBING RF.-PIPE
Fl>y> ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z b o❑ 1 understand my plans shall Is,used as public records MODIFICATION
0ZJJQ UPTO 200 AMPS INTERIOR [I CHIMNEY REPAIR
F PJ 1q"'LIt Licensed Pinfa"whel 201.1030AMPS IMPROVEMENT
'�yy!!ddyy OWNER-BUILDER DECLARATION
y 1'YaCC1l 1 hereby off. that 1 am exempt from the Cnntrucmr's License Law far the OVER la#IAMPS El BATH REMODEUREPAIR El DEMOLITION
el 06 U following reason.(Section 7031.5,Business and Professions Cale:Any city at county SIGNS ELECTRICAL []OTHER
LLl a LLwhich requires o pcmdt to conswc6 alter.improve,demolish,carrepairany suunure
LLOpnmmitais......Ba rcquian Ne applicans for[uchpermitmfileasigned smmnhDm SPECIALCIRCUIT/MIS .
y Nes he is licensed pumuentto Ne provisions of the Conmoosex License Lew(Chapter 9
p0 (commencing with Section 7001 Division Sof Ne Fwinns and Professions Coae)or TEMP.MIITER0 EINST. COMMERCIAL
:
p tY that he is exempt therefrom and she basis far me alleged exemption.Any sulmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section 7031.5 by eny applicans fora permit suM1jecu the npplicam sox civil penalty of POWF.RDHV1 ESQ
rn ❑TENANT ❑FOOD$IiRYIDE
}�S not more than Eve handout dollars($SW). IMPROVEMENT
iCI ❑ 1.as owner of she property,or my employees with wages as their sale enmpenxutlon, SWIMMING POOL ELECTRIC
'C will do the work,and the stmatum is not intended or offered for sale(Sec.7044,Dusiness / []OTHER
W and professions Code:The Conuacmr's License Low does not apply to an owner of OUTLETS 7S IXTURN d O
Property who builds or improves thereon,and who docs such work himself or thIA
rough
his own employees,provided that such improvements are not intended m offered for NEW RESIDENTL E ES -.SQ
sale.If.however,the building or improvement is sold within one yemofcompletion,she \ SQ.FT FLOOR AREA $/SQ.FP.
a ncr-builder will have the burden of proving that he did not build or improve for put, 91
poseofsade). ' /
E)I,as owner of the property,am exclusively contracting with licensed contraction m QL �y
cr mstrun the project(Sec.91X4,Dusiness uod Prnl6sxinns Code:)The Canirucwv'x come Law does not apply to an owner of property who hailds or improves thercon.unit QTY PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed pursoans m the Contractor§
License Lo, PERMIT ISSUANCE 1
O I am exempt under Sec. ,B&P C far thn otaxam
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owh¢r Dere
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. /�`^ e••f
I hereby affirm under penalty of perjury one of the following declmutionr /�0, 000
•❑I renamed will muinmi it CenifrmerdCorsenunielf-imum fm Worker's Cn open- DRAINS-FLOOR,ROOFAREA,CONII' STORILhS TYPE:CONS'I'ItUCfION
nation,as provided f of by Section 3700 of the last Co de,for she performance of the
work for which this permit is issued. FIXTURES-PER TRAP7.
❑1 have end will maintain Warker's Compensation lnsummce,m raquired by Section
37M of the Labor Code,for the performance of the work for which this permit is rowed. GAS-EA.SYS7E11.1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Imu arc,carrier and Policy number arc:
Carder. Policy Na.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not becompleted How,permit is forams hundred dollars($100) EUILDING DIVISION P[xS
nr IDaxJ GREASR TNAP PLANCHECK I+Eli
I unify that in performance of the work for which Ibis permit is issued,l shall
not employ any person in any manner so as to beemmm e subject the WorkeraCmmSCWEH-SANITARY-
pen- STORM HA.200 FT. ENERGY FEE
,Z sation Leona of California.Date
WATER HEATER WNENT/ELECTR
OO Applicant GRADING FEE
NOTICE TO APPLICANT.If,after makingthin Ccrofieste of Exemption,you broad WATER SYSTPM?BEATING
(~ become subject to the Workds Compensation provisions of she Labor Cade,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SIiRVICE
Q
� z CONS9'RUCTION LENDING ACPHNCY NEW RESIDENTIAL PLMB. SQ,FC PAID
V O I hereby offon Nat there isaconstmction lcri ngugcocy fortheperfomorame of Data Receipt#
V. L� the work for which this Wait is i...ed(Sec.3097,Civ.CJ
O VLender's Name TOTAL:
W lender's Address I TOTAL:
y 1 certify that 1 have read this application and nate that the above information is BUILDING FEE O
W7 correct l x,momemoply with all city anl..aty Mae. .and auto laws relating to QTY. MECHANICAL PERMIT FEE
V G building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for mspution purposes. PERMIT ISSUANCE. OV
(We)agree to save,indemnify and keep harmless the City of Cupeoom ugu rr o ELECTRIC FEE
iahilitim,judgmems.costsand expenses whichna,o tiny way nomic.aino'add City ALTER OR ADDIO MECH.
in asequence of the granting of this pemdt. PLUMBING FEE _
APPLICANT 'NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
S URCE R ll. TION.
AIR HANDLING UNIT(OVER Io,(IIp CIM) MECHANICAL FEE O
CONSTRUCTION TAX
inure of Applicant .amens, Data EXHAUST FRnst OvoDUCTj
HAZARDOUS MATERIALS DISCLOSURE - s.7V HOUSING MITIGATION FEE
Will the applicans a,future huilding acupim shmeof handle hazallous maurial HEATI NO UNIT(TO I WTOT BTU)
7a defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cmale.Section 25532(a)P HEATING t1N1'I',(OVEN 1p0,p(N)li'l'()) �S,v y
❑Yes ❑Nn VENTILATION PAN(SINGLE REST)) PAID u,
me Receipt#
Will the applicant or building occupancy Ana Air
Management BOILER BOILER-COMP(3HP OR 100,000 BT U)
Diss hazallous air contaminants as defined by the Roy Area Air Quality Management TOTAL:
Distinct'
❑Yes ❑Nn BOILER-COMP(OVER 100,00o BTU)
0i i Y ur l.,urtnl IND
I have read the htrrmdous materials requirements major Chaser 6.95 ofthe Cull- AIRCONDITIONER
9 m ISSUANCE DATE
inmie Health&Safety Gale e a leriia 25505,25533 and 2.5514.1 undersand moat if N° NEW RESIDENTIAL MIiCH, SQ.IT.
of Meng dam not currently have o anent that o is my responsibility(if. ca e o fy thmccupant
of Ne requirements which must ha con pnono issuance of a Certificate of Occupancy, aa--''1111��
Owner or amhodzW agent Dam TOTAL:y3, ISSUED BY•"�
OFFICE