28965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CDPERTINO - BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/IaF.RMIT PLUMBING-MECIIANICAL 28965
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRPSS: SANITARY NO. APPLICATION SUBMITTAL DATE
LbmF
OWNER'S NAMJ,+: NE: CONTRACTOR'S NAME: LICNO: - �I A
S' NIC CONTROL#
\RCHITECT/ENGIN -R: LIC NO: ADDRESS: ❑
-A atA'a
CONTACT. - - PHONE -zbzw Liv BUILDING PERMIT INFO
❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUMB MECH
CENS[D CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEL
1 heresy milrm that 1 um license.under provisions of Chopart 9(commencing JOB DESCRIPTION
�z iN Section7000)af Division 3 ofthe Business and Professions Cale,and my licensees RESIDENTIAL:
with
forte and IT PERMIT ISSUANCE
in, ❑ADWL ❑PLUMBINREMODEL
aU Latense less Lia# APPLIANCES-RESIDENTIAL
til Ume Contractor []ADDITION [I PLUMBING RE-PIPE
[F..� 4i' AR HITELTS DECLARATION
x p y❑ I undco mild m lens shall be used as public meords PANELS ❑MULTI-UNIT []STRUCTURAL
my Pu MODIFICATION
Oz4 UP T021p AMPS -
� = Licensed Professonal ❑WTERIOR .CHIMNEY REPAIR
S-i
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
yyjj 1 hereby affirm that 1 um exempt from the Contractor's License Law for the OVER I01)(I AMPS ATH REMODEUREPAIR 0 DEMOLITION
U following reason.(Section]031.3,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
R+ I"' which reyvircs a Permit to construct.alter,improve,demolish,or repair any strucrum
N prior to its issuance,also requires the applicant for such pennitto file.signed statement SPECIAL CIRCUIVMISC.
ysy} that he is licensed pursaanuo the provisions of the Contractor's License Law,(Chapter 9
C00 (commencing with Section 10001 of Division 3 of the Business and Professions Code)a, TEMP.METER OR POLE INS'. COMMERCIAL:
Q.p.2 a that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
..y
Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES TENANT ❑FOODSERVICE
Y} t mom than five hundred doBam(S5 W). �I
O ❑1,es owner of the pmpeny,or my employers with wages as their sole compensation, SWIMMING POOL ELECTRIC �4rMPROVEMENT All)
wdldothework,andthexuucmreis not imm�deJ nr nffercJ fm sale(gec.]M4,Bminess /LJOTNER f'a
and Prolessioo Cale:The Connector's License Low does not apply ro An owner of O(19LETS-SWITCHES-FIXTURFS VVVVYYOOOOOO
r property who builds or improves thereon,and who dies such work himself m though
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ Fz
sale.If,however,the building or improvement avoid within one ye4rol'mmple«ioathe SQ.FT.FUO LSQ.FT.
ey"Albuilder will have the burden of Proving than he did not build or improve for Pur-
pose of sale.). - �I.yy '`1-
[:] �u� rl1''•0
1.as owner of the popery,am exclusively contracting with licensed contractors to �� 1' V
cnam-ni' he project(See 7044,Business and Professions Cale,The Co...... s Li-
nseLawdoesnotmpplymanownerofpropernywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
who convects for such projects with a contmcror0licensed pursuanuo the Contractor's
License I.A. PERMIT ISSUANCE
0 Iamexemptunder Sec. ,B&PCfonhismason
Owner --
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CMS
1 hereby affirm under penalty of Perjury one victor following declarations: 1`�
[have unit will maintain a Certificate of Consent to self-insure for Worker's Comma. DRAINS-FLOOR,ROOF,AREA,COND.
sation.as provided for by Section 3100 of are Lor Cam,for the performance of theSTORIES TYPE CONSTRUC ION
work for which this permit is issued. FIXTURES-PER TRAP
C]I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,in, irmyro once of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Wo e/ ram c�smio n�Policy nW.R
Cartier /OJM_(r!, GAS-EA.SYSTEM OVER 4(EA)
CEI TIFICATB OF'XEMPTE R WORKF, S'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION Il?FS
(This section need not be completed ifthe Permit is forum hundred dollars(5100) ORBASC TRAP
or less. PLANCHF,CK FEE
I certify that in the performance ofthe work forwhich this Permit is issued,l shall SEWER-SANITARY-STORM FA.200 FT.
not employ any person in any manner aro become,subject AS to becsubjeco the Workers Compen- - ENERGY FEE
0 Z nation Laws of California.Dote WATER HEATER WNENT/ELECTR
z O Applicant WATER
FEE
pr NOTICE TO APPLICANT:If.after making this Cenificate of Exemption,you should WATER SYSTEMffREATING
la^ become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
G forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.Ff. PAID
Ll0 I hereby affirm that there is a constoction lending agency for the performance of Date ' t#
F the work for which this permit is issued(Sm.3097.Civ.C.)' -
0 U Lenders Name -
U Lender's Address
its 1 certify that I have read this application and state that the move information isy� BUILDING FEE
VI counter.l agree to comply with all city and county ordinancess and start lawrelating to QTY. MECHANICALPERMIT FEE
V building construction,and hereby authorim representatives of this city to enter upon the SEISMIC FEEkLk
,
above-mentioned property for inspection purposes. ` PERMIT ISSUANCE
(We)agree to save.indemnify and keep Gormless the City of Cupertino against Lwaa ELECTRIC
liabilities,judgments.costs and expenses which may in any way amme against said City ALTER OR ADD 10 MECH..
in consequence of the gmating of this permit, ALTER FEE
APPLICANT UNDERSTAND. D WIL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CIO 10,000 CFM)
SOURCE FAULAT
IONST XMECHANICAL FEF:
Al V1I�M1 AIR HANDLING UNIT IO.00d CFM) CONSTRUCTIONT X ,
Ignem of plrnnDate EXHAUST HOOD(WDUCDnm Tor
Av
IIJCZARDOUS UTI
DISCLOSURE HOUSING MITIG ION FEE
Will the Applicant or future building mcupvn snore or handle hazardous material HEATING UNIT(TO I W."BTU)
ss defined by the Cupertino Municipal Cede,Chapter 9.12,vol de,Hculth end Safety
Coro,Section 25532(.)7 HEATING UNIT(OVER 100,008 BTU)
O Yes 7 N VENTILATION FAN(SINGLE RFSID) � PAID i
Will thea Applicant or future building occupant use a ui Dote Rcceip
pp g e q pmcntordManaement BOILER IOO,000BIU
emit hazardnm air ronwminmiN as defined by the BuyArcn Air Quality Management )
Distdn7 TOTAL:
(]yes ]Na BOILER-COMP(OVER hotbed BOTH
1 have read the ha sinks s materials rauimarm is under Chapter 6.95 of the CAB. AIR CONDITIONER
q o ISSUANCES DATE
�
fomia Health&Safety Ca ,Smtiom 25505,25533end 25534.1 understand tot if the NEW RESIDENTIAL.MECH, SQ.FF. -
buildingdoesnotcutreneyhaveatenant,Couto ismyce of responsibility cae ofytheturns, t
of the rtquircmenrs which most he met prior m issuance of n Certificate of Occupancy. '
Owner or authorixed agent Dam I. ISSUED BY:
OFFICE