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28636 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF C'UPERTINO ' BUILDING-ELECTRICAL PERMIT NO. 28636 w ��w
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL LIyJ( {hJ
BUILDING PROJECT IDENTIFICATION
BUILDING ADpRFSS: SANITARY NO. APPL{C��SUBMITTAL DATE
OWNF. 'S NAME: / - �ONF::.� / CONT;i�rNAME: /a; � LIryNO: •' Z N/C CONTROL#
Get Le / tl V L L
AR HITECT/FNGINFER: LIC NO: ADDRESS: ❑
ONTACT: PHONE: BUILDING PERMIT INFO
❑'Consultant Fees Paid by Applicant(Inhial) BLDG ELECT PLUMB -MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC mPERMIT PF.F.
I hereby affirm al 1 am located ander,provisme of chapter 9 ttotnmoncing JOB DESCRIPTION
COZ with Sectlonl00(yof Division liethe Businessand Professions Code.andmylicense is RESIDENTIAL•
W 5" in full farceand effect. C PERMIT ISSUANCE /
Uz U Lice 1:1 Lic.# W{!a - ❑SFDWL KITCHEN REMODEL
yQW _ Convacmr�-�— APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING'RE-PIPE
1, ;) ARCHITECT'S DECL ATIOATt N ❑MULTI-UNIT TR3,CTURAL
PANELS O IFICATION
O pz 4 7a 1 understand my plans shell he used as public rernNs UP TO 200 AMPS
rr.`4.,1"Ia Licensed Professional El INTERIOR ❑CflI,IJEY REPAIR
es q 201-1000AMPS IMPROVEMENT' IJ
�./hd2 OWNER-BUILDERUE Ce ContrON OVER INX)AMPS ❑BATH REMOD EPAIR ❑DEMOLITION
O y'PUGS I hereby off rm thin 1 am exempt from the Contreclor's License Law for the
0.U following reason.(Section 7031.5,Business and Professions Code:Any city or ceumy SIGNS ELECTRICAL. ❑OTHER _
FyaI" which requires a pemtit to cunstmet,alter,improve,demolish,or repair any swewre _ -
qq m.5 prior to its issuance,also requires the applicant for such permit to file a signal statement SPECIAL CIRCUIq'/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
�GO (commencing with Section]000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE IN ST. COMMERCIAL'
0.q o rG that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION '❑DEMOLITION
W m rye Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
not more than five hundred dollars($500). ❑TENANT C]FOOD SERVICE
G mare wnerwI'me propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
qo will do the work,and theaweture isnot Intendedoroffered farsele(Sec.9.44,Business E20THER
ce end Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
4' propeny who builds or improves thereon,and who does such work himself Or mromdu
his Own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ ET. rr
aide.If.however,me buildingorimprovement is sold widdrimie yemofcnmplenon,the - SQ".&&
n &AREA $/SQ.FI',
ner-builder will have the burden of prising that he did not build or improve for put-
seafaalu) am SEP 15 C
❑1,asowner of the propeny,.Bexclusively convecting widelicensed contraces i- TOTAL: s �f•S^�
cnnswct the project(Sec.GUM,Business and Prafeaninns Code:)The Convector's Li- p yy
censeLaw does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBINGPERMIT FEE GI1I OF
who contracts for such pronates with a convenors)licensed pursuant the Contractor's V71I (r�rthi t`�Nr'
License Law PERMIT ISSUANCE t V
' ❑lam exempt under Sec. ,B&PCfor this reason
Owner - ALTER-DRAINA,VENT-WATER(EA)
Date VALUATION
WORKER'S COMPENSATION DECLARATION Ift
I hereby alfirmunder Penalty ofpermay one Of the following declarations: BACK FLOW PROTECT.DEVICE
LhaveandwillmainminaCenificateofConsenuoself-insumfor Worker's Compen- DRAINS-FLOOR,RDOE AREA,COND.
inion,as Provided for by Section 37(a)of the Labor Code,far the pert..Onto of the STORIES TYPE CONSTRUCTION
ark for which this permit is issued. FIXTURES-PERTRAP
❑ 1 have and will maintain Worker's Compensation Insurance.as required by Section
/ 37W ofdee Labor Code,for the performance of the work t'nr which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
/[ My Worker's Compcncatinn In surancecanlerand Policy number are: OCO GROUP APN
Cama: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASUINDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION FEES
(This section need not bo co
to asstpewit is foraoa hundreJ dollare($100) GREASE TRAP
or less.) , PLANCHECK FEE
(certify mal int he perfn eofdeer is for subject
bjech tto the W ekes'Curatoallr- SEWER-SANITARY-STORM E.A.200 FT.'
not employ any person in any a so m b arae subject to the Workers'Compete- ENERGY FEE
,x cation laws of California. to niter
O O APPlicnnt — M
W/VENT/ELECTR GRADING FEE
NOTICE TO APPLE] T If,after making this C ifcate of Exemption,you should
a1mmmeaubjectm tl orkers Compensation ,.,I sues of the Labor Cade,you mustaREATING SOILS FEE
4i1
forthwith
comply nth such provisions or this permit hall be,deemed revoked.
Q
CONST vCT10N LENDING ENC# IAL PLM.. SQ.ET. PAID
Q 1 reby effirn mat the anmstmetio di ,gency for dee perfowance ofDate Receipt#
W F
the forwhlchthis rmlti sued(Sec.311 Ci. .) '
O dens Name TOTAL:
Lender's Address TOTAL:certify mat d this ap is and arae that dee above information is - BUILDING FEE 7 correct. agrees ro r ylreyc(ys coo ty'oNinances and store laws rdming toANICAL PERMIT FEE
building ons ,undj� b/mhmim wvmtarivesofmiccitymentetuponthu SEISMIC FEE
above- propeny Tipp Pachon rposes. -
k msave,indemnify it keep hmmlesa the City of Cupertino against PERMIT ISSUANCE ELECTRIC PEE
liabilities, it, enrs,costsandexp es which may in any way arcane against said City ALTER OR ADD TO MECH.
n coherence ofibegrantingo ispermit. PLUMBING FEE
APPLICANT UNDERSTA S AND WILL CO LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1.,000 CFM)
OU REGULATION r MECHANICAL FEE
J �J AIR HANDLING UNIT(OVER 10,000C P) CONSTRUCTIONTAX
i at of App' Convector Date EXHAUST HOOD(WMUCT) t
HAZARDOUS MAiWRTALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future huildingoccupant summer handle ha..Mous mmedai HEATING UNIT ITO 100,003 BTU)
as defined by the Capetian Municipal Code,Chapter 9.12.and Ne Health and Safety
Code,Section 25532m)9 HEATING UNIT(OVER I0y"BTU)
F1 year FIN.
VENTILATION FAN(SINGLE RESID), PAID Date Receipt
Will the apPilcant or Ponpro building occupant use equipmwt or tlevices which p
Tit hazaNnus air contaminants as defined by the Bay Area Air Quality Management' BOILER-COMP(3HP OR 100,000 BTU)
tstrict? TOTAL:
❑Yes r7 No BOILER-COME(OVER IM"BTU)
(have real me hazardous materials requirements under Chapter 6.95 of Chi- AIR CONDITIONER , ISSUANCE DATE
fomla Health B Safety Code,Sections 25505,25533 and 25534.1 understand than d the of NEW RESIDENTIAL MECH, SQ.FE
building does not cuwn0y have a renam,that it i.c my responsihI it
to notify dee occupant ••
of the requirements which moat he mei''.,to issuance of a Corot
of Occupancy.
I
Owner c r authonaed agent Date TOTAL: ISSUED BY:
OFFICE
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