28600APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY C NO BUILDING E pPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
-MANCAL 28600 O6OO
ranralac-arugacn^
-ARCHIHIbUMNGINUEM',
v LIC NO:
ADDRESS: - - -
❑
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CONTACT : PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BrLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby 0) itm thal I am littI Int under provisions m Chapter 9 (enmmencing
with Seaion]IM)(1)of Division3 ofht Business and Prnfesxinnc Code and mylicenu is
in full tiacc and If
Litemc Ions Lic. M
Dmc Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
R ID NTIA
❑ SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODE EPAIR ❑ DB40LITIp
-IPOs
OTHER rOOb�. nIL
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PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
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Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that) am exempt from the Commcmr's LiII-I Law for the
following reason. (Section ]03 L5. Business and 14ufessions Cole: Any city or county
which requires a permit to contract, alter, improve, demolish, or repair any shucturC
prionoid maw:race. also rtyuires the applicant for tach pemtino Blcani nW aammcmL
6
that lm ix licensed purstmn700B of Division
the eBusin ss Licenu Law(Chape) or
(commencing.,heiswith Section ](and hDivision3 of theegedIssandve. Any
is exempt therefrom and the basis for the alleged exemption. Any violation of
hat Section
althanby any
leddapplicant
nationalars($5Permit whjeds the applicant teacivil penalty of
r (Seg).
not 1, as than fifthand properly,
'iLothe work, the property, nr myemployeeswlthwages oatheir (Sec. compensation,
saraw dJs'lot apply to an Business
will Professions
and the oLicense
Castle: The slhenContractors License law Joys not apply s if uwncr of
and property who
pmpeny who builds or impmvcs thereon, and who Jtvs loch loud himself or through
his own employees, provided hat such improvwnems arc nine tended or offerW for
sale. If, however the building or improvement issaldyk of cottppppll yy������dd,,Jppppphaaa�s the
n -builder will havetho harden of proving that he di t imp bs7�IBrtyr-
pouemf sale.).
PANELS
UP TO 20U AMPS
201-1000AMPS
OVER I"AMPS
-
SIGNS ELECTRICAL
SPECIAL CIRCUI'1'IMISC.
�
TEMPMETER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑FOOU SERVICE
OTHFR IMPROVEMENT
❑OTHfiR
CTRIC _
-FIXTURES
Ril
ECTR SQ 1T.
SQ. F1'. FLOOR AREA
- ba (i IS.
I O
VSQ. IT.
❑1, as owner of the property, am exclusively contra Lic ac 4a. rt'TOTAL:
Const act the project (Sea 7044, Basi and Pr C : W v a clot s Li-
c wIawdocsnotaPplyhwmnwncro ho J, %thereon, and
whocnntme¢ rusuch prajectcwitha:gm %)liras, 'a it oche Cmdualemh
Licenu law. \g\
❑ I am exnnpt under Sec & I' C for this reason
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OI/ _ 81995
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QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
•Owner
Date
ALTER-DRAIN&VENT_WATER(EA)
VALUATION
00
STORIES TYPE CONSTRUCTION
OCC. GROUP ATN
-
WORKER:SCOM1IPENSATIONDECLARATION
I hcrchy aRrm under penalty of perjury one of he lollowmg ah dameons:
�Ihavc and will maimuina Ccnifcmc of Conunnn sclGinsumfur Worker'z Compcn-
sminn, as provided for by Section 37M of the Labor Code, for the performance of the
work iia which nis permit is issued.
❑ I have and will maintain Wmkels Comfegssfur Insnowlt, as regrind by Sermon
37M of the labor Cale, fort he perfonnmscaf the work for which this Lacuna, issued.
My Wor Cnmpem,mion }�s T d Policy nWn��s
Carica LPeor /:Myer./ ePolicy No.: y( e'a4a3o-d
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF AREA, COND.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. 4 OUTLETS
GAS -EA. SYSTEM -OVER 4(EA)
CRRTIFICATE OP EXEMPTION FROM WORKERS'
GREASEANDUSTRL WASTE INTERCEPTOR
GRHASB TRAP
COMPENSATION INSURANCE
or ]I,,.) (Div, station need not be completed if he permit is for one hundred dollars ($ Ind,
BUILDING DI VISION PEES
PLANCHECK FRE
Qznm
z
Icenify that in the Mrformana otthe work for which this pM1dl
Nolan Worker,,'
employ any person in any manner ns asmbecome srhjecunthe Workecc'Cmmpen-
%scion Wws of Culifnmia. Date
Applicant
SEWER - SANITARY - STORM EA 200 FT.
ENERGY FliF.
WATER HEATER WNENT/ELEClR
F
a Com'
U,
NOTICE TO APPLICANT: If, after making this Cenilicatc of Exemption, you should
bccm.I subject to the Worker's Compensation pros cions of the Lada Calc, you must
fnnhwith comply with such provisions or this famart shall bodeanW revoked.
WATER SYSTEMOREATING
GRADING FEE
SOUS FEE
WATER SERVICE
NEW RESIDENTIAL. PLMB. SQ. FT
5z
V
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CONSTRUCTION LENDING AGENCY
Thereby affirm that there ix:. Crucia ctinn lendingagency fort he perforaanm of
he work for which thispearm' is issued (SIC. 3097. Civ. C.) '
Lem:;; Name
PAID
Dae Receipt#
AJJrees
1 cenify that 1 have read th:x application and state that the above information is
eore<L lsgre to comply wih an city and county ordinances and state laws alining to
building constructing an I arebyuuhoriee rcprcuntmives of his city to entcrupan he
uhnve nantioned properly for hopectian purposes.
TOTAL:
TOTAL:
U
,o yLendete
VN
z
QTY. MECHANICAL PERMIT FEE
BUILDING FEF.
SEISMIC FEE
PERMIT ISSUANCE
I ')ugrm In save. indemnify and keep handisshc Cityof Cupertino against
lmbititics,judgmcnts, costs and expenses which may in any way accrue against said City
in cmrttgrence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTPLUMBING
SOURCE REGULATIONS.
ELECTRIC FEE
ALTER OR ADD TO MECH,
FEE
AIR HANDLING UNIT (TO to," CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER I0,000 CFM)
CONSTRUCTION TAX
Stgnewre of Appl¢aHAZA Dam
HAZARDOUS
RDODO US MATERIALS DISCLOSURE -
Will bythe applicant or futurebuildingCarl, Chantsmrc or handle Health and Safety
as defined by the Cupcninn Municipal Cole, Cbapmr 9.12, and the Health and Safety
CWC. Section 25532(x)?
❑Yen 71 No
EXHAUST HOOD(W/DUCT)
-
HOUSING MITIGATION FEE
HEATING UNIT r"ro IUU,OOtI BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
Will he applicant or future building overprint use equipment or devices which
Cull hazardous air contaminants as defined by he Bay Arca Air Quality Management
District?
❑Yes E] No
PAID
BOILER -COMP (3HP OR 100,090 BTU)
Data Receipt #
TOTAL:
BOILER- COME (OVER 100,gq BI' U)
AIR CONDITIONER
Ihave waddle hawdnasma¢nalc aquimmmns under Chapter 695 of he Cali-
firma Health & Safety Cade. Sections 25ta
505, 25533 and 25534. I undersnd hat if he
building does not Currently haven mnent, that it is my responsibility mmusty he acapant
o[the talui emu wplchmus�S p non issuance of a Cenificae of Oacupweg
Owner or auhord�im Aft+ S I
Date
NEW RESIDENTIAL MECH. SQ. FT
ISSUANCE DATE
C / 1ny/�
BV: � J Lam'_}
-
TOTAL:
ISSUED
OFFICE