28621APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY ' . -
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'CITYOFCl09RTINO` BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PE IT PLUMBING-MECHANICAL
RUIE RING PROJECT IDENTIFICATION
-I. PERMIT NO.
28621 O i�
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BUILDING ADDRESS:.' - ., -
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SANITARY NO.
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APPLICATION SUBMITTAL DATE
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❑ clummitant Vthi Pa y Applicant(Initial)
BUILDING PERMIT INFO
'BBLLLDDGG ELECT PLUMB MEC
LICENSED CONTRACTORS DECLARATION
I hereby affirm Thal 1 am licensed under prev m
f Chapter 9 (commencing
Section 7") of Division Sof the Business d Professions Code and my license is
'm MIT nd effect. ' '' ?GO `6'9
License Carl, D -G_I •i
C
ARCHITECT'SDECLARATION
1 understand m 1
I y p ons shall be used us public records K
QTY, ELECTRIC PERMIT PHB
'JOB DESCRIPTION
'RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
[I ADDITION DPLUMBING RE-PIPE
❑MULTI-UNIT' DSTRUCTURAL
MODIFICATION ,
DINTERIOR', [.1 CHIMNEY REPAIR
IMPROVEMENT
D BATH REMODEL/REPAIR D DEMOLITION _
❑ OTHER
_
pERMTTISSUANCE -
-
APPLIANCES -RESID TIAL
PANELS
UP TO 200 AMPS � , ✓)
Licensed Professional
OWNER-BUILDER DECLARATION
: 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following rea(Section 7031,5, Business d professions Code: Any city or county
which minutes permit In consumer, fter, imp demolish, mmind, y smartme
nn isi ..... re,.Is.nN.i.sOu applicant fhPermit tRE.xi,red statement
Rmh licensed ed pasO thbofD of the ContractorsLicense Le (Chde)or
g tthSection](and a n3ofthalleged e endo A ladon or
that he
dhat io ro exempt ar, ri li nd th b is f r tht,the exemption: pliciA y violation of
anyapplicantfar apermit s bj cis the applicantm vii penalty of
Section than five
of more thanfilose"emeny. or (SSW).
wi Lo the wee, the theatmy,nrmyemntendedwith wegesasaleir sole compensation,
will Bothe week, Code:
and Professions Code: The Colrtraemfs Licence Law does not apply to if owner of
The Conneauti License r.ffiLaw does of apply to an weer of
property who builds or improves thereon, and who does such work himself or through
his own emplayeea, provided that such ememe to On intended or offered far
sale. If, however. the building or improvement is sold within one year ofcompletion, the
owner-builder will have the burden of proving that he did not build or improve for put-
pose of sale.). '.
❑ 1, as owner of the property, am exclusively eonimenng with licensed cortmcmrs to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li.
cense Use does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a examinations) tions) licensed pursuanto the Conttacm
License law.
❑ I am exempt under Sec. ,&PC for reason
B
201-10011AMPS e'.
OVER ["AMPS
SIGNS ELECTRICAL
-
SPECIAL GIRGDITMI$G.
t
TEMP.MEfER OR POLE INST. }
COMMERCIAL: 1 -)�
- -
'NEP' BLDG/ADDITION El DEMOLITION
E ,
NANT ❑FOODSERVICE
1 PROVEMENT i t
❑OTHER
r
_
POWER DEVICES -.
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FIXTURES -
NEW RESIDENTIAL ELECTR SQ FT.
-
'
SQ. FT. FLOOR AREA
•'
PA
8d
Dr/12r's
vv n
nO
lt,y 1995:
tr l�(jY .
$/SQ. FT
..
;
,/a} P.
:.,
TOTAL:
QTY, PLUMBING PERMIT FEE
_
PERMITISSUANCE
-
ALTER- DRAIN&VENT -WATER (EA)
BACK FLOW PROTECT DEVICE
Owner - Date
- r -NAL,
' SV 'I't(
,s :G' •yr•
• WORKER'S COMPENSATION DECLARATION
• I hereby affirm under penally of perj iry re
10 one of the following declations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
amino, as provided for by Section 3]110 of the Labor Code, for the performance of the
w..ork for which this permit is issued.
>L have and will maintain Wurker's Compensation Instimnce, as required by Section
370Oofthe Labor Code, for the performance oflhe work for which this permit is issued.
My Worker's Compensation Insurance carief and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiasation reedit be completed if the amen is furore hundred dollars 1$1 W)
'or lass.) I
I certify that in the performance ofthe work for which this Permit is issued. I shall
not employ any person in any manner so as to become subject to the Workers' Compen-
smion Laws of Califomla. Date
Applicant - „
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES'
-
-
OCC. GROUP
v
TYPE CONSTRUCTION
,
APN
-
FIXTURES-PER TRAP
GAS- EA. SYSTEM) INC. 4 OUTLETS
GAS -EA. SYSTEM -OVER 4 (FA)
GRFASFIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEPS
GREASETRAP
PLANCHECKPEE
SEWER-SANITARY-STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENT/ELECfR
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cade, yon must
forthwith comply with such provisions or this permit shall be decimal revoked. -
' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Seo. 30D, Civ. C.)
Lenders Name _
Lender's Address
I certify that 1 have read this application and state that the above information is
cortecp l agree to comply with all city and county ordinances and state laws relating m
buil1ding construction, and hereby authorize representatives of this city to enter upon the
a K-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
in conmeyueace of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. ' 1
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WATER SYSTEM/TREATING
SOILS FEE ,
WATER SERVICE
-
PAID
NEW RESIDENTIAL PLMB. SQ. FT.•
Date Receipt#
TOTAL:
TOTAL:
BUILDING FEE Y
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
-
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10,IXM) CFM)
MECHANICAL FEE
-
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
'
Signature of ApplicanVContranoi, Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(n)?
❑Yes [No r/
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? ALN o " -�
❑Yes CLN
1 have read the hazardous materials requirements under Chapter 6 95 of the Cali-
forma Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
building does not curmntly Emote ant, that itis my responsibility to notify the accupant
of 'rements net, et prionolssuanca ofe Cutificmeof Occupancy.
mor authonzed agent _ Date
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
5 J
HEATING UNIT (TO I Of," BTU)
HEATING UNIT (OVER 100,000 BTU)•
-
PAID•
- -
'
VENTILATION FAN (SINGLE RESID)
Dam Receipt It
-
-
BOILER- COME(3HP OR 100,000 BTU)
TOTAI:
BOILER- COMP (OVER 100,000 BTU).
- AIR CONDITIONER
ISSUANCE DATE
-
-
ISSUED BY:
NEW RESIDENTIAL MECH. - SQ. FT.
_
„ TOTAL:
OFFICE