28804 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYUPCUPERTINO BUILDING-ELECTRICAL ' PERMIT NO..^.8 'eco ar
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL' L l8J tl}}JJ(( 4
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNER; NAME; PHONE: C.0N.TRACTORSN ME: LIC NO:
N e - /" N/C NTR M
ARCH hQ NGINELIC NO ADDRESS
: _ ❑
IxJ N L/
CG ACT: PHONE.: BUILDING PERMIT INFO
•❑ COnSultant Feu Paid by Applicant(Initial) BL ELECT PLUMB MeViA
LICENSEDCONTRACI'OR;S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisium of Chapter 9(commencing B DESCRIPTION
aw�Z with Section]OW)of Division 3of the Busiressund Professions Calgand my license is RESIDENTIAL: '
O O PERMIT ISSUANCE
��F in full lora and effcm. ❑SFDWL e ❑KITCHEN REMODEL
U License Class Lic.X
IQ L) APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
U ZWDate Canavan,
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
[-7 ria - PANELS
ZpyZ I understand my plans shall he used as public records - MODIFICATION
OZ-O - UI'T02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F�F'W Licensed Professional 201-1000 AMPS IMPROVEMENT fid E-1 OWNER-BUILDER DECLARATION
C C OVER 1001 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
hereby affinnthar Lain exempt from the Gmvncmrs License Law Bx the
xdx O a U following reamn.(Section 70313.Business and Professions Cede:Any city or countySIGNS ELECTRICAL ❑OTHER
W 3 LL y which requites a permit ro conswn,alteq improve,demolish.or repair any sweturc
N j prior to its ikmana,alio reyulres the upplicnm fur such lamtitm flea signed notomom SPECIAL C112NIT/MISE.
f�do that he is licensed pursuant.the provieiousof the Comemor's License Law(Chapter 9
lCpO (commencingwith Smtion10IX1)Of Dtvision3ofthe Businessand PmfesuionsCNc)or TEMP.METER OR POLH COMMERCIAL:
a 4 oqq that he is exempt therefrom and the basis for the alleged exemption.Any violaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
k m W Section]071.5 by any applicant for o permit subject the applicant m u civil Penalty of POWP.R DEVICES
Wtiy ANT ❑FOODSERVICE
of more Non five hundred dollars WWI. IMPROVEMENT
I-=Q Cmc Q I.as owner ofthe progeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC J� A will do the work,and the structure is not intended mothered for sale(Sec.J014,Business (� ❑OTHER
W eco and Profession,Cale:The Cmarea r'a License Law do.aot apply m an olue,of OUTLETS-SWI'If71XTURES
property who builds or improves thereon,and who does such work himself or through
hisownemployees,provided Nat such improvements arc not intended or offered for NEW RESIDENTIAL K4rR SQ FF. -
sale.If,however,the building or improvement is sold within one yeandcompininofor SQ.FT FI RAR USQ.FT.
er-builder will have the burden of proving that he did not build nr improve fnr par- 1'�'-1TY'�,
poseofsaley �
❑I,as owner of the property,am exclusively connecting with licensed contractors to TO 'I a- A, ET
c naamn the projeet(Sce.]M4,Pusinecs anA Porfessions Cade:)11—onae-a Li- CI,
arse Law does not applymmi owneTofpmpcoy who huildsonY.
r.improves thencaand QTPLUMBING PER FEE )CT 4
whirmaracrs forsuch project,wiNtirmuocwgs)licensedpursuanno the Co..ra,...x `/ 199
License Law. PERMIT ISSUANCE 5
❑I am exempt under Sec. .B&P C for this reason xOb
)wner Date ALTER-DRAIN&VEND'-WATER(EA) V1��rYt(.1VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
v �[� ^ uX1
I hereby affimt under penalty ofperjnry one of the following declarations: .X `����
�n I have and will maintain a Cendicane of Consem to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA.COND.
avmor.as provided for by Section 37W of the labor Code,for the pcHonrtance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 has trod will arrinamin W..kcr's Cnmpunxution hoonunce,ua ,.i,cd by Section
311 of the Wbor Code,for Ne perfnrm:mccofthe work for which this permit is issued. GAS-F-A.SYSTEM-]INC.40U'I LETS WC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Cancer: Policy No: GAS-EA.SYSTEM-OVER 4(EA) ,
CERTIFICATE(IF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ORLASIJINDUSI RL WASTE INTERCEPTOR
BUILDING DIVISION PEES
This section need not h completed Rule permit is forooe haodre idollzn(SI001
ar lessJ GREASE TRAP PLANCHECKFEE
Icenify thatln the anymanneco axtobrkfof which Nis theWoeixsued,Lmn- SEWER-SANITARY-STORM EA.200 FT,
not employ any perwn in any manner m ns n0 become subject ret the Workers'Cnmpen- ENERGY FEE
zz cation Laws of California.Date WATER HEADER WNENr/ELECTR
C) Applicant GRADING FEE o
y NOTICE 10 APPLICANT:If,after making this Cedilicme of live poan,you should WATER SYS'TEMnEll"ATING
? become subject m the un Workers Com atria provision of Ne Labe,Code,you must SOILS FEE
Lk7 forthwith comply with such provisions or this permit shall be deemed revoked. WAT12R SERVICE -
D la ..
CONSTRUCTION LENDING AGENCY '- N13W RESIDLNTIAf.1'100. $Q.FT. PAID
O Uulc RaaeiptX
U ' .
1 hereby affi,m than there is.a ronswniun lending agency far the performance of
the work for which this gamic is issued(Sec.300,Civ,C.)
C) U Lenders Name TOTAL:
0. 60
O W leader's Address t TOTAL'. O
} 1 certify that I have read phis application and state that the eMve infoorigin.is BUILDING FEE
F h correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V building construction.and hereby nuthmim reprosendivesofthis city toentar upon the SEISMIC FEE
alxsve-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep harness the City of Cupertino against ELECTRIC FEE
liabilitiesjudgments.costs and expenses which may in anywayaccme against and City ALTER OR ADD TO MECH. PLUM BING FEE
in nequmme of Ne grunting of this pscmru. - -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,00)CFM) MECHANICAL.FBE
SOUR GULA '
1„6 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signae - bent, Ual 'EXHAUS'1'11WD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE - -
Willmeapplicantorfutme,building overpent store or handle hazardous material HEATING UNIT CFO IWAW BTU)
as defined by the Cupeniuo Munlci ed Code,Chapter 9.12,and the Health and Safety _
Code.Section 25532(x)? HEATING UhN r(OVER 100.001 B'FU)
[:3 Yes ON. PAID
VENTILATION FAN(SINGLE RESID) Dam ReceiptX ,
Will the applicant or fwhre building occupant use antitumor or devices which
emir hazardous at contaminants as defined by the Bay Arran Air Quality Management BOILER-COMP(3HP OR IBB.IkMI BTU)
Orono? TOTAL:
❑Yes 0 N BOILER-COMP(OVER 100.010 BTU)
t
base mad the hazvdous materials requirements under Chapter 1695 of the Cali- - AIR CONDITIONER - _ISS UANCF
f cam Health&Safety Cade.Sections 25505,25533 anal 25531.I understand that if the NEW RESIDENTIAL MECH. SQ.ET.
�(�snoteunca in is my ranpvnsibilitynt nodfy thcomcupabtmuxuane—lacOmicum to' pear
Oft
Marc ISSUED BY:
OFFICE is