28957 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPPV OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING III n KION APPLICATION/PERN1IT PLUMBING-MECHANICAL28957
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
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OW ER'S NAM" PHONE: CONTRACTOR'S NA f7 LIC NO'
eC� 3-63 Ea- S NIC CONTROL#
IRC TECDENGINEER: LIC NO: ADDRESSP1 1 '�/ ❑
CONTACT: PHONE: S, cLrix d'~+e- BUILDING PERMIT INFO
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9-71 _( �/� [J Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Ly( FO-Ew/V� o ` ❑ ❑ ❑
LICENSE CONTRAC'ITIR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby alRw that I am licensed under provisions of Chapter 9(mmmencing
p s Z JOB DESCR PTION
1u�lOp with Section]000)of Uivisiun]ofthe Boniness and Professions Csale,and my is PERMIT ISSUANCE RESIDENTIAL:
1- full force undeffmt.
CSF m ❑SFDWL ❑KI CHEN REMODEL
G U U License Class Lie.If
Nod
Dam Cnmraclor APPLIANCES-RESIDENTIAL ❑AUDITION MBING RE-PIPE
p.pw ARCHITECTS DECLARATION ❑hfULTI-UNIT ❑STRUCIURAL
Z p y Z 1 understand my plans shall bre
Ise used as public cords PANELS MODIFICATION
OZ + - IIP T02fX1AMPS
[F L-W Licensed Professional ❑INTERIOR El CHIMNEY REPAIR
Qiy�'4 OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
SM�J C e4 I hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
oU following masom(Section 7031.5.Business and Professions Cale:Any ciry or county SIGNS ELECTRICAL ❑OTHER
4411 2 r which requires a permit to construct,alter,improve,demolish,or repair any structure
I.. fig prior to its issuance.also requires the applicant for such perniuo file a signed statement SPECIAL CIRCUIT/MISC.
f�} that he is licensed pursuant 4n she provisions of the Con-dmurs License Law(Chapter 9 _
lyaj
.M
no (commencing with Section700(fiof Division 3ofthe Businessand Professions Codu)or 'TEMP.MG TER OR POLE INST.
I ,
cca o yy that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑DEMOLITION
X N Stenon)031.5 by any applicant for a permit subjects thea licantto a civil ❑ EW BLDG/ADDRION
W I pp penalty of POWER DEVICES
F+�7Y oar more than five hundred dollars(5500). TIiNAN'f FOOD SERVICP.
ASO ❑ Las owner-fthe pmperty.ormy employees with wagesasthcir soleeompensatics, SWIMMINGPOOLELECRIC IMPROVEMENT
a^m wtll J-rhe work.and theswmurein not intended mnffered for salt(Sec.](400,Business ❑OTHER
6'3 and Professions Gsle:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propcny who builds or improves thereon,end who d«s such work himself or through
his own empl-Fees,pr-vide)that such intprovemm¢arc not intended or offered lot NEW RESIDENTIAL ELECTR SQ Pic.ILhowessm the building or improvement is sold within one year ofcompletion,the SQ.FT FLOOR AREA s/SQ.FT.
owner builder will have the burden of proving that he did not build or improve for per-
❑ 1.smowner ofthe(Sm.70,14.
Business
conoacting with licensed comctors in TOTAL:
consumer the project(Scc.]f1W.Business and Prolusions Cede:)The Contractors Li-
c w Low does nm m apply an owner of property who bulids or improves thereon.and QTY. PLUMBING PERMIT FEE
who run-acts forsuch Projects with a conuactort licensed Pa...,to in,Comrsat Draft 199
OLicense Law. PERMIT ISSUANCE ass V
E] I am exempt under Sec. - ,B&P C for this reason r/ALTER-GRAI - T)
�1
•
Owner WORKERS COMPENSATION
COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
N&VENT-WATER(CA) Wr
1 I hereby affirm under perulty of perjury one of the following declarations:
❑I1,imand will oneinmina Ccrtifclue of Consenno,self-in sure Bn Worker's Confirm DRAINS-FLOOR,ROOF.AREA,CO NU
cation,as provide)for by Section 37W of the labor Code,for the performance of the STORIES TYPE CONSTRUCDON
work for which this pcmrit is ics.W. FIXTURES-PER TRAP.,, jFEE❑ 1 have and will uni nism Worker's C-mpensdtma Insurance,as required by Section3100 of the labor Code,for the performance of the work for which thin pewit is jawedGAS-EA.SYSTEM-I INC.4 OUTLET$' OCC.GROUPMy Worker penlation ly5umnm ea�er and Policy nmMeatCl/ t 1frCarrier:-(A-1 4P _-ix Polly Nu.: oV /l7 y T GAS-EA.SYSTEM OVER 4(EA)CERTIFICATE OF EXEMPTION MOM WORKERS'COMPENSATION INSURANCE GREASHq NDUSTRL WASTE INTERCEPTOR(Thisxi,eum eednot becompletedifthepewit is knonehundreddollars($100) BUILDING DIVISION FEES
or less.) GREASE TRAPPLANCHECK FEE
Foy anythat in the anyn tics ofthc laccomesubjeIt for which t to the Waken'Compued.I all SEWER-SANITARY-STORM EA.200 FT.not employ any Canon is any manner so as m become subjen to the Workeri Campen-
Zcation lawsof California.DateENERGY FF.E
Applicant - WATER HEATER W/VENT/ELEC Rz NOTICE TO APPLICANL If.after making this Certificate of Exemption,you should GRADING FEE
become subject to the Workers Cant tion WATER SVSTEM?REATING3 penst provisi-nsoedmined revoked. must SOILS PBE
fonhwirh comply withsuch provisions or this pewitshall he deemed revoked. WATER SERVICE9L.� z CONSTRUCTION LENDING AGENCY NEWRESIDENI'IALPLMB. SQ.FT. PAID
U0thereby affirm thatthen is a construction lending agency for the performance of Dam Receipt#
Frhe work for which this pewit is issued(See 309],Civ.C.)
I Leader,Name
W LendersAJJreu TOTALOL .I certify that I have read thisapplication and stale that the above information i.s NFLE
EEFYI cowct,1 agme to comply with all city and county orinances and state laws rotatngto QTY. MECHANICAL PERMIT
LJ z building construction,and hereby aathorim repmamentives of this city to enrerupoo the C
above-mentinned pmpery for inpecti-n purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against EE
liabilities.judgment,costs and expenses which may in any way acemc against said City ANTER ON ADD'IY)MECH.
msequentt of the granting of this pewit. FEEAPPLICAN U DERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)SOURCEATIO' - AL FEEAIR HANDLING UNIT(OVER 10.000 CFM) TION TAX_gnature of AplocanVConwemr Dote EXHAUS,.HOOD(W/DUCD
HAZARDOUS MATERIALS DISCLOSURE ITIGATION FEF.
Will the applicant or future building occupant store or handle hmatdous material HEATING UNIT(TO 100.(X0 BTU)
as defined by the Cuperin-Municipal Code,Chapter 9.12,and the Ilea1W and Safety ak
Caddie,Section 25532(a)' HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nn
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant orfuture building occupant use equipment or devices which Dae Rmeipt p
man trident...air nmtamininants as JCOneJ by the Be,Arco Air Quality Monagemrnt BOILER-LUMP CHP OR 100,00D BLU)
Ld�snot
❑No BOILER-COMP(OVER 1W,000BTU)
read the hazallous materials requiretxnb under Chapter fi 95 of the Cali AIR CONDITIONER
&Safety Cede,Sections 25505.25533 arvJ 25534.1 undcomnd that if the ISSUANCE DATE
not currently have a terunt.that it i,s my mapm¢i hiliry to nmi fy therpcupani NEW RESIDENTIAL MITCH. SQ.FI'.ments which must be run prior m issuance ofa Cenifi<ate ofOccupancy.boneed agent Doc TOTAL:
ISSUED BY:
OFFICE