28699 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO. AArte
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 28699
LJ LV� `9 I9
BUILDING PRf1JEer IDEN'TIFIC'ATION
ogUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DAT[
NER'S NAME: &PHONI?: L CO A A LIC NO', 'k- '_ k0�
�,o •L NIC CONTROL#
RC TE MNGINEER, LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG .LL PLUVIT, MECH
IS
LICENSED CONTRACTOR 5 DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JO DESCRI ION
Oco with Seaimn V000)ofIN,mon Sof the Bminessond Professions Code,and my liceme is RESIDENTIAL,
{a�00 in full force amt effect. PERMIT ISSUANCE
F�(r DSFDWL D KITCHEN REMODEL
�� License Clash Contractor
LLI Date Contncmr APPLIANCES-RESIDENTIAL DADDITiGN GPLDM1IBING RE-PIPE
I„py ARCHITECFS DECLARATION PANELS
❑MULTI-UNIT ❑STRUCTURAL
Z Ov� 1 undersand my plans shall be used as public records MODIFICATION
INNO Z:J� UP TO 200 AMPS ❑INTERIOR' El CHIMNEY REPAIR
Licensed Professional - 201-IMOAMPS IMPROVEMENT
IOWNER-BUILDER DECLARATION OVER IOM AMPS D BATH REMODEUREPAIR D DEMOLITION
yy I herehy affirm Ihw 1 um caempt from Nc Contractor's License Luw far the
M0 following reaaon.(Section 7031.5.Business and Professions Cade:Any airy or county SIGNS ELECTRICAL. D OTHER n =
FFV.a W I"' which requires a pentyl ,,concoct.alter,improve,demolish,or repair any structure tl Z,
I["�'-0 prior to its issuance,also requires the applicant for such Now,to file a signed statement SPECIAL CIRCUIT/MISC.
�yYI({y�{•�y that he is licensed Pursuant to the provisions of the Contractors License Law(Chapter9
W I-i00 (comment i ng with S cction7")of Division 3 of the Business and Professions Code)or 'TEMP.METER OR POLE INS'T. COMMERCIAZ:
a K n eG
that he is exempt therefrom and me basis for the alleged exemption.Any violation of O NEW BLDG/ADDITION L'MBtdDLITION
Section V03I,5 by any applicant for a pentyl subjects lbe applicant to a civil penally of POWER DEVICES L.s1 Uh
ta]^'rn ANT' Lou, OFOODSERVICE
nut more than Ove hundred dollars(5500). MPROV- ENT 1-f71
Q wi Losm socks the propeng memnotiwardelmthwugexm Neifsolecompesirrss SWIMMING POOL ELECTRIC llk(y
and dothework,and the he Cure is notintended Law
apply TBW.Badness ❑OTHER
and Professions Code:The ose,prom License law saes not apply to an ownerofTLIiTS-S CHES-FI%TURFS
progeny who bails or improves thereon.and who does such work himself m through
his own employees,provided that such improvements are not iyeaeded or offered!for NEW REST IAL EL R SQ FT.
owner-builhowevder
ill have
ofprment issoldhedidaoneild or ir of mprove
the SQ.FT.FLOOR AREA LSQ.I'r.
ownerbuiller will have the burden of proving that he did not build or improve for par
you of mule.). l -
D 1,as owner of the property,am exclusively concocting with licensed contractors to TOTAL: I
construct the project IS..]044,Business and Professions Code:)The Contractor's Li-
censeLaw doesnot apply toanowner ofpropenywho buildsorimprovesthereon,unit QTY. PLUMBI PERMIT FILE
who contracts far such projects with a conttacmr(s)licenses pursuant to the Continuities
License law. PERMIT ISSUANCE
0 1 um exempt under Sec. B&P C for this reason
Owner DateALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ^ C/
I hereby Orion under penalty of perjury one of the following declarations: z�� J
D I have and will maintain a Certificate of Conaenno self-insure for Worker's Compcm DRAINS-FLOOR,ROOF,AREA,COND. TORIES TYPECONSTRUCION
.an..,as provided for by Section 3]M of the Labor Code,for the performance of the -
rkfor whichlhisPermit isisaued. FIXTURES-PER TRAP
0 I hove and will maintain Workers Competamtion Insurance,as required by Section
37M of the Lothar Code,for the performance of tW,wnrk far which this pemut is issued. GAS-EA,SYSTEM-1 INC.4 OUTLETS OCC,GROUP APN
My Workers Compemution Insurance carrier and Policy number are:
Cartier: Policy Na.: GAS-EA.SYSTEM-OVER 4 HEO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUS'fRL WAS RCEPfOR
BUILDING DIVISION IPE$
(This nee
,action d not the completed ifthe permit is for one hundred dollars($Its))
or less) GREASI?TRAP . 044% LU
�,
I certify that in the performance of the work for which this permit is issued,i shall PLANCHECK FEE
not employ any person in an manner sn as to become suticcttothe Workers'Com SEWER-SANITARY-STORM 00IT.
y ) pen- ENERGY PEE 16,53 1
0 Z maim,laws of California.Data WATER HEATER WNENT/ELECTR
0 Applicant GRADING FEE
a2NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMGREATING SOILS FEL?
become subject to the Worker's Compensation provisions of the labor Cole,you must
W forthwith comply with such provisions or this permit shall he deemed revoked. WATER SEEVICIi
Q
CONSTinti3ONLENDING AGENCY NEW RESIDENTIAL PLMII, PAID
L) 0 I hor which rat lhauhere isacd(S.c.0lending agency truth performance of Data Receipt
W fps. the work for which this permit 1616Yu[tl(S.c.309],CIv.CJ•
0� IzZa Name TOTAL:
Leasers Address TOTA .
1 ccnify in.I have read this application and,tate that the above information is BUILDING FEE is�
w+ t0.A correct.I agree to comply with all city and county ordinances and stare law,relating to QTY, MECHANICAL PERMIT FEE
U,ZZ' building concoction,and hereby armada represenmtives of this city to enter upon the SEISMIC FEE
0111
shosameminned property for inspection purposes. PERMIT ISSUANCE
(We)agree m,ave,indemnify and kap hmmlcss the City of Cupertino against ELECTRIC FEE
Iiubilitics,judgrmnts costs and expenses which may in any way accrue against said City ALTER OR ADD'TO MECH.
PLUMBING FEE
inconsequence of the grunting of this permit.
PLICANT UNDERST/�tpS AND WILL OMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,0100 CFM) CHANICAL FEE
SOI' CC REGULAT")
\ ME
„2 AIR HANDLI NO UNIT(OVER 10,(100 CFM) CONSTRUCTION TAX
tgnatmeof Appl'anV on for Data EXHAUST HOOD(WNUCI') HOUSING MITIGATION FEE
RDOUS MARIAL,S DISCLOSURE
Willtheappliamawfumrebuil ng occ,pam sore nrhandle hazardous material HEATING UNIT(TO 1011,0011 BTII)
es defined by the Cupenino M.nicipal Code,Chapter 9.12,and Ne Hcailh and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,00#)BTU)
❑Yes FIN. PAID
VENTILATION FAN(SINGLE RPS ID) Date Racip#
Will the applicant or future building occupant use equipment or devices which BOILER-
au it hazardous air contaminants as darned by the Bay Area Air Quality Management COMP(3HP OR 100,000 BTU)
Dixlrict'l <C44T
❑Yes GNo BOILER-COMP(OVER IIIB,"BTU)
I have rad the hvsrdous matenals tuquitcmenu uolcr Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fools Hcahh&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
Wilding does no curcmly have a tenant.that it is my responsibility to notify Ne occupant
of the requirements which must he met poor to issuance of a Cenificam of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE