28848 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'EN0 2 8 8 4 .a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L ly1( yV( }V(
BUILDING PROJECT IDF.N'FIF'ICATION
BUILD( CADURF:$S: � SANITARY NO. APPLICATION SUBMITTAL DATE
OW OF ,VjC:r,/J� M ONE: CONT Cf R'S A E LIC NO:
c N/C CONTROL
ARCHf1ECT/EIJOINEER: /F O, `.'L ` ADDR1iSS: ❑
CONTACT. r ��{ PHONE: J BUILDING PIiRMfT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby nffam mat I am licensed under provlxbn,of chapter 9 Omrtmcncthg JOB DESCRIPTI N
Ofa'Z with Section?000)of Division 3.f the Business and Professions Cade,and my license is
LLOO PERMIT ISSUANCE RESIDENTIAL:
F LL in full force mW effect. ,
E)SFDWI, ❑KITCHENREMODFL
IF.UZ U License Class p
N6� Date Contractor APPLIANCES-REMDENHAL ❑ADDITION F1 PLUMBING RE-1'IPIi
F-Dut ARCHITECI'S DECLARATION PANELS ❑MULTI.UNIT ❑STRUCTURAL
Z p vn Z I understand my plans shall he used as public recoNs MODIFICATION
OZ-0 UP'1'O 2W AMPS
E)INTERIOR El CHIMNEY REPAIR
WW Licensed Professional 201-IWBAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
y a I hereby unit.that the.."m
nt I uexempt from me onlctnr's License Law for me OVER Hyla AMPS ❑BATH RIiMOUEL/REPAIk (]DEMOLITION
x 3 d U following reason.(Section 1031. .Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
tzl LL wM1ich requires o permit m construct,elteq improve,dnnnlisM1,or repair any swnurc viz
[: y prionoits issuance.also requires the applicant for such pcnniuo fie asignetl sramment SPECIAL CIRCUIT/MISC. `
yNpursuant at he is licensed pursuano the provisions of the Contractor's License Law(Chapter 9 '
�C)q (commencing with Section 7")of Division 3 of the Businessnnd Professions Catle)or TEMP..MFTER OR DOLE INST COMMERCIAL
F c LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADURION El DEMOLITION
ern Section 70315 by any applicant lisap:rmit subjects the nppl'mnmm.eivi,penahyof POWER DEVICES ❑TENANT El TENANT
ore
not mthan live hundred dollars($5W).
G has owner of the norm employees with wages as their sole compensation, SWI MMING POOL ELECTRIC IMPROVEMENT
O ❑ property, Yet in Y 6 pe
will dothework,ands,One
Coatis notintendedo Usedeafuroatepplyto n Business ❑OTHER
3 and Rofeshiob Crate:Theeomthereo License dodorsnotapply himself
of OUTLETS-SWITCHES-FIXTURES
his o ny who build,or improves thereon,and who nts such work ldo of through
his own employees,e provided than such improvements are,not intended or offend for NIiW NfiSIUF,NT1Al.EL[CTR SQ FT.
sale,
mer-loowevccll Inertia bur lntproNovin ismlhedid non build or fenmplctRuput- S0.1TE FLOORAREA $ISQ.Irl'm
nwmer-huiite.).l Inertia burden nl'Pmving than he did not buil)or imPmvc for pur-
pose of sale.). s„
❑1,azowner of the property,am,Bexclusively contracting with licensed cn.bxn's i- TOTAL: �z' P p�,
conswcr the project(See.TOW,Business and Professions Code:)The Cnntrvcmrn Li-
screw Law does not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEF, n�� ��
who contruns for such projects with a combectoos)licensed pursuant to the Contractors v
License U. PIiRM,'1'ISSUANCE n 18g§
❑ I mm exempt tinder see. ,11&P C on,hNneamn _ E �TV
AU]FR-DRAIN&VEMF-WATF.REA) 1 Cf l�V
Owner Dae
r�
Y VA U TION
WORKEWSCOMPENSATIONDECLARATION BACK FLOWPROTECC DEVICE U
I hertby aRw under penalty Mperjury one of me following declarations:
]I have and will maintain a Certifinnc of Consent o self-inxure for Worker's Compcn- DRAINS-FLOOR,ROOF,AREA,GOND.
Andior,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRA It ,
D I have and will maintain Workenes Compensation Insurance,is required by Section
3700ofthe Labra Code.fortheper-fstronceof the work forwhichido,permit kilatood. GAS-EA,SYSTEM-I INC.4 OUTLETS ICC.GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Carrie. Policy No.: GAS-F.A.SYSTEM-OVI;R 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRI.WASTE INTERCBPfOR
('His sectinnnaad..rte cmnplated ifth ,arraa is for one handml dallurs($IIX)) - BUILDING DIVISION FP.ES
or less.) GREASE'1'RAP PLANCHECK FEE
I certify Nat in the perfnnnun<c afore work for which this permit is issuetl,]shall SEWER-SANITARY-STORM EA.200 Ery.
nal employ any person in any manner so as to Mcome subject to the Workers Camnen- ENERGY FEE
Z satin.Laws of California.Data
C7O Applicant WATER HGTER WNENI'/ELECIR r GRADING FEE
NOTICE TO APPLICANT.If,a her making this Certificate of Exemption,you should WAl'EE SYSTEM/fBEATING
breathe subject but the Worker's Compen.amion Provisions of the Labor Code,you must SOILS FEE
for ,all manna,will....h provision.or thispermit.shall he decntedrevoked. WA3'13R SERVICE
d
5 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
V 0 (hereby affiant that mere is esminmswctiun lending agency forme Performance of Date Racci,i#
(Jr H the work for which this permit is issued(Sec.309],Civ,C.)
O U Underi Name TOTAL:
W Lender's Address T
1 cre ify that I have read mix application and smm that the above information IN BUILDING FHE.
4 N coned.I agree to comply with all city and county mdimances and state laws relining at QTY. MECHANICAL PERMIT FI?E
U building construction.and herchy nuthorizc representatives of this city in enter upon thc SEISMIC FU
,move-meurioned property for inspection purposes. PERMIT ISSUANCE
(We)agrte to thee,indemnify and keep harmless its,City of Conciliar,alELECTRIC FEE
liabilifies,judgments,trots on expenses which may in am ayaccmeaguinst said City AITER OR ADD T ECH.
in consequence mf gmnli Irma Permit. PLUMBING FEB
APPL.0 QRST I3ANDW l OMP( WITH LL 11111N-POINT IANDLI ,UNI'I'('1010,000 CPM)
S 1 1t. ION MECHANICAL FEE
IR HAND G ON, (OVER Ignoo CFM) CONSTRUCTION TAX
ignalum m Appherin O.Thsat, Doc EKHAU HOOD(W/DUCq
HAZARDOUS MA .RIA SDISCLOSURE HOUSING MITIGATION FEE
Will thmpplicard ar future build, g omupant,ureinhandlitemerdmnt oriel Hp ' NG UNIT(TO ,1 T )
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely -
Col Sectio.25532(x)? '.ATING UNIT(OV.R f, O Bq'
❑Yc, ❑Nn
VENT TION 'LP.R 1 PAID
Dae Receipt p
Will the air conn or future building occupant use equipment or Jevica which BOILER O
•mit hazardous air contaminants az defined by the Bay Arca Air Quality Management (3HP 100, )
)imrin? TOTAL:
C]yes -1 No f .ER-CO (OVER ,l OBTU)
Ihavereudthe haoladmsmaerinkneyuiamorts under Chamertio5ofthe Cali- ASR CO 3'10 R ISSUANCE DATE
had.Health&Safety Code,Sections 25505,25533.,it 25534.1 undersand Lha if me NEW RISIDE MECH SQ.IT.
building does nm curmntly have a term,mat it is my ses,ousibility to nod!)uncommon, AL
of me re,uiremcros which must he man prio to issuance of a Cer ificae of Occupancy. /1
Owner or aulhonzed agent Dole TOTAL: ISSUED BY: • 1
OFFICE