28856 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMI•r PLUMBING
-MECHANICAL •2 O O C C
BUILDING PROJF,CT IDENTIFICATION o o J v
BUILDINGADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATI
�+ ,�eaESR a Lb
OWNER'S NAME: PHONE: CONTRACT'OR'S NAM& LIC NO'.
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ARCHITECT/ENGINEER: LIC NO: ADDRESS: f - ❑
O AeLlRAL 4notlip MWIl h 9ioyG
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB' MECH
❑ ❑ ❑
LICENSED CONTRd ands,fr DECLARATION QTY. ELECTRIC PERMIT FEE
I imi 70 affirm this I am licensed under nd 11 ions tum Chapter 9(commencing JOB DESCRIPTION
�'Z
th Scdi.n 7000pd Division J of the llusin.es and l'rnfuslons Colc,:mam Tisanes is
00 in full force and eIt �j y PERMIT ISSUANCE RESIDENTIAL
F 4 (o 6134I%g ❑SFDWL ❑KITCHEN
a U U License CI s Lic.N
��W Dare � ConsracfK APPLIANCES-RESIDENTIAL ❑gD01TION El PLUMBING RE-PIPE
g,Dy ARCHITECTS DECLARATION PANELS [I MULTI-UNIT [2 STRUCTURAL
Z Or�7�I. �n `Imy�plan s��II j�lrnnc used as public reaads - MODIFICATION
OZ�O \.(.(a#'L CIYA�/ - UP TO 200 AMPS
El INTERIOR 0CHIMNEY REPAIR
W Licensed emowl 2014000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
X Q 1 hereby affirm that I and exempt from the Contractors License Law for she OVIIR i"AMPS ❑BATH REMODFUREPAIR ❑DEMOLITION
30.U following reason.(Seesion 7031.5,Business and Professions Cole:Any city or county SIGNS ELECTRICAL. ❑OTHER
W which requires a peril to construct,Idler,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit n file a signed statement SPECIAL CIRCUIT/MISC.
Tdalheislusupsip...inno the proviziotu oflbe Cnmmcmrs License Law(Chipter9(commencing with Section 7")of Division 3 ofthe Business and Professions Crlde)ur TEMP.METER OR POLE INST. COMMERCIAL:shat he is exempt therefrom and the basis for the alleged exemption.Any violation of C1 NEW BLDGIADDITION ElDEMOLITION
Section 7031.5 by aunyapplieaut fora permit subject,theppli.el lou civil penally el POWER DEVICES ❑TENANT ❑FOODSERVICE
>P',x, not more than five hundred dollars(55110}
�q< Las owner.fshe property,or my employees with wages as their side compensation, SWIMMING POOL ELECFRIC IMPROVEMENT
� O willdothe work,and the structure is not intended oroffered for sale(See.7614,Business ❑OTHER
W and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCITES-FI%TORES "
4i 3.r property who builds or improves thereon,and who docs such work himself of through
his own employees,provided that such improvements am not intended or offered for NEW RESIDF.N'I'IAL ELECT'R SQ IT
side.If.howc,c,she building.,improvement is sold within one year ofcnmple,i.n,the SQ.PT.FLOOR AREA SISQ.ET.
owner-builder will have the burden of proving Out he aid not build or improve for pur-
poseofsale.).
0 I,as owner of she property,am exclusively concocting with licensedcmoracm'sm to TOTAL:
.unrum the project(See.7044,Business and Professions Code:)The C.nnacl.rLi-
cense Low docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT EEE CTI
whocommets for such projects with unnunclnr(s)licensed pursuam.,he Contra ba', O
License Law. PERMIT ISSUANCE G�� -
O m 1(g199
^
I eaeinp,under Sec. ,B&PC for lnkocioen 1
AI:I'Elt-UkA1N&VENT-WATER EA)
AZ
Owner WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICC !"E114116 ALION
I hereby affirm under ..].yet pc,j.,..e.f the following dedariamus:
I have and will maintain o Certificate ofConsen to self-insure for Workers Cooper. DRAINS-FLOOR,ROOF,AREA,COND,
cation,a,provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPECONSTRUCTION
work for which this Perini,is issued G TURES-PER TRAP
0 1 have it will maintain Workers Comperomit n Insurance,a+required by Section
3700 of the Labor Code.far she performance of the work for which this permit is issued. GAS-HA.SYS'IENI-1 INC.4 OIJZ 'S OCC.GROUP AI'N
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No.: GAS-EA.SYSTHM-OVER 4 R?n)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GNE45F/INDUSTNL WASTE,INTERCEPTOR
io ucuon need not be completed ifthe permit is fortune hundred dollars(S 100) BUILDING DIVISION FEES
or less.)(ThGRIiASE TRAP
PLANCHECK FEE
Toy any that in the any
tumthe work for which this the Wl.ke,Comma- SEWER-SANITARY-STORM EA.200 FT'.
not employ any person in any manner so us 1.bTc'sOysybFlgtn,hu Workeli Compen- ENCRGY PEE
OZ selom Laws of Date [ I(A[QQrI 14'S WATER HEATER WNENT/F.LF.CTR GRADING FEE
O
Applicant '
fA NOTICE*10 APPLICANT.IL aper making this Cenificme of Exemption,you should WATER SYSTEM/IREATTNO
abecome subjecuo she Worker's Compensmion provision,.fine tabor Code,you most SOILS PEE
W
forthwith comply with .in pon,Wnm nr this penni„bnll be deemedrevokaL WA'1'IIR SERVICE
5Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
V O l hereby aRmt that there is a construction lending agency for she performance of Dare Receipt at
[Fw F she work for which this penin is Issued(See.3097:Civ.C.)
O Lender's Name
OTAL:
06 Lenders Address
�ysl pr 1 certify she,I have read this npplicad.n add unite Ihul the ulnae information is BUILDING FEE
N7 correct.I agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V L7 building construction,and hereby authpire representatives of this city to enter upon the SEISM IC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ugme m save,indemnify and keep lurnaess the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in tiny way accrue against said City ALTER OR ADD TO MUCH.
in consequence of the griming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0(0 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
1 x'1.4�yai /O'10 AIR HANDLING IINIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgnewre of Apphcnnl/Cnnuacsnr D e E HAUST FOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant or future building occupant store or handle hazardous material HEATING UNIT OO 100,000 BTU)
as defined by she Cupertino Municipal Code.Chapter 9.12,and the Herith and Sammy
Coda Section 25532fn)'! I]RATING ON]T(OVER I00.nXI OTU)
❑Yes C]No PAID
VENTILATION PAN(SINGLE RESID) Data Raeipt4
Ik Will she applicant or antures a building occupant use ear Air Qm or devices which BOILER-COMP(314POR 100.0 f;BTU)
emit hazardous air contaminates as delinea by the Bay Ama Air Quvllty Management 'TOTAL:
Dislrid7 '
O Yes FIN. BOILER-COMP(OVER 100,00 BTU) -
1 have Tsai the hazardous materiels AIR CONDITIONER
rtgmornams under Chapter fi 95 of the Cali ISSUANCE.DATE
fomin Health&Safety Cole,Section,25505.25533 and 25534.1 understand that if the NEW RESIUENTIAI.MECH. t SQ,FT.
huildingdousn.scurrelly hovev annot.lut lti,Iny ri,pnnsibilisymnolay lhenoapunt
of the requirements which must be met prior to issuance of a Cenificlne id Occupancy. ,
Owner oramhnized agent Date TIYI'AU ISSUED BY:
OFFICE