28625APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ON[
r BUILDING OF. CUPF.RTINO '
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING.MECF
- BUILDING PROJECT IDI
%Js( BUILDING ADDRESS:
Z ^-7 —0504 I ❑'Consultant Fees Paid by Applicant (Initial)
%�Z I heub ya fmi that I are lcense] under na of Chapter 9 (cammn
V I a
with emion 7fK(pnfDivisinnJfthe Business said Professions
Crude, and my license is.
in full farce and effect.
'aVV License Class Lie#
LDa¢ Cantmcmr
'ARCHI'GXT'S DECLARATION
0F Z 1 understand my plans shall be, used as public mcrnds
zz �
r4 i-. W Licensed Prnfessiunol ,
....II OWNER BUILDER DECLARATION
C 6 1 hereby uflirm that I am exempt train the Contractor's License Law for the
O6 V following rcawn. (Section 703 1.5, Business and Professions Cade: Any city or county
,O F which requires a permit to constmn, alter, improve, demolish, or repair any smtcmre
prianoits ixsuanee. ulsurcquires 0¢upplicaet fnrvuch penninn Nee signed, a am
} thm he is licensed pursuannn the provisions of the Cnntracmrz License Law (Chapar
10EO (urmmenaing with Section 700fq of Uivision3nf the Hurinexs and l•mfessinns Cadcl err
L °n Y that he is exempt therefrom and the basis for the ulleged exemption. Any violation of
I w Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
.H. nmmme than five hand,.] dollars (5500).
f�0 ❑I, as owner of the property. or my employers with wages as their sole.nnpensation,
will der the work, and the structure is not intended or offered for sale (Sea 7044. Business
and Professions Gale: The Contractor's License I,aw does not apply to an owner of
lit— property who build's or improves thereon, and who does such work himself or through
his own employees,'provided that such improvements am not intended or offered for
sale. IL however, the building or improvement is sold within one year of cmnpletion, the
owner - builder will have We burden of proving that he did not build or improve for pur-
pnseofsaleJ; '
❑ 1, ins owner of the property, am exclusively contracting wild licensed cnntmcvns m
contact the project (Sec. 7041, Business end Pmfessians Cade:) The Contmcroh Li-
rnLawdoesneapplytoanownerofpropertywhohandsorimpraveamarcon ,and QTY.
who contracts for such projects with a contractors) licensed pursuant m the Contractors
License Law.
❑ I am exempt under Sec. ,B& P C far this rcawn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of the following declarations:
I have and will maintain a Certilicae of Consent to self -insure for Worker's Compen-
ution, as provided for by Section 37W of the Labor Code, for We performance of the
work far which this permit is issued.
❑ 1 have and will maintain Worker's Conifu salon Insumnce, as required by Section
3700 of the Labor Cade, for the pedommnce of the work for which this permit is iswcu.
My WOr 'n ot�ensapRnlN�e carrier and Policy number amt
Carrier: hr CC....00 Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sceno. need ram be completed nine permit is fusion hundred dollars (SI W)
or lass.)
1 certify that in the performance offn work for which this permit is issued, I %hall
not employ any person in any manner so as to become subject o the Workers' Compen-
Oz sation Laws of Cnlifamia. Date
z Applicant
y NOTICE TO APPLICANT. If. after making Wis Certificate of Exemption, you should
a become subject to the Workers Compensation previsions of the Labor Cade, you must
Forthwith comply with such provisions or this permit shall be deom.l revoked.
Q
CONSTRUCTION LENDING AGENCY
L) 0 Ifar, hieh his Wet there isuconswdiun lending agency for the performance of
{2+ ter the work fur which this permit is issued (Sec. 3097, Ci, CJ
0 U ,Lenders Name
Lenders Address
I certify that I have mad this application and state that the above information is
TaR1 correct. 'I agree to comply with all city and county ordinances and state laws relating to QTY.
U z building construction. and hereby authorize representatives ofthis city m enteruptmthe
aMtvc- mentioned prnpeny in, in,cau npurfam,
(We) agree to save, indemnify and keep handless the City of Cupertino against
liabilities, judgments, casts and expenses which may in any way accme against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI. NON -POINT
-fieA \ (.(----- 3 lit (?C,
Sigrmwre of Applicant /Cmanaccr m
HAZARDOUS MATERIALS DISCLOSURE
Will the appliem or faun building occupant store or handle Warn m, ma¢dal
as defined by the Cupertino Municipal Coda Chapter 9.12, and the Hwlth and Stray
Cade, Scotian 25532(01
❑Yes ON.
Will the applicant or fumm building Mcup at use equipment or devices which
nit humrdous air contaminants as defined by the Bay Area Air Quality Management
:strict? '
❑Yea 0 N
1 have red the hazardous humerals requirements under Chapter 6.95 of the Cali -
fornia Health & Safety GxM, Sections 25505, 25533 and 255M.1 understand that if the
building does not currently have a tenant. thin it is my respmsibility to notify the occupant
of nu requirement. which must be mete lm issuance ofo Cenilicae of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
PANELS v
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT /MIS
TEMP. METER OR P0I.17 INST.
SWIMMING I
OUTLET S- SWITCHES
NIE W RESIDENTIAL ELECI'R
_.,. ... . ,,,.. 28625
SANITARYNO. ' APPLICANON SUBMITTAL DATE
Ci, I Lk.�
�5 N/C CONTROL 0
BUILDING PERMIT INFO
FIFE
RLDO
L t P1- t)p1B M
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWI. ❑ KITCHEN REMODEL
` ❑`p//pDD�'ITION ❑PLUMBING RE -PIPIT
( ZULTIIUNIT ❑ STRUCTURAL
// MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR ,
IMPROVEMENT
❑ BATH REMODEVREPAIR ❑DEMOLITION
❑ OTHER
COMMERCIAL,
_ ❑ NEW BI.DG /ADDITION ❑ DEMOLITION
❑TENANT ❑FOOD SERVICE
IMPROVEMENT
^"THER
PLUMBING PERMIT I FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER IEA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC.4 OUTLETS
GAS - RA. SYSTEM -OVER 4 (EA)
GREASUINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER- SANITARY -STORM BA. 210 FT.
WATER BEATER WNENT/ELECTR
WATER SYSTEMITREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, PT.
MECHANICAL PERMIT 1 FEE.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
HEATING UNIT GO 100,000 BTU)
HEATING UNIT (OVER 1(N),0M BTU)
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (3HPOR 100,000BIV)
BOILER- COMPIOVBR 100,000BIG)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. PT.
OFFICE
SQ. P. FLOOR AREA S /SQ, Fl.
e jfoL"'t Z 1 Lki
PA10
STORIES
CfI Y Ur l,urcEC 1
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY THE
GRADING FBI.
SOILS FEE ILA .r
PAID
Date
BUILDING V7E F .SEISMIC S/�CJkJK_ _I(L 'Q/fls1�i, r �h y�
HOUSING MITICfTTON FILE
PAID
Data Rece 1#
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ISSUANCE DTI
ISSUED BY:
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