28803 (2) 'APPLICANTTO FILL IN INFORMATION WITHIN.RED LINES•USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO. O
BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - - - SANITARY NO, APPLICATION SUBMITTAL DATI
OWNr^NAME: PH E: CONTRACTOR'S NAME: LIC NO: -
L/� , N/C CONTROL If
ARCHITECFIENGINEM: - LIC NO: ADDRESS: _ ❑ "
CONTACT - PRO—NE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE _
I hereby affirm that 1 to
�0with Sen licensed under provisions of Chapter 9(commencing JOB DESCRIPTION-
C Section of Division 3 oftbe Business and Professions Code.and my license is PERMIT ISSUANCE ,RESIDENTIAL:
in full force and effect.
O� ,ElSTOWE D KITCHEN REMODEL
•M-UU License Class Cmear APPLIANCES-RESIDENTIAL
'y�a Date Cnntranur �� ❑ADDITION [I PLUMBING RE-PIPE '
br D y ARCHITECTS DECLARATION - D MULTI-UNIT D STRUCTURAL ,
l understand 1
Z O y plans shall be used as public records PANELS MODIFICATION
OZ UP TO 200 AMPS -
= Licensetl ProfessionalDIR C1 CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-I WOAMPSIMPROVMPROVEMENT'
1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER IfXO AMPSD BATH REMODEURRED�PAIR DEMOLITION
iWSOyU following reason.(Section 7031,5,Business and Professions Code:Any city or activity SIGNS ELECTRICAL•, DOTHER _Ae
sR WO l••' which requites a permit to construct,alter,improve,demolish,or repair any structure Jt/
,n prier to its issuance,also requires the applicantfor such pamen to file a signed statement SPECIAL CIRCUIT/M19C.
y Nat he is llmpard pursuant provisions of the Contractor's License Low(Chapter9
CC (commencing with Sec[ionJ(XXp of Division 3 of the Business and Professions Cede)or TEMP.METER OR POLE INST. COMMERCIAL.
0.ryt m 1'
that he is exempt therefrom and the basis for the alleged exemption.Any violation of, D NEW BLDG/ADDITION D DEMOLITION
{iYC V.
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWERDEVICES C1 TEN DDEMOLI FOOD ION
y not mom than five hundred dollars(8500). IMPROVEMENT
OVICE
Dl,as owner of me property,or my employees with wages as thcirsnle compensation. SWIMMING POOL ELECTRIC
will do the work,and the Income is not intended or offered muscle(Sec.0044,Business 'EIOTHER
and Profesaiem Code:The Contractors License Law does not apply to as gwner of OUTLETS-SWITCHES-FIXTURES '
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SOFT.
sole.If,hnweveq the building nrimpmveinem is solJ within one yeerof completion,the - SQ.FT.FLOOR AREA, S/SQ.FT.
avii,t uilder willm
he the human ofproving that he did not build m improve for pur-
poseorade.)..
❑'l,as owner of the limpeny,am exclusively contracting with licensed cmorseme,toNCZ; - -
construct the project(Sec.7044,Business and Professions Cod_The Centrad'..Li- (n ❑
cense Law does oat.,],teen ownerofpropeny who builds mimproves thereon,and QI'Y, PLUMBINGPERMIT FEE H )
who contracts for such projects with a commands)Iimmed pursuant o the Contractor's 1
License Law. - PERMIT ISSUANCE tl/•'}'
❑'Iomexemptunder Sec. _ ,B&PCforthisrcamp V A
ALTER-DRAIN&VENT-WATER(EA)
Owner �Dote 'VACUA
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE'Y 1✓h 4I x
I hereby air,.under penalty of perjury one of the following dedamtim
❑Ihave and will maintains Certificate of Conuntmself-insure for Wer ompen- AINS-FLOOR,ROOF,AREA,COND. STORIES ,TYPE CONSTRUCTION
gotten,as provided for by Section 37M of the Labor Code,to the ormance of the -
work for which this permit is issued. FAURES-PER TRAP
D I have end will maintou'VArkera Compensation Ins as required by Section
37M of the Labor Code,fur the Performance of the w for which this permit is issued. GAS- .SYSTEM-I INC.4 OUTLETS -OCC.GROUP APN
My Workers Compensation Insurance cameran ]icy comber pe: -
Carrier: icy No.: - GAS- .SYSTEM-OVER4(EA)
CERTIFICATE OF EXE ION FROM WORKERS'
COMPE ION INSURANCE n: GREAS NDUSTRL WASTE INTERCEPTOR BUILDING DIVISION IP,L.S
(This section need not bac plated if the permit is Towne hmndad dollars(81 W) G 56 AP
or lees) PLANCHECK FEE
I certify that in the pedo once ofthe work for whlich Tisper is issued. R- NITARY-STORMEA.200 PT. -not employ any peison any h pane,so ae w become sobj t orkcrs'Cd
ENERGY FEE
spau mwsof Califomia.Dat -
�O Applicata _ F.RHEATERWNENT/ELECTR GRADING FEE
r~Ns NOTICE TO APPLICANT:If, fter mnkin [ 's e n ou d WATER SYSTEMITRP.ATING
f~ ' become subject to the Worker's mnFaema isi ns f e La r Cod you must SOILS PF,E -
i.y forthwith comply wait
such pro is ns'o� ,mit"all eked. WATER SERVICE
Q e
CONSTR CTION LE INE AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
UO 1herebyaffi,m that there i.a amstmdimilendingagen,[orthep rmaneeof - Date Receipt III,
W. Ne work for which this permit I.i sued(Sec 3097,Civ.C.) -
O Lenders Name - TOTAL:
WLender's Address . TOTAL: .
I certify,that I have read this lication and m at the above informpion is BUILDING FEE
V) wrest.I agree mromply'with all citya minces and state laws rolming to QTY. MECHANICAL PERMIT FEE
V Z buildth
filing construction,and hereby auorizerepresentaMIC tives ofthis city to enter upon the SEISFEE -
above-metdioned property for inspection purposes. -
(We)agreem save,Indemnify and keep hamdess the City of Capenino agximt PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,toms and expenses which may in any way accrue against said City ALTER ORADD TO MICH. PLUMBING IEE '
in consequence ofthe granting ofthis permit. _
APPLICANT SII DE TA NO ILL P WITH ALL NON-POINT ,(10
AIR HANDLING UNIT(TO 100 CFM)
OURC MECHANICAL PEE
S
AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTION TAX '
a. re df Ap,Iipmr0 mracmr ate EXHAUST HOOD OODUCT)
HA9ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store orhandle hazardous maprisl HEATING UNIT(TO 100.000 BTU)
.m
deft d by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)^ HEATING UNIT(OVER 100.000 BTU)
D DNo Yes VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt if
emit hamNous air contaminants as defined by the Bay Amb Air Quality Management BOILER-COMP LIFT OR 100,000 BTU) -
District? - TOTAL: -
DYes DNo BOILER-COME(OVER 100.000 BTU) ,
I have read Rte hamrdous materials requirements under Chapter 6.95 of me Cali- AIR CONDITIONER - �' ISSUANCE DATE -
fomie'Heblth&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. s[W'• SQ.FT.
built ingdces not currently have a tenant,that it is my responsibility to notify the occupant -
• of Ne re ulreme to which must be met prior to iesuanceofa Certifieata of Oc upancy. "
Owner or aphorized agent Date 17T t TOTAL: ISSUED BY:
OFFICE