Loading...
28816 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CI TY OF CG T. BUILDING-ELECTRICAL. PERMIT NO. 'LJ yI(l 881 'BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL LVA BUILDING PROJECT IDENTIFICATION BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE DI ab �/6 (�' ��aT.•,os [Jct g�o # a �, OW R'S N ME: PHO nE: /Wk CONTRA R'S NAME:' LIC NO: qS ��•Qn f z6av oga(9ne NIC CONTROLM ARCH]rE /EIJGINEEU CNO:' - ADDRESS: CONTACT: PHONE �: BUILDING PERMIT INFO eeCoo e Lr0 J �Q6, CongiallenlFees Paid byApplicant(Initial) BLDG ELECT PLUMB MEEC©CH LICENSED CONTRACTOR'S derp DECLARATION QTY ELECTRIC PERMIT FEE I hereby etfsrm that I am licensed under provisions of CTade, 9(commencing JOB DESCRIPTION IOy�Z oh Sm,ion]000)of Divisian3of theBminesz anJ Professions Csdq and mylicense is PERMIT ISSUANCE F OO in fall force and effat. g.UZ U License Class Lic.M WL ❑KITCHEN REMODEL" yQw Date Contractor APPLIANCES-RESIDENTIAL OADDITION ❑PLUMBING RE-PIPE ' on ARCHLI ECP'S DECLARATION PANELS [I MULTI-UNIT [I STRUCTURAL >> ZOPv��q Iundecsmmd my plans shall he uuA us Puhlie records O Z:d 1 MODIFICATION rz UPTO 200 AMPS D [I INTERIOR ❑CHIMNEY REPAIR, W Licensed Professional 201-1000AMPg IMPROVEMENT ped •aj Oat I am exempt fr DECLARATION OVER 1000AMPS ❑BATH REMODELIREPAIR [I DEMOLITION yy K 1 hereby affirm Nat 11. exempt from the Comms Ccar License law for the ed34U following rcasom(Section L3,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER LLLL1l 0 .which requires a permit to constrvct,alter,improve,demolish,or repair vny zwctum ^�-O print its issuance,also rcquiresthevppheart fursuch permit to Glc a zignedzmtemen, SPECIAL CIRCUITIMISC. rWrW��� that he is licensed pursuanuo the provisions ofthe Comuctors License Law(Chapter 9 5p0 (commencing with Section 7")of Division 3 ofthe Business and Professions Cuba)or TEMP.METER OR POLE INST. COMMERCIAL: 4 4' that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION t� Section 7031.5 by any applicant for o permit subjects the applicant to a civil Penalty of POWER DEVICES Asn []TENANT ❑FOOD SERVICE ZZZZZZ y of more than foe hundred dollars(Sett). QO ❑ do the serofthe pc,tmc,or myemployeestheir sole cnmpenomem SWIMMING POOL ELECTRIC IMPROVEMENT t ill Aothewons nd Co,11: mmcmrcisnot intended Gio,doesficreal mappl c.7044, .neteof []OTHER d �_ nnJ Professions Cain The Contractor's Limnse Law imus not apply to ..net of . OUTLETS-SWITCH135-FIXTURES " progeny who builds or improves thereon,and who rices such wnrk himself or through , his Own employees,e provided that such improvements ere not intended m offered for NEW RESIDENTIAL IiL[CTR SQ pr. I.own ILboldr,MEbase dingodkoof cement issoldhewithin one build r improve orioM1e SQ.1-7.FLOOR AREA E/SQ.FT. owner will have the buNcn of proving that he did no,build or improve for Aur- pox of sale.). ca 1,as owner of the Progeny,am exclusively contracting s with licensed ntractcmrs to TOTAL canm actLo the prones(Sec.o an ownBuser of and ity who CodeD The Contracture Li �[ cense law does not apply ro an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT PEE who convects for such projeckr with a amttacmr(s)licensed pursuant to the Contractors Licenx La, PERMIT ISSUANCE ❑ 1 am exempt under Sec. ,B&P C for this reason ALTER-DRAIN&VENT-WATER(EA) VALUATION Done, Date _ ra. WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1-7 -1�� I hereby affirm under penally of pef th rjury one oe following declarations: (7 ❑Ihave send will mainOinv Certificnte ofConxm mself--insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCDON ration,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this parmit is issued. FIXTURES-PER TRAP ❑1 have and will maintain Workers Compensation Insumna,as required by Section 37M of the labor Code,For the p,dommnce of the work for which this permit is issued. GAS-reEA.SYSTEM.I INCA OUTLETS OCC.GROUP APN My Workers Compensation Insurance carrier and Policy number a : Carder. Policy Na: GAS-EA.SYSTEM-OVER 4(EA)_ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINUUS'fRL WASTP,INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES (This section need not hecompleird i0he permit is fnrone hundred dollms IS PINI) GREASETRAP or less.) - PLANCHECK FEE Loy any matin to any...a, ,,thework beetior s.bjm,his permit the Wrkers' d.Izha. SEWER-SANITARY-STORM EA.200 FT. imt employ any person iia any manner xn as to become subjeena the Workers'Compere LNERGY FEB C pof California.DoneAplicant WATER NEATER WNCNT/ELELTR GRADING FEE .~Ns NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING become subject m the Workers Compensation provisions of the Labor Code.you mus, SOILS FEE forthwith comply with such provisions an this permit shall be deemed revoked. WATER SERVICE CONSTRUCf10N LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID U O Uate e h I (hereby vffimrthavhert isacnnstmction lending agency for the performance of Re[eiptN W t-t ,he work for which this permit is issued(Sec.3017,Civ,C.) C U lenders Name ey TOTAL'. Lender's Address TOTAL: 4 4 I cenify that 1 have read this application and state that the above information is BUILDING FEE y �60•� ..i fA correct.I agree m comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE U building consiuction,and hereby authorize mprcsentatives ofthis city to enter upon the SEISMICFEBIf LV}• unv above-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC IEE liabilitics,judgmenrs,costs and expenses which may in any way accrue allmort mid City ALTERORADDTOMECR PLUMBING FEE AST,2 in romequence of the grandng of this permit. APPLICANT DERSTANDS AND WILL COMPLY WITH ALL NON-POINT " AIR HANDLING UNIT(TO to."CFM) SOURCES ATIO �k/// MECHANICAL FEE " 6 74 y /,o -: /4L7- AIR HANDLING UNIT(OVER 10dptI CFM) CONSTRUCTIONTAX Signaure ol'ApplicamlContaftor I Glim EXHAUST HOOD(WMULT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicantorfmvre building occupamshnom andle hamNousmatnia) HEATING UNIT(TO 100,000 BTU) u defined by the Cupertino Municipal Cody,Chapter 9.12,and the Health and Safety Cade,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) ❑Ya MNo VENTILATION FAN(SINGLE RESID) PAID Will Nee licant or forum building occu m use t tar Jevicez which Data Receipt M PP B W ea Air n BOILER-COMP(3HP OR 1(0,0%X)BTU) emir hazardous air containments a deGmd by the Bay Area Air Quality Management - O^ TOTAL: a+X District? ❑Vas []NoBOILER-COMP(OVER 1OB000 BTU) I have reel the hauNous matedols requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE fomio health&Safety Code.Sections 25505,23533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ,pp. mddingdi 0emrrently na tenum.rho it is my responsibility to notify the occupant ufoho requi ratsw ' rat he met prior to issoanceofaCe 0 tocttt y. .w /"o�a61� Owmrmauthmixd agent g T to TOTAL ISSUED BY: OFFICE q