28540 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 2 8 5 T o
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 1 `4Ja
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
aV4a..._ Dr'• I C v6iitt o C( FJIS
OWNER'S NAME: PHON@ NTRACIDR. NAME: LIC NO:
TE Ch h 7 617 ac+h a✓ N/C CONTROL#
ARCHITECT'/IINGIN R: LIC NO: ADDRESS: - ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACTOR'S under S DECLARATION QTY. ELECTRIC PERMIT FEE
I ion 7 affirm than I am ftheBu under nd provisions of shaper 9(commencing JOB DESC IPTION
0OZ withS«tion 70W)ocDivision J.fthe Businessund Rofessiom Code.erWm limnse is PERMIT ISSUANCE
y
�� in full forecast]affect. O�DHNTIAL: KITCHEN REMODEL
�U License Class L10.N APPLIANCES—RESIDNTIAL
Lk..,
Dole-Contractor APPLIANCES ❑ADDITION [I PLUMBING RP.-PIPE
y ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT C1 STRUCTURAL
,z 0 f/J Z 1 understand my plans shall headed m public rtcords MODIFICATION
0Z UP TO 2W AMPS 1 T ❑CHIMNEY REPAIR
F� Licensed Pmfeuionel 201-It100AMN PROV
OWNER-BUILDER DECLARATION OVER IIXXIAMPS El BAT MO EV AI EMOLITION
0O U 1 hereby affirm that 1 um exempt from the`Contractor's Littnse Lew for the
following mason.(Section 703 1,5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL. ❑Of R
Wra which repro a permit to construct alter,improv,demolish,of repair any swcwte �f1 7`7
h.] prior,.its issmncgalso brinimsthespplicam(a...ch permit to fileasignedsratement SPECIALCIRCUIT(MISC.
th
Y e,he is licensed pursuant to the previsions of the Committers License Law(Chapter 9 COMMERCIAL
�� (commencing with Section 7000d.f Division 3.f the Business and Preficedoas Code)m TEMP:h1BTER OR POLB SCI f
tY{y C that he is exempt therefrom and me basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
tiyC] 4• Section 7031.5 by any applicant for a permit auhjccts the applicam to a civil penally of POWIiR DEVICES .➢
to not more than five hundreddollara(SSW ❑TENANT FOOD SERVICE
F C ❑ Lesownerafthe property,on my employees with wages as their sole compensation, SWIMMING POOL ELE ICS IMPROVEMENT
will do the w.rk.end the structure is not intended orurcemd for sale(Sm.7b14,eusinws []OTHER
and Pmfeaimas Cade:The Contractors License Law does not apply to an owner of O7.ETS—SWITCHEwS—FIXTU S
a 3 property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NP.W RESIDENTIAL iE.ECTR S Try. �,,;
sale.IL however,the building or improvement is sold within one yearof completion,the SQ.Ff.FLOOR AREA $/SQ,Int
owner-builder will have the burden of proving that he did not build or improve for put-
pose of tile.), I
❑1.as owner of the property,am exclusively contracting with licensed contractors to TO
convect the project(Sm.70,14,Business and Professions Code:)The Conuacmrs U.
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such pmjects with a contr.,.,(a)licensed pursuant to the Contractor's
License low. PERMIT ISSUANCE
C1Tem exempt under Sec. ,B&P C for this reason
Owner Data
ALTER—GRAIN&VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
hereby aftirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Ccnificate of Consent to self-insure for Workers Compen- DRAINS—FLOOR.RCGP,AREA,CONI, STORIES TYPE CONSTRUCTION
sarion,m Mth
provided for by Section 37M of the Inr Code,for e performmrce of the
work for which this permit is issued. FIXTURES—PER TRAP
EI I have and will meicown Wrote.Compensation Insurance,as required by Section
370(1 of the Labor Code,for the prrfimwnce of the work for which this Permit is issued. GAS—HA.SYSTEM-T INC.4 OUTLETS OCC GROUP � APN
My Worker's Compensation Insurance carrier and Policy number arc:
Carriee Policy N..: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPANDUSTRL WASTE INTERCEPTOR
(This serum,need not becomplered if the permit is(Drone hundred dollars OJW) BUILDING DIVISION FRM
or less.) GREASE TRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,IshallSEWER—SANITARY—STORM F.A.2W M.con employ any person in any manner sit as to become subject ro The Workers'Compen- ENERGY FEE
0Z salon Laws of California.Due WATER HEATER WNRNT/ELECTR n
7 0 Applicant GRADING FEE
q y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
camr,
F� �^ bee subject to the Workers Compensation pmvif
' s of the Labor Code,you must SOILS FEE
a ora f.rthwllh comply with nosh provisions or thio permit shall he deemed revoked. WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAIDLG f'
U� l herebyaRmtthmasa
thrch.couctim lendingagrncyforthe perforroureof Dam Reaipt�t/r
IL, f" the work for which this pernot is issued(Sec.3007,Cih,C.)
0 U Lender's Name
TOTAL:
W
1,Cni Address
y I certify that 1 have revel this application and stem that the move infomtation is BUILDING FP.F.
In correct.l agree to comply with all city and county ordinances and xtate laws relating to QTY MECHANICAL PERMIT FEE
U� building Constmnion,and bunchy ausloriu representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection p romax. PERMIT ISSUANCE
(We)agree m save,indemnify ead keep harmless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,costs and exproses which array in any way accrue against said City ALTER OR ADD TO MECI I.
ons
in consequence of of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Ift0WCFM)
SOURCE I EGUTATIONS. MECHANICAL FEE
p AIR HANDLING ONIT(OVER IB00f1 CFM)
CONSTRUCTIONTAX
Sig on dApplic "mructor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUSM 1'P.RIAIS DISCLOSURE
Will the applicant or furore building not.fortstorcor handle hazardous mamriol HEATING UNIT GO I00,000 BTU)
as defined by the Cupenim Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532fa)? HEATING UNIT(OVER 100,0100 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or Curie building occupant use equipncenf ur devices which Date Receipt 0
emit hazardous air contaminants us defined by the Bay Ama Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
District? TOTAL:
❑Yes No BOIL17R—COMP(OVER I W,W0 BTU)
I have read the humorous materials reauinemcros under Chapter 6.95 of the Celi- AIR CONDITIONER ISSUANCE DATE _
humin Health&Safety Code,Smdons 25505,25533 end 25534.L understand mat if the NEW RESIDENTIAL.MECH. SQ.IT,
building does not comedy have a tenant that it is my responsibility to notify the occupant
of the requirements which must he and prior to iuuance of a Certificate of Occupancy.
Owner torralodaed agent Date TOTAL: ISSUED BY' v�G—LLL
1
` OFFICE