28675 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY - - -
,CITY OFCUPERTINO ,"n BUILDING;ELECTRICAL - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL O,C C
BUILDING PROJECT IDENTIFICATION o V J
BUILDING ADDRESS: - t - ` SANITARY NO. APPLICATIONS�SUUk�BMITTIAALLL DATE
7 Awl.I O E S G: PHONE: CONT CTOR'S NAME: LIC NO: V V
C FIC CONI'ftOI.M
ARCHITECT/ENGINEER: .LIC NO J ADDRESS
.. ,.
CONTACT: PUONEi L BUILDING PERMIT INFO
❑_Consultant FeesPaid by Applicant(Initial) BLDG I ELECT PLUMB'•, MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE L
I hereby iffirm that l m live pm 'n..it trder '- n� f Chapter 9(pommencing - � JOB DESCRIPTION '
FcO00 with Section 7000)of Division 3ofthe Bu:ncccand Prnfessons Code,and my licensees - - RESIDENTIAL: -
,OO PERMIT ISSUANCE '
WE+ i ifullforce and of♦' n if .� O C� ❑SFDWL ❑KITCHEN REMODEL
�U Lmenee Cla. Lich r { APPLIANCES-RESIDENTIAL 'DADDITION ❑PLUMBING RE-PIPE '
HG Dam -%V, ,J _ Contracmr
F l y ARCHITECT'S DECLA A ION PANELS D MULThUNIT e D STRUCTURAL
zOrn'b Iundermm�d my pWns shall be used os public rwords MODIFICATION
-
O,xry. - .. ; UP TO 200 AMPS '
O - El :1 CHIMNEY REPAIR .
LlcensW Profess Doul
201-4)(30AMPS ' IMPROVEMENT-'
CCC555OWNLR BUILDER DECLARATION OVERIOWAMPS BATH REMODELIREPAIR El DEMOLITION
1 hem,byair,,.that l am ex npt from the C ntmct :Licen.e L w.lor the
ippi55,�D:U t llo ng ma. (S t 70315 : f B dPr :C I A y tY county SIGNS ELECT RICAI DO HER.
u+ WOy hickrequiresPermitt construct, It p d Ish repairyst ire - �Q.f "/j�� �•
art I ort t 1 req fl ppl tl hp lt fl 'g d t t tit SPECIAL CIRCUIT/MISC.
gthmh I' :dp- a ... p of the ContractorU L (Chpt 9
o (wmmeFin,withS cit 9000)ofU of the Business aradP fe. C d)ar t TEMP.METER OR POLE INST 1 COMMERCIAL
that he is ecciarn,l therchreen and the hand,for the alleged cxemptl a Any vioWt on of - D NEW BLDG/ADDITION D DEMOLITION
LL, Section 9031 5 by any applicant for a permit subjects the applicant to a civil penalty of• POWER DEVICES
J^m GTENANT ❑FOODSERVICE
"
� s not more than five hundredd 11 ($5(10). -
6 ❑ I,as owner of the prop ny y ply with wages thecompensation, SWIMMING POOL ELECTRIC IMPROVEMENT
_� w 11 tlotheworkatd the.t ire' not rneded R d for sale(S 7044,Business DOMER
R end Notes s ons Code The C t t Licem,c Law does not apply to an owner of OUTLETS-SWI ICHES-FIXTURE
S -t
e.3.. prepe0y who Im Ids er'nproves thereon and who d .,soon work himself t r through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ Pf.'
sale.If,however,the building or improvement is sold within one yeafef completion,the SQ.FT.FLOORAREA $/SQ.FfI
owner-huilder will have the burden of proving thin he did not build or improve for par-
Pose of svle.). t ..
- I]1,as owner of the properly,am exclusively conimaing with licensed eontmemrs m TOTAL:construct h Invoker(Sec.7044 Business and Professions Co...; '-
ceask Law does of apply t f properly who bullas or'npm e'thrumand QT'Y. PLUMBING PERMIT FEE
who contracts for auch Projects with a commcturts)lcetsed pursuant the Contractors
.U
Licese
GIani' pt under Soc. ,B&'P C for this reason PERMIT ISSUANCE
Owner Date ALTER-DRAIN&VENT �§
-WATER(EA) ALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE S
"�yUF 9
I hereby efflmt under penalty o[penury one of the following deelamuooa G(,/Aa
•� Ihavevtdwll natd ' eC nifrtmfConsenuoself ..onion WorkersCmagm- DRAINS-FLOOR,ROOF,AREA,COED. STORIES, p/- TYPE CONSTRUCTION
etion as provided for by Section 37M 0l the Labor Code,for performance of the �j yu
work for which this permit is issued. FIXTURES-PER TRAP. _
I have and will maintain Worker's Compensation Insurance,as iequifed by Section -
3700 of the Labor Code,for the performance of the work for which this permit is issued - GAS-EA SYSTEM.I INC.40UTLEOCC.GROUP APE
My WI&C'tmpensal 099 I �� uc mer and Policy nut her --
Cartier RTI MPPol cy No �. GAS F.A.SYSTEM-OVER 4(EA) „
ERTIFICCO 0 XEMpNIINFROM WORKERS
COMPENSATION INSURANCF. GREASFIINDUSTRL WASTE INTERCEPTOR
' tm _ - ). - " `� '
(fhisshon need not he ifthe permit is hundred dollars($101p BUILDING DIVISION FEES
or or Ices.) PLANCHECK FEE
Icentlythatin theperGnmvnce�f the work fyrwhlchth p.rmnt''aueJ,Isbell SEWER'-SANITARY"=STORM EA.200 IT.
note ply any person
n any manner so asm print.theW k a'Compen- ENERGY FEE, '
OZ samon Laws ofClifema Dem WATER HEATERW/VLNT/ELELTR
O Applicant GRADING FEE
y NOTICE TO APP f,after making this Cord Feet,of Exemption,you should WATER SYS'IEvEn REATING
a ^I becomes t to the,Worker's Compensetien provisions of he Labor Cede,you must - SOILS PEE
{7a G forthwi co ply with such proveons or this parmit shall deemeJ invoked WATER SERVICE `
Q
z CO STRU TION LENDING AGE CY - NEW RESIDENTIAL PLMB. SQ.IT. PAID
Ib ere by affirm the th onstmction len]og ag ey for the performance of - Date Receipt# -
the'xuktowhmhthicp ed(Sec. "/Civ C) _
OOTAL:
F+ LouLen A c -
U Len NA e ..
W
1 at In, .0fir le.timi arre,lunthe.1mociampfratimis Yz„s. BUILDING FEE '
L. In ro ct.1 P.1 in all city ande ty oplareace,rad sure nwsuchnin,m QTY. MECHANICAL PERMIT I:. 'FEE
U Z hail in,vo 7 tioi,mid n myautho” p eenmtivcc of this e'ty to emu upon the SEISMIC FEE
also -menti ed property for inspe npurposes. PERMIT ISSUANCE
(We)agate m save,lade( fy and keep hamdec.the City of Cnperlino against ELECTRIC FEE -
lianities,judSments,costsa expenses which may,in any way accrue against said City ALTER ORADD TO MECH'...
preso marter of the U ag of this Permit. PLUMBING FEE
APPI(CANT UNDF TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO,10,(1(1(1 CFM) MECHANICAL FEE
SOU MREGU IONS. "
'- • AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature of Applicenl/Conlrecmr Dote EXHAUST HOOD(WMUCT7 •R HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE '
Will the applieam or fuhoe building occupamsmre or handle hazardous material ' HEATING UNIT -
(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532(o)'P , , HEATING UNIT(OVER 100,000 BTU)
E]yes ]N
VENTILATION PAN(SINOLB RESID) " PAID
.
Will the. Itbuilding occupant u et dv -
Dam Receipt N�hhoz hazardous
itconn a ts odef nal by the Bay Area Ai Quohty Management BOILER-COMP 3HP OR 100,000 BTU)
DtdnsiP rTOTAL.
❑Yes No BOILER BTU)'
,
1 have read the hazardous mamnvls re uiremenu under Chapter 6.95 of the Coli- AIR CONDITIONER
9 p ISSUANCE DAT' s
forms &Safety Cwle,Sections 21St 25533 d 25534 1 understand tand that if the NEW RESIDENTIAL MF.CH. - SQ FT n ,
bmldi d n t yyy{{{III yhvvea moa tit t b'1'tyt Ityt e uP int •�_
of fyfh most 4 .uance of a n f cupan t ,
oic
uth medLagen hate TOTAL: ISSUED Rl :,
- OFFICE