28718 APPL16ANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
- OF CUPERTINO-- BUILDING-ELECTRICAL PERMITNO.
CITY Of ^ a�sVX��^
BUI C DIVISION - APPLICATION/PERL l8J MIT' PLUMBING-MECHANICAL'd' -
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL UATI
6 'ER LAWC
• NiL�ER
PHONE QAW' R CNO��
N❑/C
CONTROL#I%GERi1
ARCHITECDENGINEERA' LIC NO: ADDRESS
IND
19,
CONTACT PHONE', uhAM
BUILDING PERMIT INFO
t. �, v ❑'Consultant Pceg Paid by Applicant(Initial) BLDG ELECT _PLUMB MECH -
El El
LICENSED CONTRACTOR'S DECLARATION' QTY. ELECTRIC PERMIT FEE.
I hereby affirm that 1 am licenced under previsions of Chapter 9(commencing JOB DESCRIPTION
MZ with Seclion 900E of Division 3 ofthe Bualnosstnd ProfoodonsC de and my license is
0 0 PGRMIT ISSUANCE
W� in full force anal �39gg , sFDWL ❑KITCHEN REMODEL
oU U License Cles Lic.A +
Dater—W�6 Contractor APPLIANCES-RGSIDENTIAL ❑ADDITION ,❑PLUMBING RETIPE
�0
r5 G understand ARCHITECT'S DECLAR I PANELS - ❑MULTI-UNIT - ❑STRUCTURAL
I derstand my plans shall be used as public records MODIFICATION
pp UP10200 AMPS ❑INTERIOR El CHIMNEY REPAIR
[11 Licensed Pf 1 201-IOMAMPS -IMPROVEMENT -
L`
t++ p OWNERBUILDER DECLARATION
I bby ' m that I am exempt train the cammw License Law r,nn°" OVER 100AMP5 ❑ M)pEA LRSEgqOLITION
>WOlo r, DTO
xWp, to] and Professions Code Any city or courty SIGNS ELECTRICAL
which requires a permit to criestract.alter,improve,demolish, repair any structure 191
•W(p jl"FA C'
r
prix [ 'n I eqr ' theapplicant for such a t m file a signed statement SPECIALCIRCUIT/MTSC.
[hath licensedpursuant t t p of the Contractors License Law(Chapter 9
�U dOC (con tecmg with Stenon 7000)ofDvsm0ciftbe Businessand Professions Coster., TEMP.METER OR POLE INST. COMMERCIAL:
o [bat he is exempt therefrom and the basis for Ile alleged exemption.Any violation'd .• ^❑NEW BLDG/ADDITION ❑DEMOLITION
^ Sectidn9031 t5 by any applicant far.Fermitsubjectvhenpplicant to a civil pcoulty.of' _ POWER DEVICES '
to ❑TENANT Fl FOOD SERVICE
[more than five hundred dollnts(550).. - IMPROVEMENT
Q ❑Lo the work,
the properly,re isnotmoyees withwred forthe(Sec.compensation." SWIMMING POOL ELECTRIC
y$�
will doth odinas and the he Contra tots Licenseahaded La offered antlopply 9044. weer os O DTHER
W� auoperty shone Code:impolitic,
Conoocmds License haw sous work i s if owner of OUTLETS-SWITCHES-FIXTURE.$
Property who build,or improves tM1such h and who does such work sed a,or through
his own employees,provide)that such impnrvementx are at intended dr offemA for NEW RESIDENTIAL ELECTS SQ PT. '
sale.If,however,the buildingorimprovement is sold within oneyearofeamplelion,the S ;4*RAREA , .S/SQ.FT.
owmar-befider will have the human of proving that he did not build or improve for par- ,
0 1,as
6enwas,of the properly,am exclusively courting with licensed cnnlnmors to - !TOTAL: ,x
construct the project(Sea 9044,Business and fesaione Code)The Conoac[or's Li- r4OV 1
cense Use dries no[applyman ownerwf PmP ho builds or impmvcs thereon,and QTY. PLUMBING PERMIT FEE
who contracts fir such prat an ac m r( eased per no the eono-adnr's Jxy�y t' YI11 V/
License Law. + PERMIT ISSUANCE I Ur VVY�
El I ate exempt nndev"e C for this rectae
" Ownerale ALTER DRAIN&/VENT-WATER(EA, VALUATION
W OMPL SA 1 D.CLARATION BACK FLOW PROTECT.DEVICE
I herehyad:an
mdyI rye a of the following declnmtions
•Ulhave end will maintain -enifcaa mused.self-iaso.a for Worker's Cooper- ' DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
I.tlon,as provided for by S tion 390 of the Labor Code,for the performance of the
.' work fill which this permit is issued c FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
390 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensa�m.n nsmmnee carrier and Policy macro aid, s. - ,
Carrier Polley Nu.: ' GAS-EA SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
• COMPENSATION INSURANCE - GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not be completed!fine permitu fomnehuedred dollars($100) v. - - - ;BUIIAINO I)1VISIdNkEBS a -
or less.) - GREASE'rBAP PLANCHECK FEE
1 cattily that th pef ceefthe work for which fifir,pairmit I,issued,[,bull, SEWER-SANITARY STORM G.20 I'f.
not ply y person, y p tqqc� t the W k e C tepee- - ENERGY FEE
,7. sato Law.'1C•� �mi�ce D[e l�a�!'7 ryt{u6Rl1
0O APPhcom �ys�L' /'7 ]]77 WATER I[LATER WNeNTIF.LECTR, GRADING PEE
fl"j) NOTICE MAPP CAW:Jr.after making This Certificate ofE mption you should WgTBR SYSTEMITRBATING
a �^ become subjat to the Worker's Compensation provisions of the Labor Code-you must - SOILS FEB -
W �'y forthwith comply with such provisions or this permitshall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY „ NEW RESIDENTIAL PLAID. SQ.FT. I PAID Dam Receipt#
U Q I hereby affirm construction there is a consction lending agency for the performance of ^
W «+, the work for which this permit is issued(Site3099,Civ.C.) ,
Q U Lenders Name TOTAL:
W Lenders Addreas .
1 certify,that 1 have read this application moderate that the above informaii er is -
- BUILDING FEE
req correct 1 agree to comply with all city and county'ordinances and state laws relating ro QTY. MECHANICAL PERMIT FEE -
U Z building construction,and hereby authorize representatives afthis city to enter upon the SEISMIC FEF.
ahswe-mentioned property for inspection purposes. PERMIT ISSUANCE '
(We)agree to save,indemnify and keep hamdass the City of Cupemno against ELECTRIC FEE -
liabilines,judgmenw.costs and expenses which may in any wayaccme.,mrst said City, ALTER ORADDTO MECH.
in consequence of the granting of this permit. PLUMBING ME
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IgOo CFM)
SOURCE REGULATIONS. - MECI IANICAL FEE"
A IR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTIONTAX
-
SignamreofApplicem/Comractor - Date. EXHAUST HOOD(W/DUCT) y HOUSING MITIGATION tEB,
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building oempant score or handle hazardous muted.] HEATING UNIT(TO 10,00 BTU)
os defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
Code,Section 25532(.)9 HEATING UNIT(OVER 10,00 BTU)
❑Yes.. Rao
VENTILATION FAN(SINGLE RESIDE PAID
Data .
ftewipt# '
Will the it damp of furore building y the Bt use Area
Air.ent or devices which BOILER-COMP(3HP OR 100,000 BTU)
mit hazardous oil conmminuvts as defined by the Bay Arco AieQuaity Management TOTAL
District?
Yes BOILER 'COME(OVER 10,00 BTU)
❑ - �1Ve
_ 1 have read The fia,uIplams materials AIR CONDITIONER " 1� -
q requirements 553,1understand
n fi95 of - _ - ISSUANCE
fomia Hart*es nu Safety Craft.Serious 25hai i 25533 and 25A4.1 d to d[occif upant NEW RESIDENTIAL ME CH. SQ.Pr.
ofFai
does not curremlyha aenant.Nat t'' yresponsibility[ a 0fythe oecopant
of uwhah mus111he [peed '. s.eeofa en'fea[e fOccopyt�'
�� .,�la -
' Owner or authorized ug qs Date, TOTAL ISSUED BY:
OFFICE,