28701 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT,PEN ONLY> I "
I CITY OF CUPERTINO BUILDING-ELECTRICAI - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT ' o PING PROJECT
ID NDOi L , 28701
BUILDING PROJRCT IDF.NTINILA'1'I0N
LDINGADDRESS'. s SANITARY No. APPLICATION SUBMITTAL DATE
J1610 3coLM
O NER'S NAME: PHONE: NTRACT 'S NAM L O 4,
., NIC CONTROL#
�.. ITECT/ENGINEE
O . � { -
O C.LC ❑ " '
' CONTACT' .. - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid 6y Applicant(Initial) - BDG -ELECT PLUMB MECH -
Y. aI6pu.0 15.3(0)-1(003 = . . ❑ ❑ I,. ❑
'•' LICENSED CONTRACTORS DECLARATION QTY ELECTRICPERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
C'z with Section 7000)cfuivtxmn 3onheBcinte tad Profession cad any licemels
in - RESIDENTIAL
- -
�� full force and f L PERMITISSUANCE
ty� -❑SfDWL ❑KITCHEN REMODEL
�UU License ClasefLlC.#. APPLIANCES-RESIUCN9'IAL ❑ADDITION. - ❑PLUMBING RE-PIPE,
'F W Date.,y'-. ,_teaCnnwnor
" [yF..ay • _ ,� ARCHITECT'SDECLARA'ION PANELS ' , - ❑MULTI-UNIT r.. ElSTRUCTURALMODIFICATIO
oz- UPTO200AMPS ❑INTERIOR CHIMNEY REPAIR
OWNER BUILDER DECLARATION 201-IOMAMPS IMPROVEMENT '
OVER I(1W AMPS El REM EL/R IR ❑D VIOLATION
p, 6 I b by if that I nm exempt f theC ' t License Law for'he �G 4
kd 3 d U following reason.n (S ti ](131 5 Bu d Pr f si C d A y 'y unty SIGNS ELECTRICAL - E3 OF
'
Y7 u, which marinas a permit to counuma,tillon,improve,'dernalf,th,tor input aaY structure
cture
prion it, k.odimix,the applicator f h permit tofile.signed'eat...at SPECIAL CIRCUIT/MISC.'
pr that he is licensed pursumifto the provisions fthe Contractor License L (Chapter 9 -
C (cammenmog with Sect ]000) fD' 3 fNe Bu dP f Cd)nr TEMP.METER OR POLE INST. COMMERCIAL;'
se 6 se O 'hat he s exempt therefrom and the basis f II Hoped ascription.A Y 1.two of - ❑NEW BLDG/ADDITION -EIDEMOLITION
NSecion]031 S by any appy am for a permit subjects the uppl ant to a civil penalty of- POW ER DEVI S '
- ,
notm thanfive hundred dollars($50% nes TENANT ❑FOODSERVICE
IMPROVEMENT
1 fth popery rmy en pl yeesw rh wages us ih I pen.auan, SWIMMING ) ELECTTRII
willdrift ork andhettruer t 'nded dr offered for sal (Sec]1144 B si s ]OTHER THER
yEEE555^" and Professions Code:Th Contractors License Caw does not apply to on owner of OUTLETS- WIT S- TU S "s
.. properry who builds or improves thereon,and who does such work himself or Ihroogh
his own employees,provided that such improvements aro nut intended or offered for NEW RESIDENTIALEl- SQ FT.
sale.If,however,the building or improvement is sold within one year of a impletion,the- SQ.FT.FLOOR AREA $/SQ.FI'.
ter-builder will have the burden of proving that he did not build or improve for pur- '
Pose of sale). '
❑I,as owner of the property,am xclusively contracting with licensed commemrs to TOTAL'.
ons@ucnhe Project(See.]044,Business and Prafessians Code)The Cmusclues Li. -- y
cense Lew'does out apply loan invurof properly who builds or'mpmvestherebu,and QTY. PLUMBINGPERMIT t,TY
" FEE
who contracts for such projects with a coutmetoro)licensed pursuant to the Contractor's
License Law. i PERMIT ISSUANCE '
El I am exempt under Sea .B k P C for this reason
Owu - s Dm ALTER--0Po$M&P -WATER(EA) VALUATION
/ 7 W0RKERSC0MPENSATI0NDCCIARAr1ON BACK FLOWq1ROT CTD ICE
Ij. I h by B'rm under penally
❑Hhave and will maintaineCertifiwta ofC n.cube self luau for WorkusCompen- DRAINS-FLO F,AREA, D. t
STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performance sof the
work for which phis permit is issued. - " FIXTURES- TR
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700tif'he Labor Code,for the performusecto the work far
wwhich
this permit is issued GAS-EA.SYSTE INC.4O 'L OCC.GROUP APN
C Waryy i itand poll
-#�wye Pol iy No!A� v GAS-EA.SYSTEM-OVE EA) ''
mea T �/M✓
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTR AS ,INT E
(This section need not be completed if(be permit is for one hundred dollars is 1 Om) S .&•g 4' JBl1IBDIN0 DIVE 0NpBHS
OR BASE TRAP
or less) ' - PLANCHECK PEEImp
' \JJ'1v
I certify that in the performance of'he work forwhah this permit is issued,I shut[ SEWER-SANITARY-STORM .20
not employ any person in any manner w as to become subject to the Workers'Compen-• ENERGY FEE
Z Nation Luwsof Califomia.Date WATERHEATERWNENT/ELECTR d
eq
O Applicant - - GRADING FEE "
4 NOTICE TO APPLICANT If,after making this Cenific ld of Escalator,youshould' WATER SYSTEM?REATfNG
(~' become subject to the Workers Compens aunt p'avrsions M Ne Labor Circle,you mast SOILS FEE
Wti foithwithicmply with such provisions or this permit shall be deemed revoked. WATER SERVICE - x
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL )� �FTt -, PAID -
U Q I affirm th uh aconstru dfan
lending agency for the pereanc of r"�" Recmpt#
r-I the work for mliddi,pe L' Ifssued(Se 309] Ci,C)
U Lenders Name TOTAL:
" W Lender's Address <17 AL:
I certify that 1 have read this application and state that the above information is BUILDING FEB
F=i (74 correct.I ograeaeomply with all city undeounpy mdlnaneexwdstale lawsalmingue QTY. - MECHANICAL PERTT
U G building construction.and hembyau'horize representative,of thiscity reenter upon the SEISMIC FEE, .`
ahave-mentioned property for inspection purliow, - PERMITISSUANCE -
IIWO agree to save,indemnify and keep harmless the Cily of Cupertino against ELECTRIC FEE
liabilities,judgmeme,ema, nd expenses which may many wayaccme against said City ALTERORADDTOMECH. •� PLUMBING FEE
nieqsauce of the granting of this permit '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING,UNIT(T0 I0,0W CFM)
SOURCE REGULATIONS, MECHANICAL FEE
I AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION X
Signaure ofApplican o tacmr Date EXHAUST HOOD(W/DUCT) - HOUSING MITIG ION FEE -
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfmurebuildingoceapamstore or handle huzadous material HEATING UNIT(TO 100,000 BTU) - -
as defined by the Cupertiw Municipal Code,Chapter 9.12,and the Health and Safely
Code.Sutton 25532(0)'1 _ HEATING UNI'P(OVER 100,000 BTU)
.0yes I ❑N - .r. - 1 PAID
-
VBNTILATIONPAN(SINGLERBSID) '
Date Rec '#
Will the itcntapplicant future building by the B use aAiQequipment r Maas which BOILER-C0MP(3HP0R 100,000 BTU)
,mil h nN v air contaminants name as defined by the Bay Area Air Quality Manageinent ' TAL:
DistncL
❑Yes No BOILER-C0MP(0VER 100,(0!0 RTU) -
' ❑ 'f i
I have read the hazard smaterials requirements under,,napter695 of the Cali- AIR CONDITlONP.R f .. - ISSUANCE DA
from.Health A,Safely Code,Simmons 25505,25533 and 2.5.534,I understand Nnl if the NEW RESIDENTIAL MECH. ESQ.Pp building d 'currently have a'enan',that it is y responsibility' notify the occupant R/ -
I' of me requirements which must be me'prior to e of a Certificate 1 Occupancy,
" Owner or malbor wd agent 1 I Damsi TOTAL: - ISSUED
OFFI BY: .
CE