28864APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - HLECOUCAL
PERMIT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL.
28864,
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS.
-
SANITARY NO,
APPLICATION DATE
Arm,
/SUBMITTS`AAL
V it i
O 'S NAME - PHONE:
CONTRACTOR'S NAME! LIC NO:
N/C
CONTROL#
-
❑
RCHITECTIENGlaflL , LIC NO:
ADDRESS; �' -
CONTpcP. _ 'PHONE:
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BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT P UMB MECH
❑ ❑. ❑
LIC n thatI CONTRACTOR'S derp DECLARATION
1 hereby affirmaud1em17the uunder Provisionsof Chapror9 my license is
n3o(the Business and Professions Code, and my license is
antstSarice and
Lease.11 lass effect.
License Class Lip.
3 Dere
QTY. ELECTRIC PERMIT FEC
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
ADDITION .❑ PLUMBING REPIPE
[]ADDITION
0MUL'r6UNIT ❑STRUCTURAL -
MODIFICATION
PERMIT ISSUANCE
"
APPLIANC17S-RESIDENTIAL '
ARCHITECTS DECLARATION
I understand my plena shell be used is public records
- -
PANELS
1
UPTO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
El BATH RENOEUREI'AIR El DEMOLITION
❑ OTHER oti bia"N"W
'Licensed lhofcssional
OWNER -BUILDER DECLARATION
I botchy affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 103 L5, Business and Profession, Code: Any city ar cnumy
which requires a Permit to contract alter, improve, demolish, or repair any structure
]BI-10100 AMPS
OVER TWO AMPS,:
SIGNS ELECTRICAL -/
primmitairsmnce,also teyuirea the applicamforsach serotina filen sirroDamement
that he is licensed pursuantto the provisions of the Contractors License Low (Chapter 9l
SPECIAL CIRCUIT/MISC.
'I EMP. M ETER OR POLE INSII
COMMERCIAL:
(commencing with Section 7000) of Di vision 3 of the Business and Professions Code)or
mat he is exempt th,ref ori and the basis for the alleged excmptinn.'Any violation of
Section 7031.5 by my applicant for a permit subjects Be applicant to a civil penalty of
' not mom than five hundred dollars ($500). -
I,asownerofthe norm
❑ prose y myemployeestale( See 0,14,8 Boston,,
wniness
will dotbewons ande The mreisnots Livens Lawdoesot apply to
and Professions Code: The Gmmhereo License Law does not apply owner of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
BOTHER
, .
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES .
property
property who builds or vide th thereon, is
and who does such work s ll l or through
i
his own employees, building that such improvements are not intended or Offered for
deed o
NEW RESIUfN'TIAL ELECT'R SQ 1'r.
sale. If,however.wi Rhav building the
ithat lid noneildall
SQ. PT. FLOOR AREA LSQ. FT.
borimprovement
wnemfiallder will have the burden of proving that he dig not build or improve for sur-
he provetfor
"
pose of solene
TOTAL:
❑ L m owner of the property, am exclusively connecting with i-
'
ouswct the proleel (Sea.]1W4, Business nnA Pmfcesions Craft:) The Conuunor'n Li-
:)Thlicensed Coal
QTY, - PLUMBING PERMIT FEE
censelawdoesnotapplytounownerofpropenywhobuildsorimprovesthcreon.end
who commas far,uch pntjecu wim a emaracmKJ licensed pursuant mor, Commences
PERMIT ISSUANCE
License Law.
I am exempt under Sea ,Bs,PCforthis reason
a
MIXER - DRAIN & VENT -WATER (BA)
Willits 1 I AT
Owns Uate
BACK PLOW PROTECT. DEVICE
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" KF.R'S OMMNSATI CLARATION
Iherebyalfumunder sena nuryom finefollowingdcclaratiomp
„ II Z5
�r
CI�J (Ji -
DRAINS- FLOOR, ROOF, AREA, CONU`
0 I have and will maintain a Certificate ofComent to self -arum for Workers Compcn.
section, m provided for by Stolon 3)00 of rhe Labor Cade, fur Re performance or the
STORIES -
U10 CONSTRUCTION
FIXTURES - PER TRAP
work for which this permit is issued.
.
❑ 1 have and will maintain Worker's Compenwtion Insurance, as required by Section
37W ofthe labor Cade, farthe Performance oDhe work for which this permit is issued.
My Workers Compenv tion Insurance Cartier mal Policy number arc: '
GAS - EA. SYSTEM -1 INC. 4 OUTLETS P^�
LL
OCC. GROUP
APR'
Corner. 4 Policy Na.:
GAS - EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS
' COMPENSATION INSURANCE -
ndallars($Hq)
or less,(This xetionneWmu lecampleted Ban permit is for ane hudred
I certify Rat in the performusecafine work for whichthis permit is issued, l shall
not employ any person in any manner so as to become subject to the Worker: Co.,. -SA
GREASUINDUSTRI. WASTE INTE• EPTOR
# BUILDING UIVISIONiB?E,S `
GREASE TRAP z
PLANCHECK FEE
SEWER-. �
Y-510 Iw� PC
ENERGY ITE
WATER BAT EM .1,
a
,tion Lawsaf Califomin Dine
Applicata
GRADING FEE
NOTICE TO APPLICANT: IL atter making this Certificate of Exemption, you xhnuld
become subject tm the Workers Compensation provisions of me Labor Code. you most
WATERS O
"-
SOILS FEE
forthwith comply wim such Provisions milts permit shill be dttmed resulted.
WATER SE VIC Y
CONSTRUCTION LENDING AGENCY
. I hereby affirm that them is a construction lending agency funic perforation, (if
NEW RESIDEM'IAL PLMB. SQ. E.
PAID
Date Receipt#
the work for which this permit is issued (Sec. Dad], Civ. C.)
'
TOTAL:
Lender's Name
I<Mera Address '
BUILDING FEE
I certify that I have tend this application and stare mat the abuse information is
QTY. MECHANICAL PERMIT FEE
correct. l agree to comply' with all city and county ordinances and state laws relatingm
building construction, and hereby authorize representaiven al this city m emernlxm the
above-mentioned property for inspection purposes, I I
(We) egret m save, indemnify and keep harmless the City of Cupenino against
-
SEISMIC FEE /
PERMIT ISSUANCE
ELECTRIC FEE
liabiliries,judgmems, casts and expenses which may inany way evecrueagurel said City
in consequence of the grunting of this permit,
ALTERORADDTOMECU
PLUMB LNG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON,PO1NT
SOURCE REGULATIONS.
AIR HANDLING UNIT (TO I0,01H1 CFM)
MECIIANICAL. FEE -
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX ,
EXHAUST HOOD(WNUCO
.5ignamre of tcsnVCommcl Da
HAZARDOUS ATENIA- ISCLOSURC
HOUSING MITIGATION PEE
HEATING UNIT (TO JIM," HTU)
Wi theapplicam or future buildinlo.carm,mremmodle hazmdoun material
as de0ned by the Cnpemno Municipal Code, Chapter 9.12, and the Health and Safety
-
Code, Section 25532(a)7
HEATING UNIT (OVER IOBOOO III U)
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❑Yes E-] No
Will the air ricant or numhfuture building occupanttheByAequipmentterdeviceswhich,
�mir hazardous air canmminnnb as define) by the Roy Area Air Quality Management
DrmerI? - T
PAID
Date. Receipt#
VENTILATION IAN (SINGLE RESID)
BOILER- COMP QHPOR 100,000 BTU)
•
TOTAL:
BOILER -COMP (OVERIW,lk10 BTU)
❑Yes ONO
AIR CONDITIONER
1 have rend the hazardous materials of the Cali-'
fomia Health es n Safety Cala Sections 25505. 25533 aid 25534, 1 understand Rci if the
r5, 2i 533 am order Chapter understand
m eotify th,rxcnpam
of thbuilde requirements
ulnen is rrentlywhich have he me, prim , is my issuance
of me requirements which all he met prim to issmnce ofu Cnnilicam of tRctipancy.
.ISSUANCE DATE
''
ISSUED BY: " m� H
NEW RESIDENTIAL MECFI. SQ. Fr.
Owner or authorized agent Data •
TOTAL:
OFFICE /