S 2528 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT DING PROJECT
-MECHANICAL Q 2528 5 2 8
BUILDING PROJECT IDENTIFICATION lJ N
BUILDING ADDRE SANITARY NO, APPLICATION SUBMI I TAL DATE
3- -1
O E11'SN .9 PI10NG: CONTRACTOR'S NAVE: O LIC NO:
,Lv-CO NIC CONTROL#
W,ARCHITECAINGINEER: LICNO: ADI S , El
CONTACT, PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC❑
❑ ❑ y ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby aairm that I am nevi t ander.(..tabes of Chapter 9(a mmeneirg JOB DESCRIPTION
�aZ op$ectmn 90010 e1 Dlvision3 of lha Business ".ung Cede.and my lienee is TWL:
u100 wt PERMIT ISSUANCE
F W x a full face vnd eR�t� SFDWL ❑KITCHEN RI?MODEL
ctldUV Uoem Cine hicN APPIJANCHS-RESIDENTIAL ❑AUDIT'ION E]PLUMBING REPIPE
F Z W Detc Cumta"or
may ❑viurrFUNIT Ll STRUCTURAL
nRCHITLCT'S DHC,. I N MODIFICATION
p.7 N PANF.I.S
ZO4- Iundemmnd my pions shall Be used as Public rceaNa
OZ�O UP T02(10 AMPS ❑INTERIOR El CHIMNEY RIiPAIR
licensed Professional 201-IWOAMPS IMPROVEMENT E)SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER IOW AMPS [I BATH REMODEIJRF.PAIR ❑DEMOLITION
t d I hereby.Sect that 1 vee exempt from the Contractors Co License Law for the
JWGJy5 Ocf.U following uireeon.permit
t 9onstr ct,after. and pre,de ons Code:Any cion of county SIGNS ELECTRICAL ❑OTHER
1L W h which requires a permit ns ttmsvum,ulmr,improve,demolish,or repair any Iwemre
`+Od prior to its lssrmme,also requires the applicant for such permit to rile a signed smmn,mt SPECIAL CIRCUIDMISC.
`2 'hill he Iravaged pursuantin the provisions oCofactor's
f the Liwnge Law(Chapter 9
W ❑O (commencing with Section 7000)of Division 3of'he Business and Prefeasion.Cmle)or TIPARMETP.RORPOLEINST. COMMERCIAL'
6 y m C that he is exempt merefram and the basic for me alleged exemption Any violation of El NEW BLDG/ADDITION ElDEMOLITION
W Y. Section 7031.5 by any applicant far o permit subjects the applicant n a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
oo FZN neo criterion five hundred dollars H500). IMPROVIIMENT
�dQ [ I.as owner of(lie property,or my employees whop wages as their sale compen.wtion, SWIMMING POOL ELECTRIC ❑OTHER
ya^ will do'he work,and thesvucwre isnm intended creffcred forwle(Sec]044,Business
0.3
and Professions Cale:The Contractor's License Law does not apply In all owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his awemployees,provided'hat such imem
pnwems are not intended or offered lar NEW RESIDENTIAL ELEC'I'R SQ FT
n
sale.If.howevepthe building or reprooponam gold wilhin oneycerol'completion,the SQ.FT.FLOOR AREA VSQ.FT.
ownesTuilder will have the burden of proving that he did not build or improve fnr pur-
Pose crime).
[:] 1.vs owner of the property,vee exelnsively commit s with licensed contractors in TOTAL.
mmnte the pmjem(Sec.7IW4,Badness and Profession,Cale:)The Convector's Li-
seLaw does not apply in an owner of property who builds or improves mere'nand QTY- PLUMBINGPERMIT E6�
wbo contracts for such inner with a contracmgs)licensed pursuan'to the Comenors
License Law. PERMIT ISSUANCE
❑l are exempt under Sec. ,R&P C for this wasm,
ALTER-DRAIN de VENT-WATER(GA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION PACK PLOW PROTECT.DEVICE
I hereby rfrinn under penalty of perjury mm of the following declaraoione:
,mlbws andwill far by Sanction
370eofCelaranCode.firdnr WOrkcrs.d if
DRAINS-FLOOR,ROOP.AREA,COND. S'I'OR[F.S TYPE CONSTRUCTION
amino,,, provided for by Sectiond, of the Labor Qsdc,fonhe perfomtvnae of the
work for which dda permit is issued. FIXTURES-PER TRAP
E] 1 have and will maintain Workers Compensation Insurance,as required by Section
3900of the Lab or Code,for the poor empnm of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40U'TLBTS OW.GROUP APN
MyWorke' Ce Ensu acartier and Policy numhe 're: GAS-DA SYS"fEM-OVER 4(EA)
m'
Carries jE a n Policy FROM
CERI'I rICATE OF EXEMPTION FROM WORKERS'
COMPENSATION ININSURANCEGREASEANDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION PP.F:S
(opis section need not be completed ifthe pem,it is for one hundred dolor,($lot)) GREASE TRAP
or kgs J PLANCHECK PEE
I cenifytheir.the permunnerecafthe work forduch disperml.is issued,$shall SEWER-SANITARY-STORM EA,200 FT.
net employ any person in any main -tp auhjam to the Workers'Camper- ENERGY FEE
Z. s.Iran laws f 'a IT....a.Dvtc 'o t a WATER HEATER WNENVELECfR
z�''t Applkmn/ /,0.(y GRADING PEE
r NOTICES 1 T:[EYM7 inakV,this Cenificme of Exemption,you should WATER.SYSTEMU''REATING SOILS FEE
F-r became subject to the Worker's Compensation provisions of the Labor Cade,you at
forthwith comply u 0,saph provi,iars ormis permit shall be dccmW revoked. WATER S12RVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW BESIDES UAL PLMR. SQ. PAID Dale e' t#
U 2I herehy affirm ohotthere is a cowmmfon lending agency for the permnc
forae of
be work for which his Permit Ls issued(Sec 3099,Civ.C.)
�' L) Lender's Name TOTAL:
O Lender's Address TO'T'AL:
a1 certify that I have read U s application and state that the above information is ,,.�' - BUILDING FEEest V] collect.lagre.m comply with all city and county ordinances into state lows relating to QTY. MECHANIC AL PERMIT'_w"""
C.) z building construction,andherchy nuohnriu representatives or thiseltym error upon me '' SEISMIC ITE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hornless the City of Cupertino against ELECTRIC PEE
liabilities,judgments,enmsand expenses which may in any way accrue against said City AM ER OR ADD TO MECHP 0.p Q PLUMBING FEE
m consequence of the staining of this pmarit. `
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT PIR HANDLING UNIT(TO IQfXNICPM7 MF.CHANICALFEE
SOURCE REGULA'IlON5.
AIR HANDLING UI�IT OVER]ON W CPM)
'] 7 CONSTRUCTION TA
ran Ap run' emtacmr Dam EXHAUST FOOD(WID=)
HAZARDO S MAT17RIAI S DISCLOSURE _ HOUSING MIi'IGATION FEE
Will the applicant or[wure building occuprnl atom or handle hazmdnusmamnal HHATING UNIT(TO 100,000 BTU)
as defined io the Cupertino Munielpvl Code,Chapter 9.12,mame Health mW Sviny
Code,Section 2,5532(a)p HEATING UNIT(OVER IlN1,fXq RTU)
El Yes E]No VENTILATION FAN(SINGLE RP.SID) PAID
Dmc ReceiPo#
Will the applicant or future derided
eby the B use n Air a or devices which
emit ha zrdous am commitments as defined by the Bay Area Air Quality Mvnugemenl BOILER-COME(3HPOR I01,000 9'f U) T ,
Distnnp
]Yes No
BOILER-COM P(OVER 100,000 11 UJ)
❑
I have cal the abandon,residalyr{themis under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fnmia Health&Safety Code,Section,2550.5,25a533 and 255]4.1 understand mat i(me NEW RESIDEN'1'IAL MECH, SQ.Ff.
huildingmrea nm cone❑y hrvca¢nan','hmi'is my resrymgihility moot fy me occupant � �-'� l/ /
oy'herequirn, is h' ,4'4
be.mel prim m,esuancc oris C.�elli cote ofgccuRv y
(era�nt4 j �/t `Ao TOTAL: ISSUED BY:
((�� OFFICE