28514 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O C�I �I
BUILDING PROIF.GT IDENTIFICATION O J 1 4
BUILDINGADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
10`730 Nt BL-AMeY RVeN VC 1 L
OWNER'S NAME: PHONE: CONTRACTOR'S(JAME: LIC NO. • V `�
J PCRTLNO ER: - �y uQi� 1 poo LPH £ Sl.e'TTBfJ N/c CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
N 0 SiC� AI ARcHITeC-TS G-22 1 gHaFPu6rS.S.F 9No&O ❑
p
�ONTACT F �a
fQ4 OarinG1 ' 0 (`II SIJ -IQ"I- SaI Ott BUILDING PERMIT INFO
&LEnNJ�Wff150h#-CooV6 C4 ❑ Consultant Fee,Paid by Appllcent(Initial) B D ELECT PLUMB NIECE
I 1lo -5�2b ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARA'CION
1 hereby alarm Nat 1 am Ecenad under al Pmons of Chapter 9(mmmencing QTY ELECTRIC PERMIT FEE
WP with Section VOW)ecDivision 3.f the Business and ProfessiansCMe,and mylicenseis JOB DESCRIPTION
Q Licene fall Class deflect. PERMIT ISSUANCE L1 SFDW RESIDENTIAL License Class Lin# �SFDWL - ❑KITCHEN REMODEL
Date Contranor APPLIANCES-RGSIDEMI'IAL ❑ADDITION ❑PLUMBING RE-PIPE
[[..Oy ARCHITECTS DECLARATION UNIT ❑STRUCTURAL
O Z PJ 1 understand my plans shall he used as public records PAN[IS ❑MULTI-
:! UP TO 200 AMPS MODIFICATION LmenudPmlcsv.wl ❑INTERIOR ❑CHIMNEYREPAIR
LLLL`"`k'�KG OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT
yy O 1 hereby affirm that 1 am exempt from the Contracrm's License Lew for the OVEk IOW AMPS ❑BATH 'P ❑DEMOLITION
X a 4 V following reason.(Section 7031.5,Business and Professions Code:Any city err county SIGNS ELECTRICAI, ❑OTHHR _
LLn11 u, which requires a permit m mnstma,tdor,improve,demolish,or repair any swaure
Print m its isromed,.1.nquimst(tenpplicam forsuch .it b,file n signed statement SPECIAL CIRCUIT/MISC.
T Nat he is licensed pmsuanno the p xvkionsof the Contmctnr'I license Law(Chapter 9
p0 (cm n¢nch,with Swum7(m)orDivision 3 of the Bronessand Professions Code)or TEMP.METER OR POLE INST. OMMER -IA
6 y y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 byanyapplicom farapermit subjuts lheup,licam m a civil Penalty of POWER DEVICES ❑NEWBLDG/ADD ION ❑DEMOLITION
Z p- not more Nan five hundred dollars 155(x, ❑TENANT ❑FOOD SERVICE
.0 C1 the pmpeny,or my cmployceswith wages as theirsole compensation, SWIMMING POOL.ELECTRIC IMPROVFMEH
FQ and dofhewmk,anA theswcwreis notimenJeJ ser offered for rule(SecJOYe,Rosiness ❑OTHER
d3 end Professioas Cade:The Conhazmrs License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nm intended or offered for NEW RESIDENTIAL ELEMV SQ PT.
sale.IL however,the building or improvement is sold within one year of completion,the FLOOR AREA FT.
SQ.
wnel-milder will have the burden.(proving that he did not build or improve for par- LSQ FL
pose of soled.
❑I,as owner of the Property,am exclusively contracting with licensed emons mhx ro T
c...tmct the Project(Sea.7044,Business and linfessians Codd*The Convector's Li.
cense Law docs our apply war owner of property who builds or improves thereon,and QTY, PLUMB PE 11T
who c 'I'for such Proec
Projects with o canumrts)licensed punumtmthe Comme,c, FEF,
License Law.
❑ I um exempt under Sec. ,B&P C for this reason PERM IT ISS DANCE
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DFSVIC
I hereby affirm under penalty ofperjury one of the fallowing declarations Sr L)T_TO -
❑ I have and will mainminaCenifcatcof ConsenLmscltlnsure for Workers Camper- DRAINS-FLOOR,ROOF,AREA,CON
sation,as provided for by Section 37W of the Labor Cade,far the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
El have and will maintain Worker's Compensation Insurance,ns required by Section
7]W of the Labor CodgRothe perfohmehtce of the work for which this peman is issued. GAS-PA.SYSTEM-1 IN
My Workers Camppccnsation Insurance cnrticr and Policy numhdI o��yy OC qpN
'er:3N/X.�JlI/AL//4nFA •blit Nn:a0:-90 Hn
CERTIFICATE pF E%F.MY IONYMOM WORKERS' GAS-EA.SYSTEM-OVER 4(EA)
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section nmd nm W cnmpined if the permit is fmone hundred Jollan(51 W) DING DIVISION FEE
or less.) GREASE TRAP
Icenify that in the perfnrmmce of the work forwhich this pennih is issucJrunpl ,lshull PLA C
� ,� nmarfun .fC.1ioriaany manner.mwto become subjm to Ne Workers Compcn- SEWIiR-SANITARY-STORM EA.200 Fit
moon Lews o(Califomia.Date ENE G
Applicant WATER HEATER WNENTRiLECfR
r y NOTICE TOlt to he ANT.Workers Cmulaulmour sovisio sero f of C Labor
o d,You nuuld GRAUI G PE
a becomeu bdd y the muhpm Compensaionprovisions of hbe Labor Code,you must WATER SYSCFMRkEATING
Bsnhwith rnmply with such provisions nr Nis permit shall MJeemed revoked. SOILS FF:F.
d
(� WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PL PAID
U Q Thereby affirm that Nerc is eeontmctian lending agency for Ne perfohmunce of Date Receipt#
lL h the work far which Nis peat is issued(Sec.3097,Civ.CJ
Q U Lenders Name
Leaders Address TOTAL:
yy TOTAL:
L, (� I certify o c I have rind thirty and
and conte tha the above information is BUILDING FEE �.
V1
correct.l agreemcamply with till city and enunry mdinonces and score laws relutingto QTY MECHANICAL PERMIT FEE
V building constmction•and hereby suthoneempresenutivesofthls city toenterupan Ne SEISMIC FEE
abovemenumed pmpeny for inspection pu po.s.
(We)agree to awe,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE
ELECTRIC PEE
liebilities,jud,normt,costs and expenses which cony in any way acerae against said City
in consequence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WIT 14 ALL NON-POINT AIR HANDLING UNIT 10,000 CIM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OV BR 10,M)CPM)
CONSTRUCTIONTAX
hgnewm ofApplicaDao EXHAUST GOOD(WIDGET)
HAZARDOUS MATT ALS DISCLOSURE HOU TNG MITIGATION PC
Willy the
Muni ipal i rail Chapter
r 9,12,and t e Health and amnel HEATING UNIT(TO IOO,WO BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health end Safetytics 15,
Code,Section 25532(0)4 HEATING UNIT(OVER 100,000 BTU)
E]Yet ❑No 0
VENTILATION FAN(SINGLR RESID) •PAID�(. yo
Will the applicant or future building occupant use equipment or devices which Date Neceipt#
enot Distdc�ous air carman...as defined by the Bay Area Air Quality Management BOILER-COMP CHIP OR IW,a00 BTU) ; r
❑Ycs V TOTAL:
❑No BOILER-COMP(OVER Ig1,1Np BTU)
I have read the h0vcoll materials requirements under Chapter 695 of the Cali. AIR CONDITIONER
fomis Health&Safety Conde,Sections 2.111,25533 and 8530.1 understand tut if the ISSUANCE DATE
Wilding does not currently have.but tut it is my responsibility to verify the occupaot NEW RESIDENTIAL MECH. SQ.FT.
m
of n1luireents which most he met prior m issuance of.CrIifece of Occa'ars'.
Owner err authoI—agent Da¢
TOTAL: ISSUED BY:
OFFICE
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