28710 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO. 2^ 710
BUILDING DIVISION- APPLICATION/PERMIT PLUMBING-MECHANICAL L VX
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRFSS: - SANITARY NO. APPLICATION SUBMITTALDATI
Ica o P 1 -�
OWN 'S NAp1C: PHONIi: RA R'S AME:0 000 1 � LIC O:
�/L - NIC CONTROLM
ITECf/ENG EER: LIC o7 FSS: ❑.
CONTACT. �1�PHONE BUILDING PERMIT INFO
❑ Consultant Fccs Paid by Applicant(Initial) V E PLUMB ECx
�t %3-1660
LICENSED CONTRACTOR'S DECLARATION,
'0QTY. ELECTRIC PERMIT FEE
1 herehy affirm that 1 am licenud under provisions of Chapter 9(commencing J B DESCRIPTION
Z with S«.ion]OIOI of Oivision3of the Business and Rofcssianx Code,end my licenu is RESIDENTIAL,
F. infullfnrceandeRe % PERMIT ISSUANCE DSFEwl. D KITCHEN REMODEL
�U LDate icenu Class Lic.M' AppL1ANC1i5-RESIDENTIAL ❑ADDITION ,D PLUMBING RE-PIPE,
Conan
7 HITF.CTS DECLARAT N ❑MULTI-UNIT ❑STRUCTURAL
Zpy Jun comic y plansshall bevud in publicm orris' - PANELS MODIFICATION
z{�by: UPT0200AMPS ❑INTERIOR DCHIMNEYREPAIR
(:y(] Licensed Professional 201-1000AMPS - 3�—
ad
PROVEMENT
9bit OWNER,exempt
ERDECLARATION OVER["AMPS TH REMODEL/REPAIR [I DEMOLITION
5YC�7 pE 1 hereby affirm OW 1 am exempt(Trim the DECLARATION
License Law for N<
3 LV fnllnwing reason.(Section]031,5,Business end Professions Cole:Any city or county SIGNS ELECTRICAL HER
LLFa which requires a permit to construct.ulnar,improve,demolish,or repair any sbucture
prior..its issuarce,tilso requiresth,applicant formch permit m fileasigned statement SPECIAL CIRCUIT/_
{vv{yy��Y that he is licensed pursuant to the provisions ofne Contanoss Licenu Law(Chapter 9
Cp0 (commencing with Section]OW)of Divixm0.fthe Businessand professions Cox,)., TEMP.METER OR E MERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of W BLDG/ADDITION D DEMOLITION
S«.inn]831.5'by anyapplicam far,permit subjems.he uppli,aa,ma civil penalty of POWER DEVICESfz
NANT ❑FOODSERVICE
not mote than five hundred dollars(5500). PROVEMENT
O Lux owner ofthe property,or my employees with wages as their sole compensation, SWIMMINGPOOLE CTRICwill do the work,and thesrmatim is not immnded orofiered formic(Sec.J044,Business HER
Professions Cade:The Cannot Licenu Law does not apply m un owner ITL61'SWITC RES
property who builds or improves thereon,and who does such work himself or through _
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL . ELT SQ PT.
ale.If,however,the building or improvement is sold within one yeaofcompletion.the SQ FT FLOOR AREA $/SQ.PT.
owner-builder will have the burden ofpmving that he did not build or improve for pur-
pou of sale,).
D 1,as owner of the property,am exclusively contracting with licensed contmcmrs on F 1
cmamot the project(S«.]044,Business and Professions Cade:)The Contractors U.
' ,enm Law docs not apply in an owner of property who builds or improves.hermn,and QTY PLUMBING PERMIT F
whocomtme.s forxuch projects with v contractors)licensed pursuanno the ConOaemrs i��� y ��
License Lew. PERMIT ISSUANCE j (]
_❑ l um usurp.under Sea ,B&PCfnribismason 96
Owner Dam ALTER-DRAIN&VENT-WATER HEA) (!I- VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE +
I herebyaffmnunder Penalty of perjuryoneofthefollowing orrice Cou
01(have and will forbyeCeni uam37M ofConsent to Labor
Code,for
Warketsce of the
pRAINS-FLOOR,ROOF,AREA.COND. STORI , TYPE CONSTRUMTON
smi kf as provided for by Sectionsisu3]00 of the labor Cade,far the performance of the '
k fyf�a'�ich this permit is issued FIXTURES-PER TRAP
IId?Fuve and will maintain Worker's Compensation th w Insurance.It required by Section
3]IXl.Tobe Lvhor Cole,fonhepeHnrm.ncwf the work 6rwhichthis permit is issued. OAS-FA.SYSTEMd INOYO CTS OCC GROUP APN
M War Ot 1 and Poli,Y�;6 ��
Cnm'er. olicy No -711�iL— GAS-FA.SYSTEM-OVER 4 •A) r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRBASFJ NDUSTRL WA E INTERCEPTOR
BUILDING ISION FEES
(This«tion need butt,completed if.he permit is forma huMreddollarslSl00) GREASETRAP
Tor less) PLANCHECK FE
I ready Out in the performance ofthe work for which this permit is board,i shall SEWER-SANrr -STORM EA.200 IL If
not employ any person in uny manner so as m home subject m the Workeri Creation.. ENERGY FEE -
ZZ w0an laws of California.Date WATER HEAT WNENT/ELECTR
(7 Applicant GRADING
sooty NOTICE TOAPPLICANT:If,after making this Certificate of Exemption,you should WATER SEMMILEATING
boom,subject p
o the Workers Com ,naation provisions of the Labor Code,you mus. SOILS FEE
�L0 forthwith comply with such provisions or permit shall he deemed revoked. WATE ERVICE
CONSTRUCTION LENDING AGENCY NE RESIDENTIAL PLMB. SQ.FE PAID
U p Iheuby nl0zm tlwnhcrc isattmswnion lending agency for the performance of ae R«eiptp
fin P Ne .,it for which this permit is issued(Sec.3W7,Civ.C.)
Q U launders Name TOTAL: -
WLenders Addreu TOTAL: A
I unify thus 1 have read this application and state but he above information is BUILDING FEF 2e{.J /'
V) correct.)ague,m comply win 001 city unit county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEC as
V Z building curatmction,and hereby authorize representatives ofnhis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hamlcss the Ciry,of Cupertino again PERMIT ISSUANCE ELECTRIC F
Iiabilifies,judgments,costs and expenses which may in any way accme against said City ALTER ORADDTO MECIi.
in consequence of the granting of this permit. PLUMBIN EE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'r(TO ID(m CPM)
SOURCE REGULATIONS. MECHANI AL FEE
AIR HANDLING UNIT(OVER 10,0110 CFM) CONSTR ONTAX
Signature of Applicant/Contracmr Date EXHAUST HOOD(W)DUCT) HOUSINGVJITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wll the applicant or future building«cuptin store nr handle humid..,ma must HEATING UNIT(TO IOEWO BTU)
an defned by the C.Promo Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 25532(a)] HEATING UNIT(OVER IW.000 BTU)
El Yes CIN. PAID
VENTILATION PAN(SINGLE RESID) Dute mciptN
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by rte Bay Area Air Quality Management BOILER-COMP(3HP OR 100,M BTU)
atria? TOTAL:
• BOILER-COMP(OVER 100,000 BTU)
❑Yea DNo
t d d¢havvdaus'mamrials AIR CONDITIONER
1 have rea
requirements under Chapter,6.95 of the Cali- ISSUANCE DATE
forma Health& ,Sections 25505,25533 and 25534.1 understand that if the + NEW RESIDENTIAL MECH. SQ.PT.
building note n0 veete.um,that it is my resp.so"ityu notify be occupant -
of
On ui atins, _!,.teres
prior w cou s of C nit, i ceupancy.
'Owner. van need.gent Dam Ufg AL: - ISSUED BY:
OFFICE.