28502APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO -, BUILDING • ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
J
PERMIT NO. 28502
2 8 5 O^/
L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: D ��� �� I z
SANITARY NO.
APPLICATION SUBMITTAL DATE
V 2346
07-S NAM/g: / f PHONE:
<Y Ksl ell1f
C ACH)R'SNAME: e LIC NO:
QS ejy/ /,�J�
NIC
❑
CONTROL
AA CH17CDENGINEER: LICNO;
A�1{ �.� uh ^ -
CO� 4-x'1
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant EMS Paid by Applicant (Initial)
BLDG LE91a PLUMB MECH
❑ ❑ ❑
LIC -NSE CONTRACT'OR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT Fee
JOB DESCRIPTION
with Section 7M)of Division 3 ofthe Business and Professions Code. and my license is
in full force and effect.
License Class Lic. q
Dae Contractor
RESIDENTIAL:
❑ SFDWL El KITCHEN REMODEL
CIADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
PANELS
UPTO 200 AMPS
❑INTERIOR FI CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODELIREPAIR [I DEMOLITION
❑OTHER
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which terrains a permit to consumer, alter, improve, demolish, or repair any sure.
201-100AMPS
OVER I000AMPS
SIGNS ELECTRICAL
prior to its issuance. also requires the applicant for such Permit in rile a signed statement
SPECIAL CIRCUITIMISC.
that he is licensed paramount to the provisions mine Conductors License Law (Chapter 9
TEMP. METER OR POLE INST.
(commencing with Section 7010)of Division 3 ofthe Business and Professions Cocaine
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
EW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for n perritmbjects the applicant too civil penalty of
not more than rive hundred dollars ($510),
❑ Lae owner of the property, or my employees with wegesm Heir tele cnmpennatimn.
will do the work, and the structure is not intended oreffered for sale (Sec. 7044, Business
POWER DEVICES
❑T ANT FOOD SERVICE
IMPROVEMENT -
❑ OTHE '
RIP
SWIMMING POOL ELECTRIC
add Professions Code: The Contractors License Law does not apply to an owner of
OUTLETS - SWITCHES - FIXTURES
property who builds or improves thereon, and who does men wont himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If. however. the building or improvement is sold within one year of completion, the
owner -budder will have the burden of proving that he did not build or improve for put
pose i f sale.).
❑ 1, as owner of the property, am exclusively contracting wit licensed contractors to
NEW RESIDENTIAL ELECTR SQ FT.
SQ. PT. ILOIR AREA
$ISQ. Fn
'
,vS' fM PP
construct the project (Sec. 7044, Business and Professions Cade:) The Contractor's Li -
cause Low does not apply to an owner of property who builds or improves thereon, and
who convects for such pmjceD with a contmetons) Reamed Pursuant to the Contractors
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
License Law.
❑ I nm exempt under Sec. ,B& P C for this reason
Ownu Date
ALTER —DRAIN&VENT — WATER (EA)
VALU ON
BACK FLOW PROTECT. DEVICE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one ofthe following declarations:
DRAINS— FLOOR, ROOF, AREA, COND.ST
I have and will maintain a Certificate of Consent to self insure for Worker's Comped-
nation, as provided] for by Section 3700 of the Labor Code, for the Performance of the
work for which this permit is issued.
RIES
CONSTRUCTION
FIXTURES —PER TRAP
❑ 1 have and will maintain Workers Compensation Imuna c, as required by Section
3700nfthe Labor Code, for the perfonmmceof the work for which this permit is issued.
GAS — EA. SYSTEM -I INC. 4 OUTLETS
OUP
A
My Workers Compensation Insurance carrier and Policy number ore:
Cartier. Policy No.:
GAS — FA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin nation need not be complemJifthe permit is for one hundred Jolters ($I(10)
or less.)
GREASIVINDUSTRL WASTE INTERCEPTOR
BUIL IN ivisioo FEES
GREASE TRAP
HECK
Loy mythatinthe my Performanceofthewhich this thePermitWisissued. I 'Contiall
not employ any Parton in any manner so as m become subject to the Workcr%Compen-
becoork me
SEWER—SANITARY—STORM EA. 200 FT.
R E
'
WATER HEATER WNEWMLECTR
action Laws of Cal floods. Date
Applicant
GRA G FEE
NOTICETO APPLICANT: IL after making this Cer ificam df Exemption, you should
become subject to the Worker's Compensation Provisions of the Labor Code, you must
WATERSYSTEM?RHATING
SOBS FE
forthwith comply with such provisions or this permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby offinn that hem is a construction lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ. PT.
PAID
Darn Receipt#
the work for which this permit is issued (See 3097, Civ. C.)
Lender's Name
- -
TOTA4:
Lender's Address
TOTAL:
BUILDING PER
I certify that I have read this application and aero that the above information is
QTY. MECHANICAL PERMIT FEE
(;
�EIS`TGL �
cormct. l agree to comply with all city and county mdimnces and ram laws relating to
building construction. and hereby minimize representatives of this city to enter upon the
PERMIT ISSUANCEnst
ELECTRIC FEE
O
abovmmastioned property for inspection purposes.
(We) agree m save, indemnify and kap hvmdess the City of CLpenim, agai
ALTER OR ADD TO MECH.
G
IM
habilides,judgments, costs and expenses which may in any way acme against said City
in comequence of the granting of this permit.
AIR HANDLING UNITOD I0,000CFM)GULATIONS.
MECHANICALk. FEEAIR
5,P'TTu UNDERSTAND A D WILL COMPLY WITH ALL NON.P INT
HANDLING UNR(OVER IO,o00 CFM)
CONSTR 1 X
AppliaHAZA DO Oae
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOLD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,003 BTU)
Will the applicant or future building occupant stem or handle hazurdnux material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(.)?
HEATING UNIT (OVER 100.000BTU)
❑Yes ❑No
t use equipment or devices which
Will the applicant or future building omupanqui
mit hazardous air momentums redefined by the Bay Arm Air Quality Management
)umicd? t
Ely. CIN.BOILER
PAID
VENTILATION VAN (SINGLE RESID)
Date Receipt N
BOILER-COMP(3HPOR Han"BTU)
TOTAL:
- COMP(OVER 100,000 BTU)
AIRCONDITIONER
I have read the haznNous maenals reruiremema under Chapter 6.95 mthe Cali.
ISSUANCE DATE
NEW RESIDENTIAL MF,CH. SQ. FT.
forma Health & Safety Curb, Sections 25505, 25533 and 25534. 1 understand that if the
building does not currently have a tenant, that it is no, responsibility to notify the occupant
of the egrlement5 which mot be met Formula iiS.Mce of a Certificate moccuPNty.
ISSUED BY:
TOTAL:
Owner or untrained agent Data
OFFICE