28829 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL -PERMIT NO. 28829 8 8
BUILDING DIVISION APPLICATION)PERMIT PLUMBING-MECHANICAL •LJ ly!( 'LJ s�Jl
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS AME: PHONE: ONTRACTOR'S NAME LIC
NIC
ARCHITECTALNGINDIi LI O: w OKDDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fact Paid by Applicant(Initial) ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT
_a Z 1 hereby uflirm ivis I am fthe .under provisions of Chaplet 9(rommencing JOB DESCRIPTION
with Sermon addaf Division3ofNe Business and Rafessimns Code.end my license is RESIDENTIAL,a in full lane and effect, PERMIT ISSUANCE -
%UU License Clash Lo.# CSFDWL C PLUMBIKITCHENREMODEL
�� Dam Contmcna APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RN.PIPE
zi ARCHII ECI"S DECLARATION El MULTI-UNIT [I STRUCTURAL
y I undersmnd my plans shall he used us public records PANELS MODIFICATION
UP TO 200 AMPS
OZ=1p - [I INTERIOR [_1 CHIMNEY REPAIR
P Y,1 Licensed Pmfe,sionul 201.1000AMPS IMPROVEMENT
]aj
OWNER-BUILDER DECLARATION
Contractors
ON OVER]"AMPS C BATH REMODEUREPAIR�EMOLITION
1 hereby affirm . I em exempt from the Convenor's License Low for Ne
O y U following rcmnn.(Section]03 L5,Business end Profexsions Code:Any city or county 11 OTHER
iq5 SIGNS EI.ECfRICAL
FO yQ which rryuima o permit re connect,alter,improve,demolish,or repair any structure
.i
poorhe is
tensed e,also owalto res Neapplicant for
a,such Cwtur Permit Lfile aicense ned Lose(Chapter
SPECIAL CIRCUIT/MISC.
ahatheiNicemed purstion7 the of Division 3 the eBusin ss nd Professions
Codmr9
a0�q (cammcrmingwiN Semian]000)of Division 3ofthe Rosiness and Nafcssionx Code)sn TEMP.M ROR LE!NST. /a COMMERCIAL:
Is. c LL that he is exempt Iherefmm and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION ❑DEMOLITION
.`n.1i• Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEV C
rn ❑TENANT ❑FWD SERVICE
Z} not more than five hundred dollars yempl IMPROVEMENT
O ❑ Las ownerof the pmpeny,mmyemntended with cared for it,(SI.campemmian, SWIMMIN E 1
wdl Jo the work,and Ina mmnur<is not intended car offered tarsale(Sec.]OH,Bottoms ❑OTHER.
and prod.inns Crate:The Convacmr's License law does not apply lm an owner of OUTLUTS-SWI H TURES
n' Pmpeny who bunds or improve,thereon,and who does such wick himself or through
his ow employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL FTR SQ FT.
suit.If, the budding or improvement is sold within one year afcompletion.the SQ.FT.FLOOR AREA S/SQ.FT.
owner-builder will hove the burden of proving that he did not build or improve for put-
PhZraos
wncr oftheprpcnum exclusively canuacting with licensed canvacnsre tothe project(Sea]044,Business and Professions Cade)The Contractor,Li- h'0 /S does natupply m an owner of proer who muildsoc impmves thereon,and QTY. PLUMBING PERMIT FEE64 for such projects with a comm,mrfs)licensed purstommthe Convectors
E]ense lontrnlaw. -' PERMIT ISSUANCE OCT A
❑ Luexempt ua
ntlerS . ,B&PCfmr Nis reamn �J $
ALTER-DRAIN&VENT-WATER(EA) - VALUATIO
Owner Uam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE V�1 x/�flt.Ywl�jasl�
1 hereby affirm under penalty molder,one of the following declarations:
❑I heveand will natuuinaCeaificamofComent losef.more for Workers Co.,.- DRAINS-FLOOR,RODE AREA,COND.
sawn,as provided for by Station 3700 of the labor Code,far me performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
I have and will tmminmin Workers Compcnsmlon Inmrance,as required by Section
I 3200ofthe labor Cedefardaperfmmnac,. the work fm which Nispermitis issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation luamwce carie,and Policy munch rme:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEENDUSTRL WASTE INTERCEPTOR
(This section need not be Completed if the permit is forma,hundred dollars(S Had BUILDING DIVISION EEL'S
or less. - GREASETRAP PLANCHECK FEE
I certify that in the performance cOhe work for which his permit is issued,lshal gIiWER-SANITARY-STORMWTOTAL:
not employ any penton In any manner so as to become subject m the Workers'Cumpcn- ENERGY FEE
O z nation Laos nl California,pore WATER HEATER WNENT/ELE
Q Applicant "' GRADING FEE
y NOTICE TO APPLICANT:IL after making Nis Certificate M Exemption,you should WAIT E SYSTEMOREATING
a [� herome subject to the Wohds Compensation provisions of the Lamm Curt.you amt SOILS FEE
Lit I'y foMwithcomply with such provisions or Nix permit shall he deemed revoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. PAID
D.0 l,farwicI hereby h his
that.it
issued(Sumion len ding agency for the performance of Dem R p
CD. Newark for which Nis pcmait is issued(Sec.3097,Civ.CJ
0 i� Lenders Name TOTAL:
V Lender's Address
y1 Certify that 1 have read Nis application and sore thm the above information is BUILDING �s
V1 exami Issues,m comply with all city and county ordinimi and state law,palming to QTY. MECHANICAL PERMIT FEEL
U z bung comwnion,end herby auNarixe reprcsenmtives of Nis city menta upon the SEISMI
above warn oned pmpenY for impoelm.purposes.
(We)agree to save,indemnify and keep hmmleis the City of Cupertino against PERMIT ISSUANCE ELE
liabilitics,judgmenm,costs and Calcines which may in any way accrue g It. ALTER OR ADD TO MECH.
consequencein of the starting of this peach. PLUMB! E
APPLICANT UNDERSTANDS AND WILL COMPLY W H A rvON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIO' MECHANICAL E
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCT NTAX
Signa t ontrama Dme E%HAUST'HOOD(W/DUCD
HAZARDOUS MAT IALS DISCLOSURE HOUSING GATION FEE
Will the npplivent or future building occupant store at handle hazardous meterial HEATING UNIT(TO 100,1100 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
.col,,Section 25532(0)] HEATING UNIT(OVER 100,000 BTU)
El Yea, CNa VENTILATION FAN(SINGLE RF.SID) PAID
Date ReceiptN
Will the tpplicanl or(wore building occupant use equipment or devices which
Fact institutions air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
TOTA
District?
❑Yes CNo BOILER—COMP(OVER 100,010 BTU)
' _
AIR CONDITIONER
I have read the harsoll ateriels aryuimments madcr Chap¢r 6.95 of the Cali- ISSUAN E DATE
Ends
Health m&Safety CMe,Satitms 25505,25533 and 25534.1 moderated that if the NEW RESIDENTIAL MUCH. SQ.FT
lookhngdoes not currently have a mamm.that it u my responsibility to outify the recupart
of Bra requiremmix which must be met pdorm issuance of a Certificate of Occupancy.
Owner ur authmiead age.. Dam TOTAL: ISSUED BY:
OFFICE