28463 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY -
,CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL A O A C O
BUILDING PRO
IDENTIFICATION 4 v J G o
BUILDINGAEDRES SANITARY NO. APPLICATION SUBMITTAL DATE
Avf�. V % V
O ER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
_ )WIll NAC ^!!l�Cr�O�NTROL p
AR ITECT/ENGINEER: LIC NO'. ADDRESS: ❑ / r
f. �1, d ( ( `
CON ACT: PHONE: BUILDING PERMIT INFO
n�A^ \!� (&%*)zAk—b460 ❑ Consultant Few Paid by Applicant(Initial) PLUM MECH
nal LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
004Z with Sec0)aftio.700Disumn 3ofthc Nmiromiul Professions Code,and my license is - RFSIDFNTIAI•
O O full PERMIT ISSUANCE
in tome andeRect. WL ❑KITCHEN REMODEL.
�UWU License Class Lic.N', APPLIANCES-RESIDENTIAL - ADDITION [I PLUMBING RE-PIPE
�Za Date ' Contractor 47n ❑MULThUNIT ❑STRUCTURAL ARCHITECTS DECLARATION PANELS
cords r MOMODIFICATIONI understand my plans shall ba used as public re
'Z-O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
'// LicemW Professional IMPROVEMENT
� W 2U1IIMIpAMPS p
HN
OWNER-BUILDERDECLARATIONCe ContrON OVER 1000 AMPS ❑BATH REMOOEIIRE�AIR pCDEMOLITION
yq,t� 1 hereby affirm that 1 1. exempt from the Contractors Cod License Law for the ❑OTHER
W O a V{ fallowing renes..(Section 7U3LS,Business and Professions CNe:Any city l county SIGNS ELECTRICAL
47 a LLa� which its issuance,
n permit re caressed aper,i applicant for su demolish, fi repair any swcmre
Fes'Li O J pdm to iu censed q also nt 1.theres the proisinsofor Cmansch lm Permit Licensele a L w(Cunneen
SPECIAL CIRCUIT/MISC.
gig
'j Nw he is licensed pursuenuo the provisions of the Comumota License Lew(Chapter9
p0 (commencing withSection?IXq)oI'Division 3 ufthe Buvinessand Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
LL y W that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDvCraFI1DDII�ON�UtQ' DEMOLITION
iC 4. Section 7031.5 by any applicant fm a pnmit subjects Ne applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
tZto not more than five hundred dollars(ESA)). - IMPROVEMENT
x=60 0I,as owner of the properly,or my cmployws with wages as their sole cmmpenmtion, SWIMMING POOL ELECTRIC ❑OTHER
F. willdo Nework.and Neswcwrei...timm�dedoroReredforule(Sec.7044.Business
I3' and Profeseimn Cede:The Contractor's License Law does not apply tri an owner of OUTLETS-SWITCHES-FIX TURES
property who builds or impmva themon,and who does such work himself Or Ntough
his own employees,Provided Nat such improvements are not intended or offeredfor NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however the building or improvement is sold within one year ofcompletion,the SQ.FII FLOOR AREA
caner-builder wiU have the buNen of proving that he did not build or improve for Par-
possofsaleJ.
0 1,as owner of the property,um exclusively contracting with licensed contractors to /� w
cunswct the project(Seo.7614,Business and Professions Cwaq The Contractors Li- /
rise Law does not apply to an owner ofpmpcny who builds or improves thereon,and Try (. PLUMBING PERMIT FEE `
who contracts for such projects with a cormactog0 licensed pursuant to the Contractor's
Licame law. PERMIT ISSUANCE
0ramexempt derS ,B&PC for this reason
ALTER-DRAIN&V - IAT (FAj VALUATION
Owner Dam
R 'S CO .ATION DECLARATION BACK FLOW PROTE E �1
Iherebya sero under pen ml'perjury one ofthe fallowing declinations: `
❑Ihevemtd will meinumvCertificam ofConsenuosdGinsum for Workers Compen- DRAINS-FLOOR,ROOF,AR C STORIES W TYPE CONSTRUCTION
mine,as provided for by Section 37M of the Labor Code,for the perfomunce of the
work for which this permit is issued. - FIXTU RE S-PER TjtAP,
0 1 have and will maintain Worker's Compensation Insurance,as rryui ed by Section
37M.fNe Lima,Code.for the perfmmonceof Ne work fm.1,eh this permit is ismed. GAS-EA.SYST• INC.40 S I OCC,GROUP APN
My Workers Compensation Insurance emotional Policy.umber me:
Carrier: Policy No.: GAS-EA.SYST -OVL EA]
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSFJINDUSTRL WASTEI 'RCEPTOR
COMPENSATION INSURANCE — BUILD12kW NYN FH
Dfiis section need not becompleted ifthe permit is home hundrWdollars(2100) ORGSETRAP
or less) PLANCHECK FEE
I certify that in Ne performance ofma work for which this permit is issued,[shall SEWER-SANITARY-S 200
not employ any famous in any manner an into become subject to the Workns Compen- ENERGY
,Z ,variant Laws of California.Dam WATER HEATER WNENT/CLE
zApplicant - GRADING E
h NOTICE TO APPLICANT.if.aav making this Certificate of Exemption,you should WATER SYSTEMCFREATING
(~ become subject to the Workers Compensation provisions of the labor Code,you most
SOILS ME
farthwiN comply with such provisions or this permit shall be de pined revoked. WATER SERVICE
UJ
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT PAID
V Ihereby affirm Natthere is aamstructlon leading agency for the performance of Date
the work for which this pemdt is issued(Sec.3NO,Civ.CJ
U. F" Lcndces Name TOTAL:
WLenders Address TOTAL:
tIi 1 certify Nat I have seed this application and state Net are above information is BUILDING i�
rI,I correct.I agree to comply with all city and county ooinonces and sum laws rehiring to (2 y. MECHANICAL PERMIT FEE SEISM
V buildingconnmction,and hereby amhonae representatives of Nie city to enter upon me
above-mcntiorrcd property far inspection purposes. PERMIT ISSUANCE EL TC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PL G E
in camcgvence of Nc granting of this permit
APPLICANT UNDERSTANDS AN LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,(XOCFM) MECHANICIA,FEE
S RCERI' ULATIO S. -r
7 ,1I--p-6— AIR HANDLING UNIT(OVER IO.UDO CFM) CONSTRU ON TAX
Signora A N maetor _`-`-lj G1"ty e1`' EXHAUST'HOOD(W/DUCT) HOUSING MTU TIONFEE
HAZARDO' A BTAIS DISCLOSURE /a
Will the applicant or future uildingmcupanistoreorhandleh..a .usmuteri.1 HEATING UNIT(TOIW,WO BTU)
m defined by Nc Cupsmno Municipal Code,Chapter 9.12,and Ne Health and Safety
Code,Section 25532(0? HEATING UNIT(OVER 1(O,OW NIU)
D Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt p
Will Ne applicant or furore building occupant use equipment in devices which BOILER-COMP OHP OR UM EEV BTU)
emit haurdous air contaminants as defined by the Bay Area Air Quality Management I'
District? BOILER-COMP(OVER 100,000 BTU)
C)Yea ON.
I have mad the haurdous materials reptimments under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
form.Health&Safety Cade,Section 25505,23533 and 25534.I understmrd Net if be NEW RESIDENTIAL MECH. SQ.FT.
building does notcu�ndy have a tenant Dur it is my msponsibility to notify Ne co upas
of Ne regvirtrmnts wh'mh nun be seer pnmm issmrme of a Cenificam of Occupancy.
Ownermrauthmisedagenr - Data TOTAL: ISSUED BY:
OFFICE