28524 AeFLIGANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONYLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMITNO. /� ^2 4
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BUILDING DIVISION APPIACATIONIPERMIT RLl"o"INIT slo n e•„ L F��J
BUILDING ADDRESS: nUILDING PROJECT'IIHW'TIFICA'1'ION
SANITARY NO. APPLICATION SUBMITTAL DATE
02 B _ _
OW�NE�S1gME: ' PHONB: CONTRA;R'S NAME: LIC NO: NIC - CONTC �
�l``LL`` `` TLL
ARCHITECT INEEI� LIC NO: ADDRESS: - a ❑
CONTgcT: PHONE ... BUILDING PERMIT INFO
�s
�Ur 1 � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB It
ECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEP. er��l�\ 4
^ 1 hereby acorn marl am licensed unser pnrviaions of Chnpter 9(nnnmm�clns JOB DESCRIPTION
CZp with Section 7000)of Division 3ofthe BusimmaanJ Nofessiom Codgand my license is
Iyin full force and effect - PERMIT ISSUANCE
V(TC❑�� License Class Lia.p WWL ❑KITCHEN REMODEL
��trZ Dem Convector. APPLIANCES-RESIDENTIAL
4444 ADDITION ❑PLUMBING RE-PIPE
�8�.p y l ssall ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ' ❑STRUCTURAL
OZ Z Pl Z� 1 understand my glare shall be used as public mcords MODIFICATION
J UPTO I(q AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Ucenud Rofcsstonol
Ga „'Jj
OWNER-BUILDER DECLARATION 201-I000AMPg IMPROVEMENT
1 hereby affirm mat I nm exempt f-m the Con onam"s License Low for the OVER I"AMPS ❑BATH REMODELBEPAIR�O�DEMOLIT10N
W a V following reason(Section 7031.5,Businesa and Pruf esions Cele:Any city or county SIGNS ELECTRICAL ❑OTHER I
F r O which requite a Permit to consuuct,alter,improve,demimageolish,or ab any structure
y pnorto in issuance,elm requircsthe applicant for such permiuo film signed atmement SPECIAL CIRCUIT/MISC. kOOUJ
mat he is licensed pursuant no the provisions of the Contmcmrs License Law(Chapter 9
CC�O (commencing with Seddon W)Of Giobion 3 ofmc Businesamal I'mfessions Code)., TEMP.METER OR POLE INST. COMMERCIAL•
eg that he is exempt therefrom and the basis for the alleged exemption.Any violation of
ppb, 44 Section 7031.5 by any applicant for mtit subjects the applicant to a civil ❑NEW BLD(;/AD�IITON. t]OEM01.rT 6N
WZy Pe 1 PP permhY of POWER DEVICES ❑TENANT ❑FOODSERVICE
Z>. not mart man five hundred dation(5500).
Q (]1,as owner ofthe property,or my employees with wages astheirsolecompensetion, SWIMMING POOL ELECTRIC IMPROVEMENT /
O will do the work,and the structure is not intended nrnffered for late(Sea JIH4,Business DOTHER
4 and Professions Cole:The Contractor's License Law does not apply to an owner of OUTLEDIS-SWITCHES-FlXTURES
.. pmpeny who builds or improves thereon,and who does such work himself or through
his awn employees,provided ten such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,The building or inipmvement issald wiminone year ofcomPlction.lhe /� SQ.FT.FLOOR AREA VSQ.FT.
m-builder will have the burden of provins the,he did not buildorimpOw for par- lbS 4
p1 1,assole.). �I �� V I 0-3
❑1,as owner of the Sm.704,.B exclusively contradicts with licensed contractors m
cotuwd the project(Sec.]fH4,Business and Profusions Ede:)The Convector's Li-
censeLaw does not applyhformanownerofprogeny who builds or imp roves thereon,and QTY. PLUMBING PERMIT FEE
whence Law. such projects wiNucomtnclnr(s)Iittnsed pursuant to the Contractor's J t-J
License Taw.
O l an exempt under Sec. ,B&PC for this mgm PERMIT ISSUANCE
Owner Dam ALTER-DRAIN -WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION \ ^ /N'
BACK FLOW PR E ` 1 ('�1 R'y - 0.
Ihandwilffrmunderpeneltytte.l juryOne ofthefollowing dedar'i Co: 1`� /✓'Mg`
❑I have and will for by
a tion 37M of do,sent to Labor Cork,sum for Workers Comporte DRAINS-FLOOR. ,C D.
work for
provided for mi Section 3]00 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work have and this permit is issued. FIXTUR&S-P TRAP
❑1 have and will maintain fon Worker's ante offla,wrkfor whimrequiredt I Section
MyBorke Lamm CadN6fmsurance canceofthewll, forwhi,athis permit is issued. GAS-EA.S 5 -I INC.40ITfLfi1'S
My Workers Compensation Insurance earner erd Policy number ere: OCC GROUP APN
Cartier. Policy NO: GAS-EASY$ OVER 4EIA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASSINDUSTR F INTERCEPTOR
(This section need not be completed ifthe permit is forone hundred dollars(S led) BUIL N VISION FEES
m less.) GREASETRAP 1
(certify thein The any..are,eff.ccofinewmkfor which this Tondoisissued.?shall PLANCHF.CK FEF.
not employ any person in any manner so as to Mume subject m the Workers'Compcn- SEWER-SAMTAR - MEA.2110 FT ENERGY FEE ^ _
Q ,� Apth Lews of California.Dere WATER HEATER WNE W
z O Applicant - GRADING '
NOTICE TOAPPLICANTIL aftermaking min Cisions of of FLaboriadYou should WATER SYSTEM10TREATING
a 5 become subject m the Worker's Compensation provisions of the Labor Code,you must SOUS FEE
4TJ tti foMwith comply with such provisions or this permit shell be deemed evoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
U p Ihemby ,tn tent thele isaronstrection letWing agency for the performance of Date Rmcip
V., P the work for which this permit is issued(Sm.3097,Civ.C.) -
Q U Lenders Name
Lender's Address TO L:
aI mnify that I have mad this application and some that the above information is BUILDING FEE _
&Q cancer I agree m comply with all city and county ordinances and state laws mlating m QTY, MECHANICAL PERMIT
U building convection,and hereby authoree representatives of this city to enter upon the FEE SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree m give,indemnify and keep harmless the City of Cu nino a ainat PERMIT ISSUANCE e _" ^
Pe s ELECTRIC FEE Ir
liabilities.judgments,coarsing expenses which may in any way ecemc against City ALTER OR ApD TO MECH.
m APPLICANT
of the Roaming of this Permit. PLUMBING FEE
APPLICANI'U' ERSTAN 'A ' WI PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Io,000CFM)
SOURCERfD TIONS // MECHANICAL FEF.
✓ 10 X50 QLD AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCIIONTAX
Signmurtot iceon r Date EXHAUST HOLD(W/DUCD
AZARDOUS MADISCLOSURE HOUSING MITIGATION FEE
Will the applicant or futumhuildii maupam score or handle hmardous materialHEATING UNIT(TO I W."I BT U) -
ae defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Saro
Code.Section 25532(x)] HEATING UNIT(OVER 100,1100 BTU)
❑Yea ❑No
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use cquipmcm or devices which Dam Receipt 0
emit hazardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP SHP OR IW,000 BTU)
District? TOTAL:
DYcs ONo BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous mdenus rcquimments nude,Chapter 6195 M the Cali- AIR CONDITIONER
fomia Health&Safety Curb.Sections 25505,25533 and 25534.1 undersmtW that if he ISSUANCE DATE
building doss not armemly have a tenant Nat it is my msponsibility to sadly the rampant NEW RESIDENTIAL SUCH, SQ.FT.
Of the m ariremenss which moa he met pdmto issuance of a CeniOcam of Occupancy.
Owner or authorized aged Data ISSUED BY:
OFFICE