28604 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPEN ONLY
,CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING•MECHANICAL
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS: - I SANITARY NO. APPLICATIONSUBMITTALDATI
��1 STI . I.
OWNE 'SNAME: PHONE.: CO RA DR'S N'A/p1E: LIC NO '
I I V V ••Qr �SB 6 NIC .t, CONTROL p.
IV ARCHHECfIENGINEER: LIC NO: ADD E. - ❑
/ OhrriOw
CONTACT: PHONE:. - BUILDING PERMIT INFO
�fQrti /VA 1 . "0�/ ,� ❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Q E] ID ❑ . ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OZO with Section 7")of Division 3 ofthe Buainces and Profession Code,and my license is PERMIT ISSUANCE RESIDENTIAL,
�ULicene full Cl...rce d effect. ❑SFDWL ❑KITCHEN REMODEL
License Class LICtr APPLIANCES—RESIDENTIAL '
z Date Contractor []ADDITION ❑PLUMBING RE-PIPE
FFFz<Q ARCHITECT'S DECLARATION PANELS
-+h El MULTI-UNIT El STRUCTURAL
OOz.'2 . (understand my plans shall Mvsed as public records M DIFICATION
J t t uPT02W AMPS ' ❑INTERIOR HIMNEY REPAIR
Ie4 Ltansed Professional 201-1000AMpS, IMPROVEMENT , s,
OWNER-BUILDER DECLARATION ❑BATH REMODEUREPAIR ❑DEMOLITION
{Y1Thereby affirm Nat 1 am exempt from the Contractor's License Law for rhe OVER I(OO AMPSOUfallowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
E 10 F which requires a permit to conatmel,aIle,improve,demolish,or repair any stamom,
�� primal itsissuan.a also reciffiev,the ppli ant for such pere t to file a signed statement SPECIAL CIRCUIT/MISC. -
that he is licensed pursuett theprovisions of the ContrucmrsL L (Chapter9
GGC (commencing with Section 700T.17 Divin 3 of the Business and Professions Code)or TEMP.METER OR POLEINST. 'COMMERCIAL,
'•
y�d a that he is exempt therefr and[be basis for the alleged exempt Any violation of
W V. Section 7031.5 by any applicant fora .. E NEW BLDG/ADDITION El DEMOLITION
jxim lsublects the epph t; civil of POWER DEVICES
>�
not more than five hundred dallarx($500). 1 ❑TENANT ❑FOOD SERVICE.'
G I,es owner of Ne properly,nr my employees witbw
suer axle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT 11
will do line work,and the structure isnot intended muffin f le ce.704LIficiness []OTHER `
4 and Prafessidne Cude:The Contractor's License pfly to ars.�,wn r of OUTLETS—SWITCHES—FIXTURES
.r property who builds or improves t n,and •a work hi e o ough -his own employees,provided that h i in in is are not inteade far for NEW RESIDENTIAL ELECTR SQ PT.'
sale.B,howeve,thebuwitte
ilding or ssoldii10 , co of m1 atthe SQ.FT.FLOOR AREA $/SQ.PT.
owner-bonder will have the harden a 'ng that h door Aiil}Q(Improve for pur-
pose of s
[:] ale.). _ \It(`)
1,as owner of the pmpeny,am excl he y contract maracmm to TOTAL:
w
conscuheproject(Sec.?044,Busine ad Profesth waledie
ode:)The Cuntrectors Li. '
cane Law does not apply to an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE '
who contracts for such projects with a contractono licensed pursuant to the Contractor's
License Law: - PERMIT ISSUANCE - ri
E] I am exempt under Seca- ,B&P C buffbis reason rn n
ALTER—DRAIN&VENT—WATER(EA)
Owner Date VA UATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE '/ 2
1 hereby afford firunder penalty of pe jury one of the following declarations: , `
❑(have entl will meinain nCenificme of Cnnsem mself-insum for Worker's Compen= DRAINS—FLOOR,ROOF,AREA.COND. STORIES • J-
(T YPE CONSTRUCTION
anion,az provided for by Section 3?W of the Ichor C de,for the performance of the
workforwhic isp nil issued. FIXTURES—.PER TRAP
' ❑.1 have and ill inmi is Cnm nation nsumnce,ac required by gallon
J OU of the rot rfo arc ft oVk forwhich lhispermit isisaued GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN�
W e carr r J licy number ore: - -
olicy No.:
GAS—EA.SYSTEM-OVER 4(EA) ' -
CERTIFICATEOPB MFTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be complaedifthe pennit is boron hundaddollere($IIXR
or less) � GREASE TRAP
' 'I certify that io ffic performance of the work for which this permit is issued,I shall - _ PLANCHECK FEE
nmemployany person many mannerso as to become subject m the Workers ContPen-. SEWER—SANITARY—STORM F.A.200 PT.
J ENERGY FEE
�.. sailor Laws of California.Date t
O WATER HEATER W/VENT/ELECTR - GRADING E.
7 O Applicant
q 0 NOTICE TO APP the Worker's
is after Compensation
this Certificate of Labor Code.you
WATER SYSTEMITREATING r
becomeh cmfi lj the Workers Compensation provisions of the Labor Code,yon must SOILS
w
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
z r CONSTRUCTION LENDING AGENCY .
UO I hereby amrin that there is a construction lending agency for the performamNEW RESIDENTIAL PLMBSQ.FT. PAI
cenf ate I Rceipt#
e `
W !tet
the
wprk for which this permit is issued(Sec.3099,Civ.C.)
U Lenders Name - TOTAL:
{il Lender's Address TOTAL:
a 1 certify that I have read this application and state that the above information is BUILDING
VI corect.I agree to comply with all city and county ordinances and.state laws relating m QTY. MECHANICAL PERFEE
nMIT
U 7 bulldingco0uction,and hereby andemize representatives of this city to lc upanthe SEISMIC A n
above-mentioned property for inspection purposes.
PERMITISSUANCE
(We)agreo to sine,indemnify entl keep hmmlees tM1c City of Cuperioo agalnsr ELECTRf PEE' '
liabilities,judgments,costs and expenses which may in any way sector,against said City AIMORADDTOMECH.
in neegoenceo he a ming of this permit. PLUMB( FEE
APPLICANT U D STANDS ND WI L C MPLY WITH AL1.NON-POINT' AIR HANDLING UNIT(TO 10,000 CFM)
' S�URCEREC N /D MECHANIC A E
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTT TAX f
S'
AnPoicanVtra
Concmr Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUZW61TIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT DID I 00,0(10 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety ' sit
Code,Section 25532(a)? HEATING UNIT(OVER I00'"BTU)
E]Yea "••�No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt#
emit hazardous air comaminarns as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
District? - TOTAL:
❑Yes 11 No i BOILER—COMP(EVER 108000 BTU)
1 have real the hazardous materials regptreme its under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DAT&
fomie Health An Safety Coda,Satinns 25505,25577 and 255341 undersand Nal if the NEW RESIDENTIAL MECH. SQ.FT -
offine unJoel not which
have a tartan,Nato is ua to AlaCertificate
rtifica notify the arty.
of Ne requirements which must be met prior to issuance Ala CertificetCOf Occupancy.
Owner oramhoraed a gent Date TOTAL: ISSUEDBY'
OFFICE