28886APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. -ELECTRICAL.
PERMIT NO. ^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
L VX VX lXJ YV�
2 8 8 6
BUILDING PROJECT D3ENFIFICATION
BUILDING ADDRESS:SANITARY
NO.
APPLICATION SUBMITTAL DATE
S,
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C RACfOR$ A E>
NIC
❑
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AR HITECT/ENGINMB - IC NO:
73MEAUESS..
CONTACT. pF1oNE: !(� ..
tai 460 8 - L
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLU MECH
. 12 ED F-1
• LICENSED CONTRACTOR'S DECLARATION •
I hereby affirm that 1 um licensed coder on, of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
I JOB DESCRIPTION
with Section A100)of Division3a(]he Business anA Professi�nsCMe, and mylicense is
in full forte and et ec /-
Lian� ly S- ic.g /
Dam Convector
PERMIT ISSUANCE
RESIDENTIAL: -
OSFDWL C:) KITCHEN REMODEL
❑ADDITION [I PLUMBING R&PIPE
APPLIANCES - RESIDENTIAL
A CHf1' SDECLARA I N
1 understand my plans shall be mud as public records
❑MULTI -UNIT s [I STRUCTURAL
MODIFICATION
PANELS
UPTO2MAMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
O BATH REMODEUREPAIR 0DEMOLITIQN-
fir,
❑ OTHE��sa
/]fit f g J A
Licensed Professional
- OWNER -BUILDER UILDF.fr DEthe Commerce's
I hereby "(Geta that 1 1. exempt from the Coss Co License law far the11
following resort (Section ]03 sir Business trod vs,, de Professions Code: Any city or county
whichinispermits, permit" construct, slag improve, demolish, or repair any tenure
201-I WO AMPS
OVER 1000 -AMPS-
SIGNS ELECTRICAL
n the applicem for such pemtiuo fileazigneJ statement
paha
SPECIALCIRCUILMISC.
�I
is rcrocece,...requires
that heislicensed pursuao the provisionsofof Convenor's Licenselaw 9
TEMP. METER OR POLE INET.
COMMERCIAL
7
(commencing with Section 7000)of Division 3of the Business and Professions Codel<a
sCuld
that he is exempt them(.. and the basis for the alleged exemption. Any violation of
0 NEW BLDGIADDITION 0 DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil parmlty of
not more Own rive hundred dollars (15W).
01, vs ownerof the prbpcny, or my employees with wages as their sole compensation.
will do the work, and the swetom is not intended oroBcred for sale (Sce. 70a4, Business
[]TENANT OFOOU SERVICE
IMPROVEMENT -
0 OTHER ,
SWIMMING POOLLELTRIC
nM Professions Code: The Convectors License Law does not apply to an owner of
DOmm- SWITCHES -FIXTU t
pmNdy who builds or improves thereon, and who does such work himself or through
his own employres, provided than such Improvements are fat intended or 0Rered for
aide .If. however, the building or improvement is sold within ane ye�", pl"Zir the
NEW RMIDENTIALELECTR SQ Ff.
SQ. FT. FLOOR AREA LSQ. Ff.c
owner -builder will have he burden of proving Nat he did not build or improve for par-
- PA A p ® li
pose of aeleJ.
T
0 1, usa r of the property, am exclusively contracting with licamed contractors to
construct theprotect (Sec. 7(),14, Business and Professions Code:) The Convacmr's Li-
cense law does not apply to an owner of property who builds or improves thereon,and
r DEC 14 199
QTY, PLUMBING PERMIT a"FLl
who commcu for such projects with a contractors) licensed pursuanuo the Cordri
PERMITISSUANCE
Ln Lew.
0 Lon
ClaLata atvSec. ,B&PCfor this reason
ta.� A�
kI
C�IY ur Wf, hf
Owner Date
ALTER - DRAIN &VENT- WATER (EA)
VALUATION
/v}•a�'J
KHR'S COMPENSATION DECLARATION
BACK FLOW PROTECC DEVICE
I hereby under penalty of perjury one of the following declarations:
IO
s
DRAINS- FLOOR. ROOF, AREA, GOND.
lhaveandwillinaintaina Ceniricamof Comcmtoself-insamfor Worker's Compcn-
sation, as provided for by Second 37M of the Labor Code, for the perfmmmnce of the
5 RIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
work for which this permit is issued
0 1 have and will maintain Worker's Compensation Insurance, its required by Section
3700 of they fourth. "far a the work for which this permit is issued.
GAS -EA. SYSTEM -I INC. 4 OUTLETS
OCC. CROUP
APN
My Workers nm i m ad Policy
@mer: alicy No.:
GAS - EA. SYSTEM -OVER 4 (LA)
CERTIFIfAA OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action adoor be completed if the permit isfm one hundreddollers ISM)
or less.) -
GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FRES
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM LA. 200 PR '
I eenify that in the perrarmmnce ofthe work for which this pewit is issued, l shall
not employ any penin in arty m n r us m �RRte zubjea m the Workers Cnmpen-
sauon laws of I. ria. Dat
Applicant
ENERGY FEE
WATER HEATER W/VENT/ELECfR
GRADING FEE
NOTICE TO APPLIT: ILaner making this Cen fi.rec Exemption. you should
becomesubject"t orker'a Compensation provisions of the Lahnr Code, you must
WATER SYSTEMffREATING
SOILS FEE
forthwith comply with such provisions or this permit shall b, deemed revoked
WATER SERVICE
x
' CONSTRUCTION LENDING AGENCY
i hereby mffiw that then is ncnmwnion lending agency forth. perfowance of
NEW RESIDENTIAI, PLMB. SQ. FT.
PAID
Date Remipsg
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
TOTAL.:
Lenders Address
TOTAL:
BUILDING FEE
1 eenify that I have real this application and sme that the aN ,e infnwvtion is
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
correct. l agree to comply with all city and county ordinances and state laws relating"
building construction, and hereby anthodze representatives of this city to eater also the
PERMIT ISSUANCE
ELECTRIC ME
mow,-mendonedpmpeny for inspection purposes. -
(Wc) ugrc, indemnify and keep hawless the City of Cupertino against
liabili6es,jud a s.costs and expenses which may in anyway seems, against said City
ing of t a"mon.
in ronaA
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10," CFM)
MECHANICAL FEE
NDS UWILL CO�VtPLY WITH ALL NON -POINT
SOUAIR
HANDLING UNIT(OVER I0,OI10CFM)
CONSTRUCTIONTAX
Sigsmmctor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WBIUCT)
HOUSING MITIGATION FEB
HEATING UNIT (TO 100.000 BTU)
Will the applicant or future building areupam atom or handle hamoloms material
as defined by the Capetian Municipal Code, Chapter 9.12, and the Health and Safety
Cale, Section 25532(.)?
HEATING UNIT (OVER ID0,00t) BTU)
CYes []No
in ants a building occupant use equipment or devices which
` Will the air contaminants
'emit hazardous air contaminants es defined by the Bay Area Air Quality Management
III Distrio?
CYes C] No v
PAID
VENTILATION FAN (SINGLE ftESID)
Date RaceiptO
BOILER - COMP (3HP OR 100,IXp BTU)
-
TOTAL:
r
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have the hazmdnus materials requirements under Chapter 6.95 of the Cali-
- ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. Fri.
(rands Heal am y ate, Secoy9uas� 25505, 25533 mad 25534. 1 utdernand that if the
building alta Oy haveyrlenanp that it is my mspnnsibilitym notify the acupant
of trt be met 'anoissuence nfm Ce item nfOc c.
ISSUED BY:
Owner thorizcda t vs,
TOTAL:
OFFICE