28905 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY -
CITY OF'CUPERTINO. _ BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERWT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. - s .. SANITARY NO. APPLICATION SUBMITTAL DATE
p cr tDwlCk 64Pe.)yriAra
OWNER'S NAME: )� / 1. �fPHONE: CONTTRACaTTOR'SS NAME,{ LIC NO: ' O`
T G1uI IV �rllll' I L GF///GC C U 5-75006 NIC ' CONTROL#
ARCHITECT/ENGINEER:- „ LIC NO: ADDRESS - - Q
19 . �vo. 7-illf�D 5� C,�tmP�/
CONTACT: - - - PHONE: - BUILDING PERMIT INFO
04Dtd427) 7,a,Duffy 3'74-0900 ❑ Consultant Fees Paid by Applicant(Initial) BLDG E PLUMB MECH
s LICENSED CONTRACTORS DECLARATION
QTY. ELECTRIC PERMIT FEE
_,1 hereby affirm Nm 1 am bcensed under prnvrsmns of Chapter 9(commencing 1 $DE$C IPTION.
0�'Z with Section 7000)of Division 3 oft anJ PrufesmonsCSWe,and mylicense is -- RESIDENTIAL: -
OO in full force and effect PERMIT ISSUANCE
W ❑SFDWL ❑KITCHEN REMODEL
�UV License Class Conn APPLIANCES-RESIDENTIAL ❑ADDITION Cl PLUMBING RE-PIPE
LDate,_ Contractor- '
z p y� ARCHITECTS DECLARATIONPANELS �• ❑MULTI-UNIT �❑STRUCTURAL
of • 1 unfeisiand my plans shell be used as public records - MODIFICATION i
OzrOsl _ - UPT02MAMP5
❑INTERIOR
4 tLicensed P f bnal - • CHIMNEY REPAIR
w .] 20i-1000 AMPS IMPROVEMENT t
a OWNER BUILDER DECLARATION OVER 1000 AMPS - �TH REMODEUREPAIR ❑DEMOLITION
1 hereby firm that 1 m exempt f theContractors License Law for the III _
i❑O U falls ng ir (Seep 7031.5,Busines mad profession,Cod Any city or county SIGNS ELECTRICAL ❑OTHER. '
which requires a permit to construct,trued alter,improve.demolish or repair any structure
Tartaric,its issurace.alsoacquini the applicant for such permit to fie a ii,promstatementSPECIAL CIRCUIT/MISC. as
s� } that he is licensed pursu t to the previsions of the Contractor License Law(Chapter 9
LLWWKK p0 (cont g with Section7000) fDivision J of the Business dP Professions ns Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d e rte door he is exm
ept therefrom and the basis for the alleged accumulator exeption,Any violation ofZS2 El NEW BLDG/ADDITION El DEMOLITION
Y' Section 7031.5 by say applicant for a permit subjects the i licam to a civil h f POWER DEVICES
w j pp Penalty o ❑TENANT -1 FOOD SERVICE
Qnot more than five hundred dollars($500). IMPROVEMENT
[]1,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
will do the work.and Weswnure is not intended mothered for sale(Seo.7044,Business _ []OTHER
3 and Professions Code:The Cmanetbr's'License Law data not'apply 1.an owner of OUTLETS—SWITCHES—FIXTURES
property who builds sr improves thereon,and who does such work himself or through r
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ IT,
sale.If,however,the building or improvement is sold within one year of completion,the S,Q:FT.FLUOR AREA $/SQ.IT.
wrier-builder will have the burden of proving that he did not build or improve fur pur-
• press of sale.).r , - • �.
I,as owner of the property,am.exclusively contracting with licensed contractors to OV -
construct the pro44,goriest Business and Professions Code)The Coutineuns Li- ]' qpp
case Law does nm apply to an owner ofpinpmy who mild,or improves thereon,'and QIT. PLUMBING PERMIT FEE • 2.V
who counters for such projects with a contractiand licensed persuaauo the Contractors s 1995. .!
License Law. r19A
E]l am exempt under see. -,B&P C fm thea reasan PERMIT ISSUANCE cr/k VJ- 4iJrErf f( r
ALTER—DRAIN&VENT—WATER TEAT '• s - VALUATION -
Owner - - Data
WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE o A
1 hereby affirm under penalty of perjury one of the fallowing declarations: 6
0 El I haveand will maintain a Cenmficate ofComent to self-insure for Workers Compere- DRAINS—FLOOR,ROOF,AREA,COND. STORIES- I TYPE CONSTRUCTION
samm,as provided far by Section 37M of the Labor Crede,for the performance of the "
work for which this permit is issued. FIXTURES—PER TRAP
Fl have and will maintain Worker's Compensation Insurance,as required by Section -
37M of the Labor Code,for the performance of the work for which this Permit is issued GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
nrkEr'pLpmpegi,a}ton lncos/ne nivoind Policy u �r
artier://��II 1I IWN g'j 1-sl/S•i Policy No.:MU 7I GAS-EA.SYSTEM-OVER 4(EAT i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DNISION(P.ES
(This section need not be completed if Ne permit is for one hundred dollars(SIW) GREASETRAP
' or less) PLANCHECK PBB '
I certify that in the performameofthe work forwhich this permit is issued,l shall SEWER—SANITARY—STORM EA.200 PT.
not employ any person in any manner an as m become subject to the Workers'Compen- ENERGY FEE
0 sinks.laws of California.Date WATER HEATERWNENT/ELECITt� FEE -
7 O Applicant GRADING i
G NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,yooshould WATER SYSTEM?REATING
abecome subject to the Worker's Compensation powismons of the labor Code,you must SOILS FEE
W forthwith comply with such pmvi.einns or this permit aM1xll be deemed revoked. WATER SERVICE
d 0
.'CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Er. PAID
'� 'Z hereby whicBrmpennit i issued(Seconstruction0 leading agencyfor the performance of _ Data iM
UOO Liewrerk for whichdo,permaia loaned(see.3897,civ.c.)
OVLenders Name TOTAL:
LkI Lenders Address
"~ I certify that 1 have rend this application and state that the shove information is BUILDING
to) correct I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U 4 building construction,and hereby amharize representatives of this city to enter upon the SEISMIC F E
abovemna mioncd property for inspectionurpose
P PERIOD'ISSUANCE - ELE&CGkF
- (We)agree to save,indemnify and keep hnimless the City of Cupertino against
liabilities;judgments.costs and expenses which may in anyway accrue against said City pLTERORADDTOMECH.
inconsequence of the granting of this permit I LUM111k FEE
APPLICANT DERSTAND D WILL COMPLY WITH AL NON-P NT AIR HANDLING UNIT(TO
a FEE CFM) MECHANICAL E
SOU ATIONS. n '77'
AIR HANDLING UNIT(OVER IR"CFM) CONSTRUCTI -
SignatereofApplicam/Contmctor te. EXHAUST HOOD(W/DUCT) HOUSING hIITIGATION -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material HEATING UNIT(TO IPEW BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety - '
r Code.Sermon 25532pa)?' ' ' HEATING UNIT(OVER 100,000 BTU)
C]Yes LIN. -
V NTILATION FAN(SINGLE RESID) �s PAID Date ReceiptM
Will the applicant or future building neeupanruse equipment or devices which 000 BT11)BOILER—COMP(JHP OR 100, s
r�emit hazardous air comminution,as defined by the Bay Area Air Quality Management -TOTAL: .
District? BOILER—COME(OVER 100,000 BTU)
Dyes No
'
'AIR CONDITIONER -
'I have read the hazardous materials requirements under Chapter 6.95 sf the Cali- "ISSUANCE DATE -
ica ma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the: NEW RESIDENTIAL MECH. SQ.ET. '
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Cenific to of Occupancy. a
• Ownererauthorized agent Date L: ISSUED Y. '
OFFICE.