28765 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION - APPLICATIONIPERMITPLUMBING-MECHANICAL.
28765
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANH.YNO. APPLICATION SUBMITTAL DATE
O3 0 R' q.._q r 5.
OWNER'S NAME: PHONE: C N ACTOR'S NAME: LIC NO:
M
r: — L NIC CONTROL g
ARCHITECf(ENGINEER: LIC NO: ADDRESS' ❑
L i
CONTACT: ' ' - PHONE: BUILDING PERMIT INFO
❑ Consultant facet;Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ Di '
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOE DESCRIPTION
Gcalz with Section Division 3 of Ne Business and Professions Code,and my license is RESIDENTIAL:
�00 w PERMIT ISSUANCE
W full farce and egret. ❑SFDWL [I KITCHEN REMODEL
�FUz6l License Class Cmin APPLIANCES-RESIDENTIAL a []ADDITION ❑PLUMBING RE-PIPE
N<Y DntC COatreclar
�y ARCHITECTS DECLARATION .PANEIS ❑MULTI-UNIT ❑STRUCNRIO
Z, Z 1 understmtd my plans shell be used ax public reeord.v CHIMNEMODIFICY
REP
OZ.FF... UPT0200 AMPS El INTERIOR ❑CHIMNEY REPAIR
r,4 q Licensed Profeasiored 20i.1000AMPS - IMPROVEMENT '
+!! ...•llll OWNER-BUILDER DECLARATION OVER IWO AMPS DEATH REMODELIREPAIR [IDEMOLITION
I hereby affirm that 1 am exempt from the Contrsctnh License Law for the ❑OTHER
x 6U following mason.ISeelloo]031.5,Busiasas and Professions Cade:Any city or county SIGNS ELECTRICAL
tnrJJ 3{e which manures a permit to conswn,alter,improve,demolish,or mpair nny stmnure
�1y prior to its issuane,itis,ax,mestheapplicat for such puma..fife.signed statement SPECIAL CIRCUIT/MISC. -
,','��,,{{i that he is licensed pursuant to rhe provisions of Ne Contractor's License Law(Chapter 9
nZOC (commencing with Section 701101of Division 3 areae Business and PafeuionsCde)01 TEMP.METER OR POLE INIT. COMMERCIAL
Gp,e K
that he is exempt Nemfrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'Xm Section]031.5 by imyapplicuntfar.permit subjects the.pplicam to a civil penalty of 'POWER DEVICES - '
W y ❑TENANT ❑FOOD SERVICE
== not more than f vb hundred dollars y employees
Q ❑L1smoas owner of altha scny,mmyct amalo wlthwages as ne(Sm. 0,14.8 sines SWIMMING POOL ELECTRIC IMPROVEMENT
awillnd Bothework,ander he Comis un inteddor Law
dos not apply to
ma Business 0I OTHER
and Professions Code:The Convenors License Law docs not apply s if owner of OUTLETS-SWITCHES-FIXTURES
hpropertyis own who employldsees,
or improves thereon,improvements and who docs mch work himself of through - -
W own employ,the providd Nut such artisoldw Arc not intended m pHCred for NEW RESIDENTIAL ELECTS SQ FT
'
We.If.haweveq the building orimtoverrcmis sold within tine,tarot completion,the - SQ.FT.FLOOR AREA E/SQ.FT.
owner-hadder will have the burden of pursing that he did not build or improve for poo
pose of sale.).
El as owner or the property.um exclusively contracting with licensed contractors to TOTAL: h
,construct the project(Sec.7044.Business and Professions Code: a mracmrs Li- .b" p
cense law does not.pplyben owner of pmpcny wan builJa rmprovc neuron,and QTY, PLUMBING PERMIT FEE a"i ®®
who contacts fm such projects with.commit ficense ursuamb.th, bnewcou"
License Law. PERMIT ISSUANCE P
E] 1 um exempt under Sec. ,B&P C fur t is mason
ALTER-DRAIN&VENT-WATERGIA) C/Tr LUATION
Owner Dam
WORKER'S COM SATION DECLARATION BACKFLOW PROTECT.DEVICE
Ihereby.ffino un der y of perjury one of the following declaration: 4
El I haveand will main aCCnificmeof Cunsenaomlf-insumfor Workers Ce pen. DRAINS-FLOOR,RODE AREA.COND. STORIES TYPECONSTRUCION
sotto.,as em deadr.dlor
Section 3]00 of the Labor Code,for end pertnmmnce fine
wmk furwhichthiit is issued. FIXTURES-PERTRAP
I have end wiluin Worker's Cnmpelsson Insurance,as require)by Se tion
3]W of Ne LaMv the perinrrtunec of the kfor which this permit is is ed CAS-EA.SYSTEM-I INC.40UTLETS OCC.GROUP APN
My Worker's Coma.Insurance clrti and y number am:
Grrier: 'c GAS-EA.SYSTEM-OVER 4(CA)
CE TIFICATE OF EXEM 1 OR
COMPS SA RA C !- GREASEIINDUSTRI.WASTF.INTERCEPI'OR
BUILDING DIVISION PP.BS
ITiksectio need. bcco tp th )s ort hundred ars(EIO(B GRFASETRAP
orlas.) PLANCHECK FEE
I emit,Nm he .meofN to hichlhisp titisissud,ishall SEWER-SANITARY-STORM F.A.2W FT.
note
any pe n in an o as thoecome subject he Workeri Compen- ENERGY FEE
0 ,7. sation Laws of Cull arin Da tpners WATER HEATER W/VENT/ELECTR GRADING ME
Applicam
E y NOTICE'TO APPA ANT:IL ehcr making this C icme of Exemption,you should WATER SYSTEM/IBEATING SOILS FEE
E'4 become mbjat m th Workers Compemmi.. isions of the Labor Cade,you must
l W fnMwith comply wit suchpmvimmasor Ni .nit shall he Jamedmvnked. WATERSERVICE
Q
NSTRU NLENDINGAGFNCY NEW RESIDENTIAL PLMB. SQ.FT PAID
z Data Receip ll
U O Ihcreby effrm Nat s a construction lending agency for the performance of
the work for which this permit is Issued(Sec.3097,Civ.C.)
u" Leede/s Name - TOTAL:
'0 U Lendi Address TOTAL: -
�+ D1 BUILDING FEE
F certify that I have maJ Nis application end state that rheobase infonnedon is
h
correct.Isame,to comply with all city and county ardinences and sum laws minting to QTY. MECHANICALPERMIT FEE SEISMIC FEE
U building construction,and hereby authorize representatives of thi.s city in enter upon the
above-mentioned pro,emy for inspection purposes. PERMIT ISSUANCE
(Wel agree to save,indemnify and keep hamdess the City of Cupertino against ELECTRIC FEE
liabilities.judgments,oasts not expenses which may in any way acerue.,timet said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this pmnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) MECHANICAL FEE
S CP.REGULATIONS.
1 � AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCDON TAX
Si stere ofApplusuffConturstor ate EXHAUST HOOD(W/DUCT) - HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant stem or handle hazardous material HEATING UNIT(TO 110,010 BTU)
u defied by Ne Cepenlao Municipal Code,Clingier 9.12,and the Health and Safety
Cdc,Section 25532(x)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes I]No VENTILATION PAN(SINGLE RESID) PAID pate RecciptM
W II the applicant or future building occupant use equipment m devices which
emit hxzallous air contaminants as defined by the Bay Area Air Quality Managemna BOILER-COMP(3HP OR 100,(100 BTU)
District? -BOILER-COMP(OVER I W."BTU)
❑Yea C]NO
1 have read td hazudmu mmcrials is under Che fi 95 of the Cali- AIR CONDITIONER - ISSUANCE DATE
inquire pier _
(curia Health&Safety Code,Sections 25505.25533 and 25534.1 udersund that if the NEW RESIDENTIAL MECH. SQ.FT.
building does oro curten0y have a tensnL that it is my msponsibibly m notify the necupera
of the requirements which most M ern prior m issuance of a Cedifcateof Oceu Wney.
Ownamiundmiadagcm Date ISSUED BY:
OFFICE