28490 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL - PERMITNO. �a ^ ^S 0
BUILDING DIVISION APPLICATIONTERMIT PI,UMBmG.MECHANICAL 28 9
BUILDING PROJECT IDENTIFICATION
AINGADDRPSS: SANITARY NO. APPLICATION SUBMITTAL DATE
(N}ERR'S NATE: /+ PHONE: MI'RACIOR'S NA LIC NO:
J L O { {--,, MT Y NIC - CONTROL#
A0.CHITECT/FNGIN. R: LIC NO: ADDRESS: ❑ / �1
CONTACT: PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by APplic r l(Initial) MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
d'Z with Section 7")of Division 3ofthe Business and Professions Cade,and my license is RESIDENTIAL
�� full to.oral affect. PERMIT ISSUANCE
CSI„' m". ❑SFDWL ❑KITCHEN REMODEL
aU L once Class Lic.# ,
ks..Z me Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
N=y ARCHITECTS DECLARATION - PANELS ❑MULTI-UNIT ❑STRUCTURAL
p1g...yy a I understand my planshhell be used es public records - MODIFICATION
Z=f� UPT02WAMPS ❑INTERIOR [I CHIMNEY REPAIR
r41-YI Licensed Pmfcmmul 201-I000AMPS IMPROVEMENT
,ej0, OWNER-BUILDER DECLARATION OVER 1000AMP5 [3 BATH ftEMODEIIREPAIR [I DEMOLITION
yCC O0 < I hereby affirm that I am exempt from the Cootracmrs License Law for the
x36U following bournn(Section 0031.5,Business and Professions Code:Any city mention, SIGNS ELECTRICAL []OTHER -
tY LL O which requires a permit to construct,otter,improve,demolish,or rcpvir any x tura
poor to its issuance.also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUITINUSC.
y�} that he is licensed pursuant to the provisions ofthe Cotnmctors License Law(Chapter9
g00 Lmommeming with Sadon]0W)of Division 3 ofthe Business and Pmfession.x Code)or TEMP.METER OR POLE INST COMMERCIAL
Lc eq that he is exempt therefrom and the basis for the alleged exemption.Any violation of 11W BLDG/ADDITION C1 DEMOLITION
n It Section 7031 S by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
^y - ANT ❑FOOD SERVICE
m more than five t h ndredprops ry.or
rmy em). IMPROVEMENT
6 ❑Lo(be work.
. the property,or my ma
with wages rsaile solo compenmtion, SWIMMING POOL ELECTRIC
0 coed(do the work,end the structure isnm imendcJ proffered Rotate usmness ❑OTHER
tl6b6b6b end Pnfexsionx Code:The Contractors License Law does #Ply w an o ncr of OUTLETS-SWITCHES-FIXTURES
^ property who huilJa nr improves thereon,and who ch wort himxlf or I rough
his own
cmployas,pro ements me not intended m Wlc J for NEW RESIDENTIAL ELECTR SQ FT. '
sv1e.ILlm ever Ne Jding or improvement is sold within one year ofcomplef n,the - SQ.FT.ELOORAREA $/SQ,FT.
owncr-buildcrwili ave the burdaofproviag Nat he did not buiidmimprove mpur-
puce of sale.).
❑1,es owner of be pupeny,em esdi sively contracting with licensed com mrs m #� �r4
convect the proj 0(Sec.)0 W,Business and Professions Crde:)The Con ors Li- w�
cense Law does n tapply m on owner ofpropeny who huilds or improver the an,and QTY, PLUMBING PERMIT FEE I� -
whreoner ctsfor. ch pmjecu with u corresponds)licensed pursuant to the Cm tractors L
License Law. PERMIT ISSUANCE 0 _
❑Tam exempt tit cr Sm. - ,B&P C fiau tough
o� 99
Owner Data ALTHR-DRAIN&VENT-WATIER(EA) W&I VA ATION
Adak, ORKE COME : S O RATION BACK FLOW PROTECT.DEVICE
Ihercby of and ty to o fN h 'ng dttl urians:
❑Ihave vndwill air earl-asure or Wer ACompen- - DRAINS-FLOOR,ROOF RG,COND. STORIES TYPE CONSTRUCTION
moon,as pmviJaJ m by S cti,m W of the Labor Code,for the ped, m nee of the
work for which Too permit iss ed. FIXTURES-PE
❑I have and will eIrwin kers Comportment Insurance,as r,a by Section
3700of Nelabor ode,fnr Ne perfarmvnce of the work fur which Nis permit ix issuW. GAS-EA.SVS 1 .6 OUTLETS OCC.GROUP APN
My Workds Co cation Insurance carrier and Policy nu eR:
Cartier. Policy GAS-EA.SY. . -OVER Ato, ,
rRTIFICATEOFEXEMPTI OM WORKERS'
COMPENSA INSDRANCE GREASFIINDUSTNL WASTE INTE 0
ES
(This se tion mednot be< eredifthe permit is forma hundred dollar 011W) GREASE TRAP BUILDING DIISION FE
or less.) PLANCHECK FEE
keno( that performance ofthe work forwhich this permit is ismul.I shall SEWER-SANITARY-STD EA
not employ any son in any manner so as to becomesubject subjeco the Workens'Compen- ENERGY FEE
Z xamm Laws of California.Date WATER HEATER WNENT/ELEcT
O7O Applicant GRADING FEE
G s~N.x NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTF.M?RC•ATINC 14
abecome subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
{la forthwith comply with such provisions or this permit shall be clamed mvoked. WATER SERVICE
C1
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. SQ.FE PAID
V O Ihercby affirm That herc isanmstmetirn lending agency for the perfonnnce of Date/
Receipt#
pn the work for which this permit is issued(Sm.300D,Civ.C.) TAL:
Lenders Name
O C.) Lenders Address TO
W 1 certify that 1 have read Nix application and state that the above information is BUILDING
CA cortem.I agree m comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
L) Z building construction.and hereby authorize representatives of this city to enter upon the SEISMIC
above-mentioned property for inspection pmpoxs. PERMIT ISSUANCE
(We)agree m save,inuemnify and keep harmless the City of Cupertino against ELECIRI IEE �-
Iiabilities,judgments.costs and expenses which may in anyway accrue against said City ALTER OR ADU TO MECH. PLUMB GFEE
in consequence of the granting of this permit.
APPLICANT UNDP STA DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IE"CEM)
SOURCE REGU NS MECH NICAL FEB
$' AIR HANDLING UNIT(OVERIO,0IXI CM) CON RUCTIONTAX
'ignaturcof App mm/Cmrwwtor Data EXHAUST HOOD(W/DUCO HOU MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building medium store or handle hazardous material HEATING UNIT(M 100,000 R'TO)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(s)p HEATING UNIT(OVER 1OO.WO BTU)
❑Yes FT No VENTILATION FAN(SINGLE RESID) PAID
Dam - Receipt#
Will the applicant or future building em.pant um w uipmem or devices which
emit hazardous air conmmimmox us defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 1(0,000 BTU)
District? BOILER'-COMP(OVER 1I0,0001,TU)
❑Yrs ❑No
Ihave read the hnardous mateHals rtquitemcnd under Chvp¢r fi.95of Ne Cali- AIR CONDITIONER ISS NCEDATE
forms Iicahh&Safety Code,Sonans 25585,25533;rad 253M.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. -
building does oat currently have a tenant,that it is my responsibility to notify the occupiers
of the requirenums which must be met prior to issuance of a Certificate of Occupancy. ,
Owner or amho cad agent - Date TOTAL: ISSUED,
OFFICE