28770APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
•❑
0
PERMITNO. ^ O
BUB,DING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIFICATION
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BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DAT[
L�
OWNER'S AME: PHONE:
CONTR C'IOR'S NAME: LIC NO:
v b�f3
N/C
❑
CONTROL
ARCHITECT/ENGINEER: LfC NO:
ADDRESS: 4410 r arK,1..�.lV `
row U
CONTACT: PHGNE:
BUILDING PERMIT INFO
1 �6 Cay) �e+ O efT') Qirpen
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
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a�f Wi.N "gv0 (G3 Ga--a/lJ
.
❑ ❑ K
LICENSED CONTRACTOR'S DECLARATION
1 hemby all that l am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Section 7000).& Division 3mflhe Businessman Professions Codc,aod my license is
in full force and eff 3
License Cles � _ C.m Amw
Dam Comracmr
RESIDENTIAL:
CSFDWL C KITCHEN REMODEL
El ADDITION ❑PLUMBING RE -PIPE
APPLIANCES- RESIDENTIAL
' ARCHITECTS DECLARATION
I understand my plans shall be used as public renxdx
RAL
❑MULTI -UNIT C MODIFICATION
MODIFlCATION
INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
PANELS
UP TO 2W AMPS
Licensed Pmfessianal
201.1000 AMPS
OWNER-RUELDER DECLARATION
1 hemby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Sutinn 003 L5. Business od Professions Code: Any city or county
❑BATH REMODEVREPAIR (]DEMOLITION
❑OTHER
OVER Iqq AMPS
SIGNS ELECTRICAL
which requires a permit to consumer, alcor, improve, demolish. or repair any structure
prior to its isterace,alm requiresthe epplicam for such Permit file ssigmu,mmmenl
SPECIAL CIRCUIT/MISC.
that he is licensed pursuant the provisions of the Commences License law (Chapter 9
TEMP. METER OR POLE INST.
COMMERCIAL:
(commencing with Section7000)of Division 3 offle Business and Professions Crueler
that he is exempt therefrom and the basis for the alleged) exemption. Any violation of
C NEW BLDG/ADDITION C DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant m a civil penalty of
POWER DEVICES
VTENANT ❑ FOOD SERVICE
not mom than Bee hundral dollars ($500).
❑ Lmaownaafthe pmpenyI or my employees with wages as their sole compensation,
will dmhc work, and the al or isnatimendw oro rW for snle(SecJfH4, Business
/''
IMPROVEMENT
COTHER
SWIMMINGPOOLELGCfRIC
and Professions Codc: The Cnmmcmea Li enew law oes not apply to an owner of
property who builds or improves thereon, a ch work himself or through
OUTLETS -SWITCHES -FIXTURES
his own employees, provided that such imp odd oat nded or offered for
sale. IL however, the building orimprov t dwlllmir fnmmpleion, the
NEW RESIDENTIAL ELECDI SQ FT.
-
SQ. FT. MOOR AREA
ASQ. FT.
nerbmider will hover M1UNcn thathedidnjll�tdn'mpmveforpar-
pose fmle.). 11 eaa V�
❑ T. o owner of the xdusi ly ctda1," ith licensed contractors to
answer the project (Sec. usi est P/P4 s Code:) The Contmctnes Li.
owner
'
TOTAL:P
cense Law Ares not npplY lou of pl sywbo builds.1impoow thereon, and
QTY. PLUMBING PERMIT PEE
whncamnenfo"coln project th ncnor ads) Reserved prrauam to the Contmetoex
Q'
PERMIT ISSUANCE x
License law'
C lam exempt undo Sa.' B& P C for this reason
.
ALTER - GRAIN & VENT -WATER (LA)
_
Owner Onto
VALUATION
I
v -fes Q 0 V
- WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hemby affirm under Penalty of perjury one of the fallowing declarations:
l.J
Thaw and will maintain a Certificate of Consent to self-insum for Workers Compcn.
sation, as provided for by Section 37W of the labor Code, for the performance of the
work for which this permit is issued.
DRAINS- FLOOR, ROOF, AREA, COND.
SsFGRI
TYPE CONSTRUCTION
L
FIXTURES - PER TRAP
have add will maintain Workers Compensation Insurance, m required by Section
7U10oflhelaborCode,fm they munarew of the work for which this permit is issued.
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROUP
APN
My Worke s ympepsgtiea Ip. J� wrier and Policy
Cartier: /MR�u Policy No.: nu
GAS -EA. SYSTEM -OVER 4(EA) -
GRF,ASIVINDUS'IRL WASTE INTERCEPTOR
CERTIFICATE OFEXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section new not becompietw ifthe Permit is for one hundred dollars ($100)
or less.)
GREASETRAP
PLANCFTECK FEE
I certify that in the performance ofthe work for which this permit is issued, Isall
cot employ any person in any manner so as m hecome mbjem nc the Workers' Camper-
SEWER -SANITARY -STORM EA, 200 IT.
ENERGY FEE
WATER HEATER WNENT/ELEC'TR
odium laws of C.1ifo rd.. Date
Applicata
GRADING IEE
NOTICE TO APPLICANT. If, one, making this Contreate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
WATER SYSTEM/BEATTNG
_
SOILS FEE
foMwith comply with such provisions or this Permit shall he deemed meadow.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm float here is a construction lending agency for the Performance of
NEW RESIDENTIAL PLM9. SQ. PT.
PAID
Data ReceiptN
Ne work for which this Permit is issued (Sec. 3097, Civ, C.)
Undoes Name
TOTAL:
TOTAL:
Lenders Address
BUILDING FEE
I certify that 1 have read this application end siote that the above information is
ca.=1. I ugra on comply with all city and county ordinances and state laws teluling to
building construction, and hereby authorise representatives ofthis city to enter upon the
above-mentioned pmperty for inspection purposes.
(We) a,. muse, indemnify and keep harmless the City of Cupertino against
QTg MECHANICAL PERMIT FEC
}q N
SEISMICFF.F
ELE "E
1995
PERMIT ISSUANCE Q7
Iia,o ieiroljarmenms, costsunJea Fsewhich mayor any way accrue against mid City
in edit.. - s n6 oft' pans .
APPLIC IND .25 \ ❑) TILL OMPLY WITH ALL NON -POINT
SOU ERF ,UL. TIO
ALTER OR ADD TO MECH.
2
PLD `2 0
.J 0
ry b
9,q; VI"�L FEr I,, 11711 O V
AIR HANDLING UNIT 10,000 CFM)
AIR HANDLING UNIT (OVER 110,000 CEM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT]
HOUSING MITIGATION IEE
Signamrto pp reanVC Dam,
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (70 100.000 BTU)
Will the applicant or boom building occupant store or handle ha arduus material
as defmaw by the Cupertino Municipal Code, Chapter 9. 12, and the Health con Safety
Code, Section 25532(m)?
CYes 00
(future
HEATING UNIT (OVER I W,(1011 BTU)
R
PAID
m Rurip a
VENTILATION FAN (SINGLE RE SID) -
Will the a licmt or building ..part use a em or devices which
PP S pan .Air
emit hmardous air conutninavta'ss definW by the Bey Area Air Quality Management
IF
BOILER-COMPOHPOR IW."BTU)
TOTAL: y OV
BOILER - COMP (OVER I W,00(l
Theme?
❑Yes 70.
AIR CONDITIONER
I have read the haxnrdous materials mgmmurams under Chapter 6.95 of the Cah.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. M.
fomlu Health & Safety Code, Saclimas 5505, 25533 and 23534. 1 understand that done
building does hot currently have nomad, that it is my responsibility mmud,mhe ucco,nt
of the "marrouts which must be met prior as issuance of a Certificate of Oecupmey.
t 1� aQ
ISSUED BY: -„0� • '�� a
TOTAL //O
Owner m.wham edugon - Data
OFFICE