28478 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMrr NO. ^ ,k
BUILDING DIVISION APPLICATION/PERMIT PLUMBING•MECHANICAL L 4
78
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Id
5o sLwo t5u i Tie, ' 175 ® A,;
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
. E NIC CONTROL M
CHITECHENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: LOW* Z O) BUILDING PERMIT INFO
n Q�
Consultant Fees Paid 6y Applicant(Initial) BLDG pyELy PL MECH
LICENSED CONTRACTOR'S DECLARATIIONvv1 QTY ELECTRIC PERMIT FEE fly'( 1(yJ[`
1 hereby arum that I ant licensed under provisions of chapter 9 Rammenring -JOB DESCRIPTION
woZ wird Section 7000dofIivision 3 ofthe Business and Professions Cade,and my license is RESIDENTIAL,
O PERMIT ISSUANCE ��
m full farce and effect.
Q,U Lken Lic.la ❑A DWL ❑KITCHEPLUMBINREMODEL
rF Dam Contact APPLIANCES-BSIDIiNTIAI. [-)ADDITION C1 PLUMBING RE-PIPE.
F' ARCHITECTS DEC N PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O!9 Z 1 undcrsmnA my plans shall local vs public receNs - MODIFICATION
OZ UI11'0200AMPS El INTERIOR ❑CHIMNEY REPAIR
I:4 VJLicensed Professional 20t-IMAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
yy 1 hereby affirm that 1 am exempt from the Cnntamor's License Law for the OVER Will AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Se 3 d V following revmn.(Section 70315,Business and Prufeasiow Cade:Any city or countySIGNS ELECTRICAL ❑OTHER
which requires a permit to constant,alter,improve,demolish,or repair any swcmre
.2'71 prior to its issuance,also requires the applicant fm such germirlo file.signed statement SPECIALCIRCUIT/MISC.
ythat he islicensedpursuant mthe provisioesofthe Comemam's License law(Chapmr9
CSO (commencingwith Section 7000)uf Division3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST.
dy ea pC that he is exempt therefrom and the basis for the alleged exemption.Any violation of W BLDG/ADDITION ❑DEMOLITION
Scathed 7031.5 byany applicants,.pandit subjects thuapplievmma civil penalty of POWER DEVICES ANT ❑FOOD SERVICE
gYY.17 t more than five hundred dollars($500). I OVF.MENT
pZpQ ❑ 1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC'
C$ will do the wml use structure is not intended oroffered for mle(Sec.7044 Business ❑OTHER
P.�33• end Professions Code:The Cont. -License Law does not apply to an owner of UTLETS-S W ITCHES-FIXTURES
pmpery who build,m improve. clean, who does Inch.wool,himself of through
his own employees,provided at such impro eats are net intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
salcHhoweveethe buildi orimprovememisso sill irioncyeanfeoard,lion.the SQ.Pr.FLOOR AREA LSQ.FT.
owner-builder will hav a burden of proving the 'd not build or improve for par- ve
Ca aas own the,, r.7 .am axil in ith licensedrimiatmrsi- L:
nstm Project(Sec.](thy Halt .The ici thecae's Li-
cense awd«snotapply muno buil im'ortha marso end QTY. PLUMBING PERMIT FEE
who. facts for such project to o pars ue Ne COmactor's
Licen law. u an PERMITISSUANCE
1 a exempk.Rder P C for this mason
Owner - 1e ALTER-DRAIN&VENT-WATF,R(FA) VALUA/T��q'N�
R T M ATION DECI BACK FLOW PROTECT.DEVICE I/C�a `� r•
the yafii�tn uaJ ea perjury one of he I mgdeel i ` V
•I]llail an illmaihteia msec cf Cnnaenu s -i s re
ark is Camper- DRAINS-FLOOR,ROOF,AREA.COND.
moon;m prov ed for by'S on 3'100 i f the t f the STORIES TYPE CONSTRUCTION
work for which t 1 pe s issued. NF DeT4trmance o OPV RES-PER TRAP
❑I have a.d wil sin Worker's Co tion In e cy ♦q✓cored by Section _
370044.Labor Code,hurdle perfor m Rti�is perm it is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier two u1 I'll
Cartier. Po yNo.: GAS-EA.SYSTEM-OVER 4(EA) ,\/\
CERTIFICATE OF EXEMPTION FROM WORKERS' - `\e '
COMPENSATION INSURANCE GREASHANDUSTRL WASTE INTERCEPTOR
BUD. N.D ISION FEES
(Thisscetinn need mol becompldWif the permit is fnnmc hundred dollnrs(EI001 GRHASEI'RAP
or lewd PLANCHECK FF
I cenifythat inthe rf..a..fNcworkforwhichtho pens,is issued,l shall SEWER-SANITARY-STORM EA,200 FT.
not employ any � a)y manner• ^. e t s the Workers Comped- ENERGY
z ,z moon laws u alild co WATER HEATER WNENT/ELF.CTR
,0 Applicant - GRADING
NOTICE TO APPL7C,NT.IL after making this Ce ¢to of Exemption.ywashruld WATER SYSTEM?REXONG
E-! become subject to the Worker's Compensation prow m of the Labor Code you arm" SOI
{pS.lt fonhwith comply with such provides s.r this permits all be deemedrevnked. WATER SERVICE
CONSTRUCTIONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ,PRI
R PAID
V Q thereby effitm Nat thenem is is aconstruction lending agency for the perfarm.ttce a( Date ReceiptM
the work for which this permit is issued(Sec.3097.Civ.C.)
QLender's Nome TOTAL:
L�L1 LcndcOAddmss : t
G. 1 rarity that I have read this application and swat Nut the above information is BUILDING FEE
fA cormc0 l agree to comply with all city and county ordinances and start lows mating to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby authod.e representatives ofthis city to enter upon the SEISMIC FEE
above-memional property for inspection purposes. PERMIT ISSUANCE
(We).Me losave,indemnify and keep bmmless the City of Ctmethi a again F1 m 11, ELECTRIC IRE
liabilities,judgments.costs and expenses which may in any way accrue against said CityALTHRORADDTOMECH.
on
in csequence of the gaming co'dur permit. i PLUMBING FEE
APPLICANT I' .RSTAND IL COMPLY 'H r LL NON-PO T IR HANDLING UNIT(T'O M.WOCFM) MECHANICAL FEE
SO' .1 TIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCIONTAX
Si of
HA2ANntlContr.DOUSMATERIA.S DI CLOS aor et EXHAUST HOLD(WOUC) HOUSING MITIGATION NE
and)
Wily the Ch
or(.sent building occ pants tred,1andte Health ad Safety HEATING UNIT(T'O 100,000 BTU) Rpt
es Defined by the Cupertino Municipal Cale, apse 9.12,.nil the Health unJ Safety Aii
Crile,Section 25532(x)? HEATING UNIT(OVER IOEODD BTU)' v
❑Yes ❑Nn P
VENTILATION FAN(SINGLE RESID) a Receipt
Will the applicant or future building occperm use equipment or devices which Militia BOILIiR-COMP(3HP OR IBO,IKKI BTU) ry
DituhavNotn air contaminant as define)by the Bey Arev Air Quality Mawgement ,! / TOTA .
Distrieq
❑Yes ❑NB BOILER-COMP(OVER 100,000 BTU) I- a" t1 I1
I havemad the harardnus materials requirements under Chapter 6.95 of Be Cali- AIR CONDITIONER - ISSUANCE DATE
forma Health tit Safety Code,Sections 25505,25533 and 25534 1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT.
building it...commily have.mount.data is my responsibility to notify the occupant
of the Requirements which must he met prior to issuance of a Certificate of Occupancy.
Ownero rotimrimdagem Data or ISSUED BY:
OFFICE