28869 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL28869
BUII.IIING PROJECT IDEN'FIFICKr10N
BUILDINGADDRESS. SANITARY N0. APPLICATION SUBMITTAL DATE
45 'S
OWNER'S NAM - PHO E: CONTRACT9J+'S NAME: LIC NO'.
e 2 838 qLp C= NIC CONTROL It
\ CHITHUI'ZUINELR: LIC NO: ADDRESS: ���Z
e 7- o o $ 22 .A < 3. S1
In oNTACU PHONE: - BUILDING PERMIT INFO
6 JO O Consultant Fees Paid 6y Applicata(initial) BLDG ELE PLUME MECH
LICENSED CONTRA OR'S DECCLARAT'ION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nm I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aZ with Section 7")ofDivision 3 ofthe Business and Professions Crile.and my license is PERMIT ISSUANCE RESIDENTIAL
ID NTIAI.
1py�O O
f-Iy in full farce and affect. ❑SFDWL El KITCHEN REMODEL
�U License Class LioO APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
G Date Cmarecou
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
C2�774 (understand my plans'lol be madrispuhlicme"ON PANELS MODIFICATION
UP TO 200 AMPS [I INTERIOR E3 CHIMNEY REPAIR
a,�1"'Iq�i Licensed professional ,201-IWBAMPS IMPROVEMENT ,
aQ OWNER-BUILDER DECLARATION OVER LBW AMPS [I BATH REM D EPA( DEMOLITION
W 6 I hereby affirm that I am exempt from the Commemr's License Law for the
O y eU. following reason.(Section'](131.5,Business and Professions Codo Any city or county SIGNS ELECTRICAL ❑OTHER
F tr.�y which requires a Permit w coast.",alter,improve,demolish,or repair any structure
!� prio"O its issuance,also mouires the applicam for such pertiJOo file a signed statement SPECIAL CIRCUIT/MISC.
�} that he is licensed Panama to the provisions of the Cimossamrx License Luw(Chapter 9
apo (commencing with Section 11010 of Division 3 elthe Rosiness aadl'odessions Cudal or TEMP.METER OR POLE INST. _� COMMERCIAL:
a e eC Nat be is exempt therefrom and the basis for am nllegcd saemptinn.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
k, Section]031.5 by anyapplicant fora permit subjects the applienon,a civil parity of POWER DEVICESMm ❑TENANT ❑FOOD SERVICE
�. manture than five hundred dollars($500), IMPROVEMENT
G01,mowner of the propcny,or my employees with wages as their sole compensation, SWI MMI NO POOL.ELECTRIC
will do the work,and the stmdure is not intended oroRertd formle(Sec.]pi4,Business ❑OTHER
soand Professions Cade:The Contractor's License law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES.
lempeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ P-L
We.If,however the building or improvement is sold within one yearnfcompleBoothe SQ.FT.FLOOR AREA 9SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pouofildeJ.
❑ Las owner of the property.em exdmively contracting with licensed eontracmom TOTAL: RT L\ 11 RT
construct the Interior(Sec.]014.Business and Professions Code:)The Convectors Li-
cane Law does not apply to an owner of pmKny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a connmeoas)keened pursuant to the Contractors _ OCT '1 f1 199
License Law. PERMIT ISSUANCE (� .L (J k�
❑ Ium exempt under Sec. .B&P C me this room. AL
AL'I ER—DRAIN&VENT—WATER MA) LA UC VUI'Cli Ij UV TION -
Owner Date V
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I lately from under penalty of perjuryone of the following deelma imms
I have and will mainwin a CeniOcme'if consent to self-insure for Worker's Compete DRAINS—FLOOR,R0017.AREA,COND, STORIES TYPECONSTRUCTION
-nation,ses providW for by Semon 3700 of the Labor Code,far the performance of the
work for which this parnm is issued FIXTURES—PER TRAP
❑I have and will maintain Worker's Compensation Insurance,is required by Section'
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS—PA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Immm me camor it policy number are:
Cartier Policy Nn: GAS—PA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSIE WXSTE INTERCEPTOR
BUILDING DIVISION FEES
This section need not becomple,ed Urns,pcmtit is fur one hundred dollar(Elfxl) GRGASETRAP
or less) PLANCHECK FEE
Loy any that in the offormiany
of the work for subjecth t it)
the W res Compall S RY—S ORM EA.
' not employ any Person in any manner so as m become mbjen m the Workers'Cnmpen- ENERGY PEE
,Z radon laws of Califomia.Date HEATER W R
7�7 Applicant GRADING FEE
t�a NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WA ,Y R.A NG SOILS FEF,
become subject Ne Worker's Compensation provisions of the Labor Cale,you must nhwithcomro
only with such pvisions rmit Or this Peshall be deemed revoked. WATERS E
fo
Q
U Z CON
stthem REJECTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.17, PAID,
U work
which
hthis ouhere isammSee.30lending agency for performance ofW. Uate R xpt
the work for which this permit is issued(Seo.3(19],Civ,C.)
0[—t lenders Name AI.:
U Lenders Address TOTAL:
d1 certify that 1 have tend this application and state that the shove information is BUILDING FEE
h correct.l agree to comply with ail city and county oninances and state laws rtlming to QTY. MECHANICAL PERMIT FEE
U Z building convection,and hereby authariu representatives of this city mentor upon the SEISMIC FEE
I above-mentioned Property for inspection Purposes. PERMITISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino again [MECHANICAL
ECTRIC FF.E
liabilities,judgments,costs and expenses which may in any wayacemeagains,said City ALTER OR ADD T'O MECH,
in conuquence of the grunting of this permit. UMBING FEC
APPLICANT UNDERSTANDS AND WILI, .OMPLY WITH ALL NON-POINT AIR HANDLING UNIT('10 10,WOCFM) FEE
SOU CB RI ;ULATIONS. /D JIZ9AIR HANDLING UNIT(OVER 10,000 CFM) N$TRULTIGNT X
fAppli nV ons tar 1 toEXHAUST'HOOD(WIDUCD USING MITIGATION E
7A )ODS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 HTU)
as defined by the Cupeninn Municipal Cade,Chapter 912,and the Health and Safety
Code.See0on 25532009 HEATING UNIT(OVER 00.000 BTU) i
❑Yes - ❑No PAID
VENTILATION FAN(SINGLE BESIDE � Date Recur tN
Will the applierm or furore building cumpant me equipment or devices which -
,it hara7doua air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP DHP OR 100,fXp BF,)
TOTAL:
u,nc,7 BOILER—COMP(OVER 100,0011 BTU)
❑Yes ❑No
I have resd the hazardous materials m mrsocnts under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
o forma Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that if the
Wilding does not currently have a reason,that it is my responsibility to notify the Occupant NEW RESIDENTIAL MECH. SQ.FT.
of the"iderve ra which mus,be met prior no Toone of a Certificate of Cocupancy.
Owner or authorized agent Date TOTAL I ISSUED BY:
OFFICE