28941APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING - ELECTRICAL
PLUMBING-MECHANIC
BUILDING DIVISION APPIACATION/PERMIT M
- BUILDING PROJECT IDENTIfICA'fION
PERMITNO.
28941
BUILDINGADDRESS:
3 / ..D c �N z,is e r _C (
SANITARY NO.
APPLICATION SUBMITTAL DATI
to zrc q6
JL�2227
OWNER'S Nr� _ 111NE: �S C
L.7
Cq _ NAr1B_ LIC 7403/
NIC
CONTROLp
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❑
4RCHITECT/ENGINEER: _LIC NO:
APE s: 6o�L�• 0
`L o
CONTACT: PHONE: ,
BUILDING PERMIT INFO
'
❑ Consultant Fees Paid 6y Applicant (Initial)
BLDG ELECT .PLUMB
ECH
❑ ❑ ❑
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
nolo Section IIlW)of Di'cionlnf�eBusiness and PmfessiotlyCoyle, xnd my license is.
full( eadd effect 22 Y(i3
LicroseC ass Lich
One Contmcmr
ffECT'S DECL f
1, undeaWnd my plans shall be used as public records
QTY ELECTRIC PERMIT FEE
DESCRIPTION
WL ❑ KITCHEN REMODEL
ADDITION ❑PLUMBING RE-PIPE
�MUUMUNIT ❑STRUCTURAL -
MODIFICATION
PERMIT ISSUANCE
gppLIANCPS-RESIDENTIAL -
PANELS ,. t,
OZ aO
UPT02MAMPS
[I INTERIOR _ (3 CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ 'EMOLITION
ER
F121pul
,gg •�]
yGy 0 C�
Dd3tYU
YY1I O
Licensed Profeasianal
OWNER-BUILDER DECLARATION Commences
I meso affirm that 1 1. exempt from the Canons Co License Law for the
whicfolloh Code: Any city., muum
requiresa ceaion ]OJLS, Business and improve, repair any swcture
which requim a slag improve, demolish,
demolish.
mates
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
-
�fj-.
e. ma de the file
men mes ices
SPECIALCIRCUIT/MISC.
2y�j phi.
Inonoioiunsedpilound... et... i,iicmtfoe cmuratir Law(wuommt
Law (s
that he it licensed pSection7
the Cdnwmorand
TCMP.MEFER OR POLE INST.
,
COMMERCIAL:
O NEW BLDG/ADD ION O
OCO�'hat
6
) ofDisision 3 Code)laam
ofbasisone th al Business and Professions Anyvi Code) or
Prof
(commencingwith Section 7") and
that he is exempt Werefrom and tar .psis for the alleged exemption. Any violation of
he
POWER DEVICES
rat
'J-=O❑Lo
3
Sector fl 7031.5 by hundred dollars($50 mil subjects the upplicvnunacivil penalty of
M more lone Esc hundred dollars y employees
the work, thepesmictrmyemntendewithwages rtale(soleSm. compensation,
de: Ile Ctrre is not inandW or sedoesfficandl oro]apply to an Business
will dothework, Code:owner of
and professions CW e: The Contractors License law does nm apply
FOOD SERVICE
OTENANT, ❑FOODSERVICE
-
IMPROVEMENT
❑OTHER
SWIMMING KILL ELECTRIC
OUTLETS -SWRCHES-FlXTURfS
theory
s if
his myproperty who builds m improves thereon, and who docs such work himself or through
arc ow intended or offered for
his own employees, pnrviJW that such mentis sold
sale. If, howeser, the building or improvement is sold within one year ofcompldion,the
NEW RESIDENTIAL ELECTR 4.
SQ. FT. FLOOR AREA
SISQ. FT. '
canerboildcr will have the burden of proving that he did not build or improve for par.
le
pose of sale.).
❑ I. as owner of the property, am exclusively contracting with licensed contractors to
TOTAL:
construe the project (Sec. 7044, Business vad Professions Code:) The Contracmrs Li-
ceresse Law does not apply to an owner of pmMorf who builds or improves thereca, andi
QT'Y. PLUMBING PERMIT FEE
whocommits forsuch p jests with a nmtmetomalicenmdparsuarn tonle Conuaaor's
PERMIT ISSUANCE
License taw.
OIumcxemptunder Sec. ,B&PCforthisrxmxm
-
Owner DatALTER-DRAIN&VENT-WATER(EA)
VALUATION -
WORKERS COMPENSAT[ON DECIARATION
BACK FLOW PROTC7F. DEVICE
-
(, I hereby affirm under penalty of perjury ane of Ne following declarations:
OlhaveanJwillmainlainvCertiftcmeofCunsvnuoadGinsureforWorkersCompcn-
sation, as provided for by Section 37M of the labor Cada for the performance of the
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES -PER TRAP
El 1 have and will maintain Workers Compensation Insurance, as required by Section
370g3 ofthhee jLabYor Code, for the performance ofthe work for It hill pemdt. am
My Cerierr`-/kmntto �Nayr fAllO/(LS(/'A
lAr V
GAS-EA,SYSTEM-IINCAOUTLETS
OCC. GROUP
APN
GAS-FA. SYSTEM -OVER
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
GREASEIINDUS9'RL WASTE INTERCEPTOR
BUILDING DIVISION FEES
('Ihissection need not becompleteJ ifthe permit is farone hundred dollars (1100)
or leu.) �
GREASETRAP
-
PLANCHE
PPLAID
I certify that in the performance of the work for which this permit is issued, Ishall
nemploy any personnn erome object the Workers' Comn-
ot in any manner so as to hnpc
swoon laws of Califomia. Dae
z Q Applicant
`Na NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
f" become subject to the Worker's Compensation provisions of the Labor Cole, you must
Wforthwith comply with such provisions or Nis permit shall he deemed revoked.
7 1 Q CONSTRUCTION LENDING AGENCY
that this a consuction lending agency for the performance of
(2 l hereby affirm ere tr
L) I. the work far which this permit is issued (Sec. 3097, Civ, C.)
Ila I. Lender's Name
>.{Uii Lenders Address
y I cannily that I have read this application and state that the above information is
F.t h correct. I sgrte to comply with all city and county ordinances and state laws relating to
U Z building conwowlmo nd hereby andimme repmsealmiveso(chis city to enter trend the
above-mentioned pmpcny for inspection purposes.
Dod agree m save, indemnify and krep harmless the City of Cupertino againn
SEWER-SANITARY-STORM EA. 2M FT.
ENERGY FEE
WATER HEATER WNENT/ELECTR
-
GRA E
2 1995
WATER SYSTEMOREATING
WATER SERVICE
SOILS FEE
,•
PAID"
Data Receipt la -
NEW RESIDENTIAL. PLMB. SQ, ET.
TOTAL:
TOTAL.
BUILDING FEE
Q MECHANICAL PERMIT FEE
-
SEISMIC FEE
PERMIT ISSUANCE
L _CDUC FEE
PLUMBING FEE
liabilities,judgmeno, costs and expenses which may in any way accrue uyninst said City
i. consequence of Ngranting anting of this pemsit.
ALTER OR ADDTO MECH.
AIR HANDLING UNIT (TD 10,000 CFM)
MECHANICAL FEE �
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE' REGULATIONS,
AIR I IANDUNO UNIT (OVER I D," CFM)
CONSTRUCTION TAX
'
Signmme of Ap,doxna Conovco, Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCE)
HOUSING MITIGATION FEE'
HEATING UNIT (TO 100.000 BTU)
AE
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Willmeapplicent orfware building occupant smrc or handle havudou....Iwsl
e defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(e)Y
HEATING ONI'P (OVER 100.000 BTU)
C Yes -Chin
Will the upplicard or fora building occupmt use muipment or devices which
emit haraninis air conaminams as definNby the Buy Area Air Quality Management
VENTILATION FAN (SINGLE RESID)
PAID -
Date Receipt M
BOILER- COMP(7HP OR 100,0010 BTU)
BOILER - COME (OVER 100,000 BTU)
Monier?
El yes ONo
AIR CONDITIONER -ILI
I have read the hmudnus rnaanals requirements under Coupler 6.95nfthe Cali-
ISSUANCE DATE
. SQ. .
NEWEESIDENTIALMECHFT
fmmia Heal & ty Cade. Sections 25505,25577 25574. I understand that if Ne.
huild�ntly havesananLthvtit is my aponsibiliry mnotify the occupant
IISSUED BY:
OFFICE