28468APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
- PERMIT NO.
BUILDING PROJECT fll) TIFICATION
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
2-Zz0
d-- 17.4.E
OWNER'S NAME: PHONE:
�0f I Z �9�
CONTRA 'S NA LTC NO:
i
N/C
❑
CONTROLp
LIC NO:
Ate, ..H�/E`NybOINEER,e
ADDRESS: + -
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CONT� PHONE:
PAID
Date R. pt
ILDING PERMIT INFO
J, PIt
❑ Consultant Fees Paid by Applicant (initial)
PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm :hat 1 am licensed under provisions of Chapter 9 (commencing
QTY
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
with Section ]Wt) of Division 3 of the Business and Professions Code, and my license is
I. full forcemid effect
Dmehm Class Lb.#
e Contractor
PERMIT ISSUANCE
O
RESIDENTIAL,
❑SF L.- ❑KITCHEN REMODEL
TION ❑PLUMBING RE -PIPE
MULTI-UNIT []STRUCTURAL
MODIFICATION
APPLIANCES - RESIDENTIAL
�
ARCHITECT'S DECLARATION
I understand my plans shall be used us public records
JELECTRIC
PANELS
UP'10200AMP5
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
Licensed Pmfessionel
NSTRUCTON X
201- 1000AMPS
OWNER - BUILDER DECLARATION
1 hereby affirm the 1 sin exempt from the Contractors Liccnsc Law for the
following reason. ( Section 0 031 5, Business and Professions Code: Any city ter county
❑BATH REMODEi/REPAIR (] DEMOLITION
❑ OTHER
OVER IOq AMPS
SIGNS ELECTRICAL
which requires a permit to construct, alter, improve, demolish, .r repair any swetum
PAID
prior to its issuance, also requires the applicant for such permit to file a signed statement
SPECIAL CIRCUIT /MISC
• TOTAL:
that he is liccnmd pursuant to the provisions of the Contractors License Law (Chapter 9
TEMP. MLTC•R OR POLE INST.
-
COMMERCIAL:
(aomarreat with See.. 7") of Division 3 of the Business it Profession. Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG /ADDITION ❑ DEMOLITION
POWER DEVICES
Satin 0 031.5 by any applicant for a permit suhjurs the applicant to a civil penalty of
m than rive hundred dollars US
ownerofthepropeny.merye ployees hwegesasdukratecompensalion,
will Jo work,anithestratureisn intendedmu redforsale(Sec.T)44,Business
and Rofessioru Code: The Cmrrect t License Low s hat apply m on owner of
OTENANT ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
-
LC
OUTLETS - SWITCHES - FIXTURES
property who builds or improves the an, and who does s work himself or through
his own employees, provided that s It improvements are n 'mended or offered for
m1e.ILhowever,1hebuildingorimp vamminkmAdwithinane ofcompletion, the
owner - builder will have the burden fprovingthathedidnotbu impnsveforpun
pose of sale.).
1; as owner elusively contracting or 'd room
NEW RESIDENTIAL F.LECI'R SQ FT.
SQ. _ETp. FLOOR AREA
1 uT'
S� v
5/SQ. FT.
T
use project 70pU
onsuan whe project (Sec. .mess and a tar. Li-
QTY, PLUMBING PERMIT
FEE
0 so 0 rt, whoorm
cease Law does forsapplymena ner of property who �p It.. moeand
who contmc¢ for such pmjats thucanuanort %11k �ihe mmnoY%
AUG 2 91995
PERMIT ISSUANCE
License Law.
❑ lenaemptaeder See . P ` his mason
CftY Ur CUPEH`fINO
, '
Owner • - t
ALTER - DRAIN & VENT -WATER RA)
- I /VALU ^ATION
/ (_ �O
WORKE SCOMPEN TI
OMof
BACK FLOW PROTECT. DEVICE
I hereby affirm uKEIr
h II gJe lemtions:
111 NG
DRAINS - FLOOR, ROOF, AREA, COND.
Iluveandwillmainmi dice tree n 1 a murW rkers Campers.
satiun, as pmvidel for by Section the formance of the
t
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
work for which this permit is issued. / �Y
❑ 1 have and will maintain Workers Co .set In nee. as aired by Section
37000fthe Labor Cede,fortheperformann ftheworkfarwhich permit is issued.
GAS - EA. SYSTEM -1 INC.4 OUTLETS
OCC. GROUP
APN
My Workers Compensation Insurance carrier Policy number
„�,,,ayy;yfw.>rr(g._ _ _
(This section need not be completed if the permit is OTean111n do]). ps I
or less.)
1ceaify Netintheperfonr my oftheworkforwhichthis permit tp issued, lshu
not employ any person in say manner. a. is to become subject'. she Wa ocr%I in
%. sation Lows of Cnli4smia. Dare
zApplicant
t/J NOTICE TO APPLICANT: If, after making this Certificate of Exempttt{{{999 yo should DA
become subject m the Worker's Compensation pm,i,iore of the L dsh [jide, y
Q faMwith comply with such provisions or this permit shall be deemed died.
a
CONSTRUCTION LENDING AGENCY
U 0 IherehysRrmthnnheren.conssmction lendingagencyfo ureperformonceof
V. — the work far which this permit is issued (Sec. 3097, Cie. C.)
O C)Lender's Name
lfa Lender's Address -
1 runty that 1 have read this applicasim, end state that the above information ix
rrAA correct, ) agree to comply with all city and county ordinances and state laws relating to QTY,
L) building construction. and hereby authorize tepremnmrive% of this city m enter upon late
shave - mentioned property for inspection purposes.
(We) agree m save, indemnify and keep hanNess the City of Cupertino against
liabdities,judgmems, costs and expenses which may in any way accrue against said City
in consequence of the graining of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the epplirnnt or future building occupant state or handle le dousmmiamil
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532p)?
❑Yes 0 N -
Will the applicant or future building accupant use equipment or devices which
t hamrdoa air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes ❑N.
• 1 have reed the hamrdom materials requi or ems under Chapter ii of the Cali.
hernia Health & Safety Code, Sections 25505, 25533 eM 25534. 1 underand that if the
building date not currently havea tenon, dead it is my responsibility to hardly the occupant
of the requirements which mutt be met prior to imminence of o Certificate of Occupancy.
Owner crauthodzed agent Dam
WATER SERVICE
MECHANICAL PERMIT
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,00) CFM)
AIR HANDLING UNIT (OVER 10,008 CF
EXHAUST HOODfW/DUC)
HEATING UNIT TO 100,008 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,001 BTU)
BOILER- COMPIOVER 100,088 BTU)
NEW RESIDENTIAL MECH.
OFFICE
1i ®_'A ION
HUILD!NCDIVI.yJN
FEES
PLANCHECKFEE
ENERGY FEF
GRADING E
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ryr
SOILS
PAID
Date R. pt
J, PIt
3TAL:
LDING
• r
SMIC FE
O
EE
�
JELECTRIC
MBING E
CHANICAL P.
NSTRUCTON X
USING MITIGA NFEE
PAID
Date ceiptp
• TOTAL:
ISSUANCE TE
1i ®_'A ION