28830APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
PERMIT NO. O
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRFSS:
SANITARY NO.
AP PLICATIONsuBmiTFAI, DATE
OWNER'S NAME:PHONE,:
fq�OC
CONTRACTOR NA E: LIC NO.
NlC
CONTROLp
•�
ARCHITECrIENGINEER: LIC NO:
ADDRESS:
CONTACT: I,
BUILDING PERMIT INFO
gPHON
SqM� p 822 �66a3
Consultant Fens Paid by Applicant (Initial)
"ELE PLUMB MECB
❑ ❑
1.10ENSEDCOMHA OR'S DECLARATION
1 hereby affirm that I am licensed under provisions of chapter 9 ecommeneing
with Section 7000E of'Divi«on 3 nnhe nosiness and professions Code. and my license is
in full force and eRem.
License Class hic.ro -
Dme Contractor
QTY ELECTRIC PERMIT FEE
wo,
1-ty�j-
aUU
FZW
Foy
Z O y Z
O Z
F��'W
G E'4 OWNER-BUILDER
C o W Q
4 m U
O N
.F.�Inunwininsuance.aLopturmtheapplieant
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B DESCRIPTION
RESIDENTIAL
❑SFDWL ❑KITCHBNREMODEL
'ADDITION ❑PLUMBING RE-PIPE
❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
CI INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
011PIR
PERMIT ISSUANCE.
APPLIANCES- RESIDENTIAL
ARCHITECT'S DECLARATION
1 understand my plans shall IN used as public records
PANELS
UP TO 200 AMPS
Licensed Professional
DECLARATION201-10Y)AMPS
1 herehy effort that 1 am exempt from the Conlmam'x Licence Law for the
fnllowing mason. (Sorion 7031.5. Business tend I'rofessiMe, Code: Any city or courtYS[GN9
which requires u Ionil to ronffrur1..11 , improve, dcmoli,h, nr aTair any arucme,
forsuch Penin,, lilotte,rstsewomem
reml he is licensed pasuant m the perviaionsofthe Contractor's License law(Chapmr9
(commencing with Section 7000) of Division 3 sums, Business and Pmfeusions Cule)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9631.5 by any applicant for a permit subjects the applicant to a civil penalty of
on, mere than Dve hundred delta,,($SIXe.
I. as owner of the wngeartheir Selemnnprnsalion.
❑ praprny.mmyemployees or offered
will do rework. and the oCom erces Livens omff do esnto apply to a4. Business
anJ Professions Curie The Cammnar's License Law Jas not apply m nn owner of
poli who builds or improves thereon, and a he does anon work himself or through
OVER I00OAMPS
ELECTRICAL�
SPECIAL CIRCUUUM[SC.
TEMP. METES OR POLE INOMMERRIAl.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
WW-R DEVICES
SWIMMING V(RIL ELEC'1'RIG
OUTLETS-SWITCHES-FI%TUR
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL ELECTR S
sale. If, however, the building or improvement is cold within one year of completion.the
,builder will hove the burden of prno
oving thin he did build ar improve for par-
SQ. FT. FLOOR AREA
$/SQ. ET.
Imret
poso ofsoleJ.
-
with Iicunsed.mt Isro
I,reownerof the pro,ortSec.7,1minsinesi vuly ormaProfessions
camewho bei ds or i The Contractor's
ome La the es not (Site "Ilan. Business and property
.he emera docs ml apply man owner orrosiony whosedpea improves menton,and
who forsuch projecu with aronuacmrts)licenced pursuam to the Contractors
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
License Law.
seLaw.
❑ex
I empt under Sec. ,B&Freason Nis an
CT 31995
ALTER - DRAIN & VENT - WATER (EA) /
BACK FLOW PROTECT DEVICE yl
Owner [)are
VALUATION
11 yr LIV U^H��P�
(r
WOR K ER'S COMPENSATION DECLARATION
I hereby utrnit under penalty of perjury one of me following declamtiens:
DRAINS- FLOOR, ROOF. AREA. CON .
] I have and will rewra e a Certificate of Corwin mself-insert for workers Compete
action, as provided for by Section 37M of the labor Code, for the performance of the
STORIES
YPE CONSTRUCTION
FIXTURES -PER TRAP
work for which this permit is issued. -
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3000ofthe Labor Gsde. forthe perfomaneeofthe work for which this permit isisseed
My Worker's Compensation lnmmnce came, and Policy number arc:
Currice Policy No.:
GAS -EA. SYSTEM-1 INC.CTS
OCC. GROUT'
AI'N
\ -
GAS-EA.SYS'H?MOV 4(LA)
CERTIFICATE OF IXEMP1 ION FROM WORKERS'
Of
GREASFJINDUSTRL ASTE[NTERCEPTOR
sZ
zO
COMPENSATION INSURANCE
(ibissenion need not IN completed ifrhe power is for one hundred dollars($ IW)
or IessJ
[cenify that in rhe nnofthe work for which this mi
is pertisissucal ,lshall
not employ any person in anyy manmannerer sit its to become subject
est to the Wnrken:Com
cation Lwsof CalilinM. Date pen-
Applicant
BUILDING [VISION FEES
PLANCHECpersona
GREASE TRAP
SEWER -gA l'ARY-STORM1f GA. 2tYJ FT•
ENERGY FE
WATER H A'I'ER W/VENT11A I'S
GRADING
NOTICE TO APPLICAN E If, after making this Cunifcale of Exemption, you should
bwmne subject to the Worker's Compenacnon pnwisinnc of the Labor Code, you moa
foMwith comply with such provisions or this permit shall be darned revoked.
WpTE SYS'TEMIfREATING
I,
a0
SOUS
sup cR SERVICE
N WRCS[D1iNT[AL PCMB. SQ, FT
�z
UO
CONSTRUCTION LENDING AGENCY
I herebyalfirm that hem is acnn.swction lending agency forth c performance of
PAID
as, Receipt#
Dy H
the work for which this permit is issued (Sec. 3097, Co, C.)
Lender's Natnc
TOTAL:
U
N
U Z
Lender's Adores,
I certify that I have read this application and state that me above information is
coerce,, l agree to comply with all City and county eminences and slate laws relating to
building constmerion, and bereby aurhorim rtpmsentatives of this city ro enter upon the
above-mentioned property for inspection porpswes.
(We) agree to,ave, indemnify and keep harmless the City of Cupenino again.a
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
IiuhilitiClJ.dgmcnts,co... and cxpansrs whichouy in any way nccmen,eins taint City
incense n
rose cofthegranlingaflhi,permit.
pLTF,R OR ADD TO MECH.
PLUMBING FE
AIR HANDLING UNIT(TO 111"I CFM)
APPLICA T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOUR - EGUI \TIONS.
MECHANICAL s-
AIR HANDLING UNIT (OVER I0.00D CF
A,�
CR
CONSTRUCTION X'
i
eof Applicm Dae
AZARDOUS MATIiRIALS DISCLOSURE:
EXHAUST HOLD(W/DUCU
USING MITIGATI NEER •
HEATINGUNI'P('1O1WpIX)6" 1
•
Will ter applireanl or future buildingoampum senor handle ha'u.Mou, mwend
as defined by he Cuecnine Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(a)I
HEATING ON] 'F(OVER .016 BTU)
Fl yes ❑No
VENTILATION PA' SINGLE RESID)
Will mea applicant m future building
pp g b,,hC By Acquipmauality vinatneT ch
,nit bammous air contaminates m defined by the Bay Arcu An Quality ManagemI
>ixmicrF1 ❑N`n '
Yes
[PAID
Dam R. ci tp
p
BOILER-C I'(3HP OR 166,(X16 BTU )
BOB.-COMI'(OVER I V,(XX) BTU)
A[IrfONDLTIONER
I have mad the hvnrdous materials requirements under Chapter 6.95 of the Cali-
media Health & Safety Code. Sections 25505. 25533 send 25534.1 understand that if the
building does not currently have a tenant, that it is my responsibility to neeff the occupant
'of the requirements which must be met prior 10 issuance of a Conferee of Occupancy.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
ISSUED6 —
Owner or wuhor,cd. agent Dae
TOTAL:
OFFICE