28749APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL -
BUILDING DIVISION APPLICATIONIPERMITPLUMBING. MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
lJ 1 V
7 89
B .DINGADDRESS:
/080 w : 456-"NrJQ� Tee
SANITARY NO.
APPLICATION SUBMITTAL DAI
to -Z1 S
HER' AML:._ PHONE:
CO CI'OR' N M1 CNO.
NIC
CONTROL
1`G
ARCH]]ECI'/ENOI/MIiE LIC NO: 2, 3 5 �
AD ESS: O� I O PEl
CONTEAACV/T, PHONE:
IO ' r/..a '
l/'7
i,
El Consultant Fees Paid by Applicant (Initial)
I ILD'IN PERMIT INFO
BLDG ELECT PLUMB . MECH
LICENSED CONTRACTOR SS DECLARATION
I hereby affirm that I am licensed under ons of Chapter 9 (commcncin
y a pmvisi p g
with Section]gXlptf DivisionJof the Rminess and ProfessionxCode, and mylicens isV
in full force and effect
License Class Liu. is
J Date Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
WL [I KITCHEN REMODEL
;RZITION F1 PLUMBING RE -PIPE
❑ MULTIUNIT❑ STRUCTURAL
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELTEPAIR [I DEMOLITION
[]OTHER
PERMIT ISSUANCE
APPLIANCES -R&SIDEN'GAL
j ARCHITECTS DECLARATION
1 understood., plans shall be used as public tccmdsMODIFlCATION
PANELS
UPT02011AMPS `
LicensW Professional201-INMAMPS
OatIam BUILDER DECLARATION Contractor's
� I hereby affirm that I um exempt from the Cnntraaor's licence Law for the
following cease.. (Section 7031.5, Business sed Professions Code: Any city or county
j which requires a permit to construct, altar, improve, demolish, or repair any structure
3 prior o its issuance, also requires the applicant for such permit to rile a signed statement
that he is limmall Palmer. Mc Incloi... i—Ohc Commcur's License Law (Chapter 9
(commencing with Section 1") of Division 3 ofthe Business and Professions Code)or
that he is exempt therefrom and Ne basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a armitsubjects Ne applicant to a civil penalty of
not more than five hundred dollars($500).
D 1, as owner of the co,vmy. or my employees with wages as their sole compensation,
will dome work, and the stmcmre is not intended oroffered for sale (Sec 7144, Business
D and Rofessions Code: The Commnnrs License law does not apply man owner of
property who builds or improves Mercian. anal does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If. however, the building or improvement is sold within one year ofmappletion the
owner -builder will have the burden of proving that he did not build or improve for par-
owner of the progeny, exCus ad sstmmninwith licensed contractors i -
nom
aer the project (Sec. ]ILLS,B Business and Professions Code) The Connacmrs Li-
seLuwdoesnntapplymanownerofpropertywhobuildsorimpmveaMerron,and
who contracts for such pntjec¢ with a contractors) licensed pursuant to Me Contractor's
Lima. law.
❑ I am exempt under Sm. ,B& P C for this reason
OVER 101I(IAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS- SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ Fr.
SQ. Pf. FLOOR AREA
�❑has
-
.$/SQ. ET.
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- NATER (EA)
Owner Dain
1 o21,gt�
I WORKER'S COMPENSATION DECLARATION
I hand%ill ll mou under penalty of oforynateofthefnsiumior W ou,',Cm
❑Ihave arovidelfor bineio37Certificate of the
aad tobor sole, forthe Worker's Comp the
Imam, as pro h thi for mi Ss issu d. of Ne labor Coda for the Per4nmance of the
work for which ilia permit is issued
1 have and will maintain Worker's Compensation Insurance, as Bquiml by Section
3700ofthe Labor Cade. fon he padharana ofthc work for which this permit is issued
My Wahelx�j ��yy� carrier and Policy nomhar ora '
Cerlmn GNsa Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This 'union need not be completed i f 0a permit is for,) ndredd,)llars(SIU(1
or lux,)
1 certify that in the pert or which Mis anti' ural lshall
not employ any person m en manner sea as m bs c= su t' nope
.union Laws of Calimum.. D to
Applicant c
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOE.ARFA,COND.
STORI
TYPE CONSTRUCIOI
FIXTURES -PER TRAP
GAS -EA. SYSTEM-] IN EfS
OCC, GROUP
APN
GAS - EA.SYSTEM air
GREASEffNDUSTRL WAST INTE R
GREASETRAP \
ED LDINGD ISION RES
PLANCHECK FEF O
�
SEWER -SANITARY -STORM CA.2
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT. , after ma kingXuld
,)rkcdy
become subjecta the Works sCones ,art.f thstSOILS
complywithsuchpv oro orthid
CI' ION LCNEW
lherehyaffrmthauaci. msouencof
Ne work for which this pcnnit is u, cad (Sec
Lenders Name
Lender's Address
1 certify that 1 have mud this ap b anon and stat Nat the above information is
correct. I agrcem comply wins all dtya aintyorJ'anm, andaaa laws relating to
building construction and hcmM1y authni, crepte, tivcsnf thiacitymcma'U'ribe
abovememienad proper for insPcai ani
(We) agree to save. itdcmnify and kee teannless the City of Cupmino against
Iiobiliticsjudgmarce. costs and expenses which may in any way accmc against said City
a. consequence of dic grating of this Permit
APPLIC DEP 'TA' WILI 'OM PLY WITH ALL NON -POINT
SOL I- 01GULAT/�{,jNS.
/ ((Iw0/I u/ � y(
•nammt��-tfAppVVVhcaVVVIII///Ct car �/ Det J
HAI YCOGS MATERIALS DISCLOSURE
WII Me, plicaut or future buildingomepint store or handle haeuNous material
m Jdined by t Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(x)'!
❑Yes []No
Will the ant pplicaor building occupant use equipment or devices which
kithaaanlwa air contaminants
nu a as define) by Me Bay Arca Air Anality Management
BicC
❑Yes Fl No
I have read the harardoux materials imaimmenss under Chapter 6.95 of the Cali
forma Health & Safety Code. Sections 25505, 25533 and 25534. 1 understand Wes if the
building does caw currently have a tenant that it is my neponsihility to notify the occupant
of the tequirmtwrtcs which must he met prior to issuance of Certificate of Occupancy.
WATER SYSTEMiTREATING
RF.Etnhwith
WAIERSERVICECONSTR
PAI
m RecciptM
RESIDENTIAL PLMIL, SQ. ET.
'TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMITS FEE
SEISMIC RE
PERMIT ISSUANCE
ELECTRIC FE
ALTER OR ADD'1'OMECH.
PLUMBING FI
MECHANICAL FEE
AIR HANDLING UNIT (TO 10,000 CFM) I
AIR HANDLING UNIT (OVER 10,110(1 CFM)
EXHAUST HOOD (W/DUCI')
- L"'\I -
CONSTRUCTIONTAXi .t .
tt `
HOUSING MITIGATION RE
_
BEAT ING UNIT(0100.0011 BTU)
_
HEATING ON] r (OVER 100.000 BTU)
VI
PAxDnS t jL tact :.
Data "' LOtx
Relt;M
p
VENTILATION FAN (SINGLE RESID)
BOILER -GD,MP(THP OR 100,000 BTU)
TOTAL: ,
BOILER-COMP(OVER 100,000 RTU)
AIR CONDITIONER
ISSUANCE DA
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. P.
Owner or uuncriud agent Dae
TO 'A
OFFICE