28786 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO. 2 8 7^6
BUILDING DIVISION APPLICATIONIPERMIT
PLUMBING MECHANICALATL VX / XV VM
BUILDING PROJECT IDENTIFICION
]DING DDR S, SANITARY NO. APPLICATION SUBMITTAL DATE
O M PHONE: O C ME LIC to
NIC CONTROL#
AR m [NEER: LIC NO. ADORES : ❑
COM' PHONE':�.I •�J d ❑ Consultant Fees Paid by ApplicanC(InRiap I BLDG BUILDING ELECT
�' �/�// ECH
LICENSED CONTRACTOR'9 DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby rearm,mat I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
O0Z with Section 7010)of Divi ion 3 ofm uxine dPrafessio C denylicenseis RESIDENTIAL:
{{B�OO g� PERMIT ISSUANCE
F in full force un fife . & Q D (J f,? ❑SFD WL ❑K TCHEN REMODEL
U Li,e.. C V Contra
e.� APPLIANCES-RESIDENTIAL ❑ADDITION MBING RE-PIPE
to<Z 0. Dale Comractor CCC��_
Z�Ny ARCHITECT'S DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL
u1 Z 1 undersand my plans.shall he used as public records MODIFICATION
OZ UP To 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional - 201-INMAMPS IMPROVEMENT
OWNER-BUILD ER DECLARATION o OVER 1000 AMPS ❑BATH REMODEDREPAIR ❑DEMOLITION
Sy�d I hereby affirm mal I am exempt from me Course x License Lu fm Ne
003 U following reform,(Section 7031.5.Business and Profexsions Cal e:Any of SIGNS ELECI'RICAI. ❑OTHER
LL which requites a permit to concoct,first,improve,demolish,or rc any x car
I:O prionoia issuance,also requires the applicwrtmr such perminof signal me ant SPECIAL CIRC LSC. -
, y mal he is licensed pursuant to thslmwidomx of the Common' nerve wIChapmr9
apo (commencing with Section 7pxXFdDivision 3afthe B as and Professions Coda)or TEMP.MEG OR POLE INST. COMMERCIAL:
M y-y e K mat he is exempt me afmm and the basis for t gad exemption.Any vi Is ion of ❑NEW BLDG/ADDITION ❑DEMOLITION
h!^LN4 Section 7031,5 by any applicant for a suhjects the applhuratiacivF penalty of POWER rVICE3 []TENANT ❑FOOD SERVICE
LL[-ZY mol more then five hundred 501N IMPROVEMENT
Fl Leo
swnerifthepro ny,fir my employers wird wages as theirsnle compensation SWIMMING POOL ELECTRIC
M
y0pd willdothe work,mouth strolum is not intended oroffened for sale(Sce.JIH4,Basin x ❑OTHER
6,3 and Professions Code The Conte sloes Licen Isco J s ooi apply m an o f OUTLETS-SWITCHES-FIXTURES
propcny who builds improvex thereon,and dce bit cook hi^ryryryryryy If or u -
his own ca pluyces, rovided that such improv m a of immmffert for NEW RESIDENTIAL ELECFR SQ PT.
We.If,however.the wilding ori proveme i rte f one ion, - SQ.FT.MOOR AREA I;/SQ.Pf,
ownerbullder will ve me bard IF did n t I parr-
pose of sale.). i TOTAL: 0 Y
El 1,as owner of eine, Y mai lys sein Sml anse musemrsor /9� iy
construct the proj (Seed B ineas end FSS+ Sion Code:) Commences Li-
cause
i- t,d
c se taw Joos mo apply m an o e of pmpeny� Ilds o proves thereon,find (YrY. PLUMBING PERMIT FEE
whoconimeb fors ch projaa wi a ommetmg) then, nmamlothe Cmarecmr's
❑cl ora exempt uner Sec. B&P C for this reason PERMIT ISSUANCE pL
ALTER-DRAIN&VENT-WATER TiO WA.TION
Owner Date
W RKER'SCOMP: ATION DECLARATION BACK FLOW PROTEGE.DEVICE FG
hereby etfirm der pen f perjury line of the following dalurmionr
and will malnlai nirimwofConxnuoselGinmmfor Worker's Compen- DRAINS-FLOOR,ROOF AR FA.COND. STORIES TYPE CONSTRUCTION
tion Bass provided for by Section 3700of me Labor Cade.forme performance of the Pr
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Wokees Compensation IRwranfe.as regYlred by Ses ion tAe
3=,flhe Ivi Ortheperfmrrrmce nl theworkfor which his permit is iszuad, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Work s pe ml on h x ranee comer and Policy i ll G
Cartier. Policy Nw; ml! / GAS-EA.SYSTEM OVER 4(EA) -
CERTIFICATEOFEXCMPf1ONFR0 WOR .RS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This saron need not be completed ifthe permit iv forome hundred dollars IS I DO) GREASETRAP
or IessJ PLANCHECK FEE
lcenify that in Beeperfonnancemfthe work forwhich this pennilisis.sued.lxhallSEWER-SANITARY-STORM EA.20D FT.
not employ any person in any manner so as to hecome mbjeclfa the Worker'Compen- ENERGY FEE
0Z sation Laws of California.Date _ WATER If EATER WNENTAILECTR
Z L) Applicant GRADING FEE
IA NOTICE TO APPLICANT:If,after muting this Cernificate of Exemption,you should WATER SYSTEM?RRATING SOILS FEE
a h become subject to the Worker's Compensation provisions of the lobar Cale,you must
forthwith comply with such provisions or this permit shall be decmedrevoked WATER SERVICE 16
-
r.I
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID
V p I hembyoffmn that mem isoconstrued...lcndingugeneyfor the perfanfromeof Date Receipt#
W r the wait for which this Fenn is issued(Sec.3097,Ci,C.)
Q f't Lenders Name TOTAL:
{U Lenders Address A
1 scarify that I have read this application and Stam that the above information is BUILDINGFEE-
y correct.l agree to comply with all city and county ordinances and state laws relating in QT MECHANICAL PERMIT FEF.
V Z building construction,and hereby amhnrize remostrafives of this city to enter upon tire, SEISMIC FEE
above-memase l property far impenion purposes. PERMIT ISSUANCE
(We)agree,to as,indemnify and keep harmless the City of Cupcnino assure, ELECTRIC HE
liubilities.judgments,costs and expenses which nmy in any way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CF1,I) '
SOURCE REGULATIONS. MECHANICAL FEE -
AIRHANDLINGUNIT(O R10,N00 CFM) CONSTRUCTION TAX
Signature of Agplicum/Contractor Date, EXHAUST HOOD /DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantorfar.building occupant swmor handle hamrdous material HEATING (TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safely
Code.Section 255321a)? HEATING NFF(OVER IN0.000 BTU)
❑Yes ONO PAID,
VENTI ATION FAN(SINGLE RFSID) Data Receipt
Will the applicant or future building occuponl use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOIL R-COMP(3HPOR I I10,000BTU)
TOTAL:
District?
❑Yes 0N BOILER-COMP(OVER 100.00((BTU) -
AIR CONDITIONER
I have read tit hazardous materials requirements under Chapter 6.95 of the Cali- ISSUANCE DAW,---�
fmrN Health&Saf Cade,Scedom 25505,25533 and 25534.1 mW,.x that if the NEW RESIDENTIAL MECH. SQ.FT -
bui g mtc n0 h ve mL shift it is my responsibility m firmly the occupant
oft an, rcme p�'i r' ismacenfm Cenircfpgf Ofcypagyc`y
cr raunai agent �'ryaVy �l/ate I TOTAL: ISSUED BY:
OFFICE