28691 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL O C ��I
BUILDING PROJECT IDENTIFICATION o v 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
al r r101 - ' �i3 vs-
OW 'S NAME:- PHONE: ONTRACIOR'S NAME: LICNO:
✓1
N/C CONTROL#ARCHITECDENGINEF,R: LIC NO: ADDRESS: El_
CONTACT. - PHONE:
BUILDING PERMIT INFO
❑ Consultant Fats Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1hereby0)of that Iemfffic Business
under provisions of Chupmr9(commencing JOB DESCRIPTION
7s2 with Section it0jor Division of the Business and Professions Gds,and my license is
�OO iPERMITISSUANCE � S RESIDENTIAL -
n ram farce ma ercert.
VZ�j License Class Contractor
❑SFDWL ❑KITCHEPLUMBINREMODEL
N6� Dam Canvaaor APPLIANCES-NESIUENTIAL ❑ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z C h Z I underslarlansm my pshall moved!m public recaNs PANELS - MODIFICATION
OZ 0 UPT0200 AMPg ❑INTERIOR El CHIMNEY REPAIR
F. of Licensed Professional 201-100DAMPS IMPROVEMENT
eye ^aJ OWNER-BUILDER DECLARATION f7mo ON OVER I"AMIS
1yys'g� I hereby off roe Lha I am exempt from the Commctor's License Law for the ❑RATH REMODELBEPAIR Q DEMOLITION
W 01UE following ressom(Section 70.3 1.5,Business ofem,mrs Cole:Any city or county SIGNS ELECTRICAL ❑OTHER
it,Ca which requisrcs a permit m construct,a'om burro demolish,or repair any structure ���fj`g•-��'
mJ prior to its is an ce,aHoregoirestheap camforsuc pc rminofile.si,rodsmmmean SPECIAL CIRCUIT/MISC.
} Net m is licensedpursuunuo the pro sof the Con eburs Licensa Law(Chapter 9
{yI 00 (commeucing with Scetim]0(0) ivimcs.3ofthe Btu mxs mdProfammns Code)ar TEMP.METER OR POLE INST. COMMERCIAL:
h q M C
that he is exempt therermm the hasis for Ne vllega scmpIm..Any violmma of ❑NEW BLDG/ADDITION ElDEMOLITION
Y• Section 7031.5 by an team fora permit subjects the plicant to o civil penalty of POWER DEVICES
h tmore Na undred dollum(S500). ❑TENANT ❑FOODSERVICE.
^zQ0 I,as er of the PsupYnorm can la ms with wages atheir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
.1
it etas Cost Chemo Canmm's mnense Law does sale(,],to.. Business []OTHER
atd fessiora Cale:The Cammcmrs License Law does of Achi mif owtmr li OUTLETS_SWITCHES-FIXTURES J
r pro any who builds or improve thereon,and who does such ark himselfcr Nrough
hi own<mployces,provided the such prvvenmm'me not'mm�dcd or offend fur NEW RESIDENTIAL ELECfR SQ FT.
a. .IL hawever,the building 'mprov ntissaldwidimu a onfcomplaion,the SQ.FT.FLOOR AREA t/SQ.Ec
o nerbuilder will have flim,Net he Ji as m improve for par-
Is corsair.).
I,as owtmrof he pr elusively tract ah re eccontracmrsm TOTAL: -
00
co 1Z.the pro I u ss and s oro c:) amracmr's Li
-
ceseLawdoes ton o prsyen mi mpo sthereor Cod QTY. PLUMBING PERMIT FEE
w consmasfms er jttIsw tmdor(s)licertad i mmmth Comrachns
Li rose Lew' PERMIT ISSUANCE
am exempt on er Stt. .B&P C for this remain
Ow er Dmc
ALTER-DRAIN&VENT-WATER(EA) VALUATION
�}
WORKER'S COMPEN ION DECLARATION BACK FLOW PROTECT.DEVICE /�� C U
I hereby uRrm under penalty o erjury one of Ne following declCmtions: '{
❑Ili vend will mainain a Ceni�acof Consentmsell-insure for Workers Comren- DRAINS-FLOOR,ROOF,AREA:COND, STORIES TYPE CONSTRUCTION
cation, provided(or by 5.11J t/37M of the Labor Code,far the performance of the
workfor ichthis permitifnated. FIXTURES-PER TRAP
❑Ihavann if 'rlaln Workers Compensation lnsmouce,aa,,uirM by Section
3700ofthetabe Co c,for the performance ofdre work for which this pemmt is ismed, GAS-EA.SYSTEM.1INC.4 OUTLETS OCC GROUP "NMy War is Cc pe sa ma a Cartier Cod Pnfq number ate:
Cartier. olicy No.: GAS-EA.SYSTEM-OVER 4(EA)
R F CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
(This sadont W not m completed Him permit is for one humbeddollare(5100) BUILDING DNISfON EEFS
or less.) GREASE TRAP-
PLANCHECKFEE
Loy a.,not in anymanpriformanrce o ustdrebecome
bjectch 1.the Wnt islssu C..,a11 SEWER-SANITARY-STORM EA.200 FT.
rat employ any pawn in any manner so az m become subject m the Workers'Compen- ENERGY FEE
,7. scion Laws of California.Date
Q WATER HEATER W/VENT/ELECfR
0 Applicant GRADING FEE
y NOTICE TO APPLICANT.Worker's
after Compensationng pr visio sso of "fair on,youshould WATER SYSTEMlIRFATING
a
become subject m the Workers Compensation provision of Ne Labor Cade,you must SOILS FEE
{>a fomhwith comply with such provisions or Nix permit shall he deemed revoked. WATER SERVICE ,
� .
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FILMS. SQ.FT. PAID -
O I herebywhich
this
pe mere is a ed(So.ion terming agency for the performance of Dom Receipt#
{7••r !+
the work for which this permit is issued(So.3097,Ci,C)
O !'+ I<nder's Nauru TOTAL:
LULL Lender's Address - TOTAL:
fy� gys 1 certify that I have read this application arm sum that the.brae information is BUILDING FEE
r
is IA coset,l agree to that
with all city and county ordinances and state laws mlating to QTY, MECHANICAL PERMIT FEE _
U building consuuctim,Cnd herebysathodze rerresentmiveso(this city brntm upon Ne SEISMIC PEE
above-membered property for inspection purpores.
(We)agree tons,indemnify and keep harmless the City of Cupertino agaimPERMIT ISSUANCEt ELECTRIC FEE l Ui O
Ihabilides,jud ems costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH.
inconsequen fthe gmnlingofthis emit, PLUMBING FEE
APPLICANT INffI�II����ATTTTRS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ000CFM) MECHANICAL FEE
SOURCE RF,"IIA
AIR HANDLING UNIT(OVER IO.(gO CFM) CONSTRUCTIONTAX
nm-fj pplican onracmr Dam EXHAUST HOOD(WNUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or furnace building occupant mom orhade baurdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Come,S.Rm 25532(.)? � HEATING UNIT(OVER 100,00 BTU)
❑Yrs *o - VENTILATION FAN(SINGLE RESID) PAID s•
Will Ne applicant or future building oecupmt use equipment or devices which Data B BOR rpt#
• emit hazardous air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(3HP OR)00,000 BTU) - -
Dimrictl TOTAL:
❑Yes BOILER-COME(OVER 100,0110 BTU)
1 have hand die hazardmrials rryuiremems under Chnptm 6.93 0l the Cali- AIR CONDITIONER
ry, a ISS RAE DAT
fnmia Ileahh&S.fety Cade,Sections M505,25533 arm 25534.1 undersand Thu if the NEW RESIDENTIAL MECH., SQ.FT. CITY J UI-
building it nsuuquu��y��cozen tyro hat it is my msponsibiliry m notify the coni t,Uilth�INU
of the requirem/M1ts h a rerpriarm is.u... s Iificag:of qcu y, T s�'0
Owns uN^^i ag B - 1 1 (l�Da� TOTAL: ISSUED RY:c- be- �����t�LY
OFFICE