28738 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL 'PERMIDNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. , , 28738
„ BUILDING PROJECT IDENTIFICATION
WILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL GATT
CD/A _ - PHONII: C tACI'OR'S NAME: LIC NO,
3_ NAC CONTROL#
,•AR ITECf/CNGINEF:R: d LIC NO: D pNS: _
e v _
CONTACT. -' PHONE. dBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG EF OM MECH
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERM IT FEB?
.'I hereby affirm that I ant licensed undm
le,provisions of Chapter 9(uomencing JOB DESCRIPTION
' Cl%Z�00 with Section]000)of DivixionJoftheBminess and Profesions Cedpandmylicenseis PERMIT ISSUANCE RESIDENTIAL,
in full h#ce and eff
'�Wr s 3(0 J ❑SFDWL '❑KITCHEN REMODEL
U L' ase s Lic.#� APPLIANCFS-RESIDENTIAL ❑ADDITION �TIMBING RE-PIPE
rf ale CnnlNalof _ � �r
I,,, rn ARCHITECTS DF:CLARATI1. PANELS ❑MULTIUNIT � ❑S UCTURAL
Zpv�Z r'I understand myplensshaB bemedaspublic recandf - MODIFICATION
O Z=1� _ IIPT0200 AMPS 0INTERIOR. El CHIMNEY REPAIR
FVJ� Licensed Prolessicand - 3oL1000AMPS IMPROVEMENT
g9d is OWNER-RGILDER DECLARATION
3 Oygµ.laM1AMP5 - ❑HATH RFMODF,I/REPAIR ❑DEMOLITION
U 6 1 hereby affimt that I am exempt from the Contractors License Law for the
X d U following reason.ISectinn](131.5;Busincex unJ Professions Cala:Any city ar county SIGNS ELECTRICAL., - ❑OTHER
uY1l Ir. .which requires a permit to construct,alter.improve,demolish,or repair any structure
C�� Prioffe its issuance;also requires the applicant for such permit to File a signed statement SPECIAL CIRCUTUMISC.
;!(a� that he is licensed pursuant o the provisions ofthe Commences License law(Ch2ptnr9
tsSa�a po (commencing with Sconce](11)0)of Division of the Business and Professions Code)or 'DEMI'.ML'I'ER OR POLE INg'I'. _ COMMERCIAL:
G"o rL Ina,he is exempt therefrom and the basis for no alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
iy5 o, Section 7031.5 by any applicant for a permit mbices the applicant m.civil .say of POWER DEVICES
Fitt^m ❑TENANT ❑FO(ID SIiRVICE
�, nmore man Eve hundred dollars($500).
F. far[]I,mnwncr of the y g K � IMPROVEMENT
propeuctur myemplh intended
withwa cs for
(Sec.
cote nsadon. SWIMMING POOL
TI dothework,and the sh Com isnotsi License
offeredfar sola(Sec.o an Business ❑OTHER
3 and Professions Code:The Cnnwearn License Law Jas not apply to an owner of OUTLETS—SWITCHES—FIXTURES ,
prupeny who builds or Improver th uch antl wan nes such work hinvoclf m through
his awn employees,providN that such pros n ere n I intended or offered for NEW RESIDENTIAL ELECTS SQ FT -
sola lL however.me building mint at" en '. d ithin ane car of - SQ.FT.FLOOR AREA 5/SQ.lel'.
owner-buildt� p
.it fund fp in - did not build or improve for pm- '
pose of sale '
Las owitn elusively contracting with i! amem 1. TOTAL: P p
construct m ,Business and Pr s Q&:) tractor's Li- a'i
c se Law n fp pen ho ildsmim nva three ,and QTY, PLUMBING PERM IT FEEoywho contraccu wi tm 0. need pursuant m the Conwctars `�License Lo3Ism exe ,B&P C for this PERMIT ISSUANCE r17 "j
Owner Date
ALTIR—DRAIN&VENT—WATER(EA) - ' l; AL1'ATION
BACK FLOW PROTECT.DEVICE / wrCii��/YU
WONKERS COhIP1iNSA'I'ION DBCLANATION
I herebyv(Irm under thinly of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent o self-i neure for Workers Comism- - DRAINS—FLOOR_,ROOF,AREA,COND. - STORIES 'I TYPE CONS'TRUC'TION
sation,as provided for by Section 3700 of the Lthor Code,for the perfuntrance of the
work far whicbtbia permit is issued. oPIXTURESi—PER TRAP
1 have and will maintain Workers Compensation Inmrnne,as required by Section
3]W oft "Code
fon he perfnntunceafthe work far which this permit is issued GAS—EA.SYSTEM-I INC.4 OUT'LETti OCC GROUP APN
MyW r'n Compen..do.lnsuiunco canieronA policy number art:C.
Policy Nn.: GAS—EA.SYSTEM-OVER'CIiRTIitICATF.Oh F.%LEvEr ION FROM WORKERS' -
COMPENSATION INSURANCE GREASHANDGSTRL WASTE INT TERCEPTOR'
(l'his section need not ire completed it the .it is Intone hundred dol los(S lal) BUILDING DIVISION FEES
or less) t ORIASE TRAP' - PLANCHECK PBC
Boy any personthe anymannrof the work for Subject
the Wrkers'Camara. SEWER—SANITARY—STORM EA.200 FT., -
notempl�y�nypennnin�nymannermasmbccumesnbjecuameWmkerdCompen- ENERGY FEE
O Z anion rota. WATER HEATER W/VENT/ELECIR '
rplicunt WATER GRADING FEE
OTICE O APP CA .If,ager mekingihia Cenifimto rf Examptinn,you should WATER SYSTEM/IREATING -
r�aar# R me subject It,the Worker's Compenoinim provisions of the Lahnr Code.you must, - SOILS FEE
t�O forthwith comply with inch provisions or this permit ha deemedvo
reked. WATER SERVICE "
4G CONSTRUCT NT
ION LENDING AGENCY NEW RESIDENTIAL PLMI. SQ,FE PAID '
aa
I�UZ Iherchy affirm Inst thereieacanstruction lending agency finale Performance of Dote Receipt If
the work for which this pennit is issued(Sec.3097,Civ,C.)
O Leaders Name ' TOTAL:
[ULl Lender's AAdress T `
I certify that I have read this application and state that tla+above information is BUILDING PER
hcorrect.l agree to comply with all city and county ordinances and onto laws relating to QPy. MECHANICAL PERMIT FEE
U Z building construction,end hereby amnorize mpreaematives afthis city to enter upon the SEISMIC FEB
aMwe-memmard progeny for inspection puapme.a.
„ (We)agree to save,indemnify and keep h.mticas the City of Cupertino ageimt PERMIT ISSUANCE ELECTRIC IEE
litibilinex.judgmetis,costs and expenses which may in any way uccmc against said City ALTER OR ADD TO MECH. "
inconsequence ofthe granting ofthis permit. - PLUMBING FEE
APPLI,ANT UNDERSTANDS AND WILL CO PLY WITH ALL NON-POINT AIR HANDLING UNIT(TD I0,000 CFM) -
SOI' S,. - MECHANICALFEE "
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
SignN6wfAppli VCommmo Date EXHAUST HOOD(WIDUCD, HOUSING MITIGATION FEE
". HAZARDO(ISMATERIALSDISCLOSURii
Will the applicnntnr futvm foundation,sooner handlfoundation,material HEATING UNIT(TO I0k00()BTU)
a,defmW by the Cupertino Municilwl Coalc,Chapter 9.12,antl the Health and Safety
Code,Section 25532(x)'? HEATING UNIT(OVER 100.000 BTU)
❑Yes No - -
s _ VENTILATION FAN(SINGLE RESID) PAID -
Dat Rmcipt p
.Will the epplicnm or future building occupant use equipment or devices which•
emit BOILER—COMP(3HP OR IW,000 BTU)
hau
zdnus air conmmivams as defined by the Bay Arca Air Quel ity Management TOTAL:District? L]No'
_ BOILER—COME(OVER I Di BTU) - r
❑Yes
"1 have read me hazardous materials rcuircmema under Chapter fi 95 of me Culi- _ AIR CONDITIONER
4 p ISSUANCE DATE'
fare Hmlm&Safety Code,Sections 25505,25533 and 25534.1 understand Nat if the NEWRESIDENTIAL MECH. SQ.FT.
building doesnot cuarendy love.air.[,gam it is myrespoasibuity mnutil Ida,recupnnf -of the do,t irnmentx which must he arict prior to issuance mf u Certificate of Occupancy.
Owner or authorized agent Date - TOTAL: ISSUED BY:
OFFICE .