28837 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
•CITY Of CUPERTINO BUILDING-ELECTRICAL PERMITNO 28837
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BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 2 g g 3 7
BUILDING PROJECT IDENTIFICATION V
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL.UNIT
20400 MA !ate J /a x!67
OW H'S AME: t� PHONE�j /' ^y� CO A H'. AME: LIC NO:
WG IZIN yrM OS7tC JGrO-Ji II N/C CONTROL p.
h�ARCHITECT/ENGINEER: LIC NO: ADDRESS: .,. ❑
CONTACT PHONE: BUILDING PERMIT INFO
/O.Al2=1,4y
3G G - 9
a39 BLDG: ❑ Consultant Fees Paid by Applicant(Initial) ELECT' PLUMB MECH
�J ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under pmvisiou,of Chapter 9(commencing JOB DESCRIPTION
W0Z with Sectim,700unf Division 3utthc Badness and Professlans Code.and my license ie RFNI�, DENTIAL
FT�WO in lull roccind effect. PERMIT ISSUANCE ❑SFDWL ❑KITCHEN HIiMODEL
QUULicense Class Lice APPLIANCES-RESIDENTIAL ❑ADDITION C1PLUMBING RE PIPE
FZ41 Dam Commctor
ARCHITECPS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
I-D y PANELS MODIFICATION
Z O rn Z I understand my plain,lull be used as public accords
OZ-� UPT02MAMPS El INTERIOR CI CHIMNEY REPAIR
[F�FW Licensed Pmfe.whal 201.1000AMPS IMPROVEMENT
C C 6 1 hereby affirm OWNER em esellnp EfromElhe DECLARATION
License Law for the OVER IOf10AMP5 ❑BATH REMODEUREPAIR 0 DEMOLITION
yes,a:1 U follm ing reason.(Section 7031.5.Baine,mad Professions Cole:Any city m county SIGNS ELECTRICAL ❑OTHER
413 LL N which requires a permit m construct.tiller,improve,demolish.m npai any suucmm
F 4i Og prior to its issuance,also requires the applicant bnsuchperntt to lileasignedsmmmcm SPECIM,CIRCUIT/MISC.
4y (commencing
cdpurstion70hc Division
She Commchv'and Professions
rof (C Code)or
�C�O (cat he iscingwiN Section middle
Uivlslon3 he me BusinessandProf ny violation
TT!MP.METE,OR POL6INST. COMMERCIAL:
d C.c e that mr is exempt lhercfmm and the basis for the alleged applicant
to Any viPenion of ❑NEW BLDG/ADDITION ❑DEMOLITION
��N Sation OBJLS by any applicant fnrvpennit subject the upplicum toecivil Penalty of T'ON'ER DEVICES ❑TENANT FOOD SERVICE
l marc than five hundred dollart(5510). IMPROVEMENT
=Q ❑ 1.us owner of the property,or my employees with wages a their ole compensation, SWIMMING POOL TEL 1 []OTHER
p.. will do the work,and the suuaum is nm intended reoffered for sale Soc.—Rosiness
I�il and Professions Code:The Contractors License Law does nor apply to an owner of OUTLETS-SWITCHE - XTUR
�'.. property who builds or improves ransom and who docs such work himself or Ihmugh
his own employees,provided That such improvements am not intended or offered for NEW RESIDENTIAL ELELTR
tete.IL however,the mildingor it..pmwen,ent is sold within one year of conmletion,the SQ.FT.FLOOR AREA 5/SQ.FT.
nut erbuilder will have The harden of proving than he did not bold or Improve for pur-
po>catsale.). w L� rY
1,as owner of the property,inn exclusively contracting with licensed emuractnrs to TOTAL:
construct the project(Sec.7044.Business and Professions Cwe:)The 0muecmrs Li- ` OCTc selawdoesnotapplytoanowneroftaxiwhobuildsorimprovesthercon.and Q1 Y. PLUMBING FERMI 5FEL C2 199
who contracts fm such pmjeets with a commena s)licensed pursuant m the Conuactoes . C
License law. n r�
I am exempt under Sec. ,B&PCfordE,owson PERMIT ISSUANCE ..IIr U)- UL�L .
ALTER-DRAIN&VENT-WATER WA) -'VALUATION
Owner Dnle 0 •
WORKERS COMPENSATION DECLARM[ON BACK FLOW PROTECT DEVICE � O /�/�
1 hereby nfrom under penalty of perjury one of the following don
cclan tis: W )
I have hod will mninmina Certificate of Concemmsdl-incnre for Wao,".v Compen- DRAINS-FLOOR.ROOF AREA,COND. STORIES TYPE CONS'1'RUCTION
ration,as provided for by Section 3700 of the Labor Code,far the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
or
37M of the labCwe.fin,the perfonwnce of the work far ishichrhis Permit s issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP PN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4IFA) 1
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiASF/INOUSTRL WASTEINTERCEPTORCOMP17NSATION INSURANCE BUILDING DIVISION S
(Thi,ssection neednm bemmpleted lfthepennit isforone hundreddollars Blg) GREASETRAP
nr lcsn.) PLANCHECK IEE
I certify that in thelerfnmminecof the work lot which this peril is issued,I shall SEWER-SANITARY-STDRM Id .200FT.
not employ any pecan in any manner so as to become%object to the Workers'Compen- ENERGY FEE
Z nation Laws of Califomia.Date WATER HEATER WNENT/ELF.CTR
zQ Applicant GRADING FEE
N
NOTICE TO APPLICANT:11 after making this Certificate of Exemption,you should WATER SYSTEM EATING SOILS FEE
I-' become subject to the Workers Compensation provisions of the Labor Code,you must
fonhwidt comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
P.iQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ.FE PAID
L) 0 I hambyaffirmm there ser construction leadingagency lin the performance of Reaiple
F the work for which this peril,,iasued)Sec.309],Civ.C)
OLendcrs Nano 'TOTAL:
0 WLendcrs Address TOTAL:
BUILDING FEE
0. I certify Nat 1 have read this application and slam that the above information is
F fA correct.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
Vz huildingcnnswction,and herebysuthorde represcnativwofthis citymenteruponrhe SEISMIC FEE
above-mentioned amparty far inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the City of Cuperino agaiat ELECTRIC :E
liabilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH.
PLUh1BING
in sequnc
aee of th SAof this perlr.
APPLICANT ON 'RSTANUS AND /LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 1(110X1 CPM) MECHANICAL RiE
SOURCE REGI A NS ��(`1��/��/s-(C//Tf
—f-� /L Z AIR HANDLING UNIT COVER In.1H0 CPM) CONSTkUCT[ON TAX
Sigbem fA,heinacartmctor )ale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FE
HAY.ARDOUS MATERIALS DISCLOSURE
dl the applicant or future buildinguccupvm store or handle havudous material HEATING UNIT(TO 100.000 BTU)
m defined by the Captain Municipal Coast.Chapter 9.12,and rhe Health and Safety
Cole,Section 25532od? BEAT
E]Vic, ❑No VENTILATION PAN(SINGLE RLSID) PAID ING UNIT(OVER 100."BTU)
_
Date Receiptp
Will the applicant or future building occupant use equipment or devices which
emir hazardous air contaminants to defined by the Bay Area Air Quality Management MOILER-COMP(311P OR IN).0 N)BTU)
TOL
WDlslricYl❑Yes Fl No TOILER-COMP(OVER 110,00 BI'Of
I have read the hoomous materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
famia Health&Safety Code,Saloons 3505,25533 shot 25534.I understaw that if the NEW RESIDENTIAL MECII. SQ.PT.
building clues nes currently have v tenor,that it is my resrymsibiliry m nmify the occupant
of the"maimenn which must be nor prior to issuance of a Certificate of Occu,shey.
Owner m omhorized agent Date TOTAL: ISSUED BY:
OFFICE
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