28501 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PF.RMITNO. /� r
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL' /A 5 O 1
BUILDING PROJECTIDENTIFIC-AT'ION L V VVV JJJ...
BUILDINGADDRP.SS: SANITARY NO. APPLICATION SUBMITTAL DATE
03 i/� s /1 $ " n qK
OWNS 'S AME: - _1'H�)NhC[�A"fR CfOR'S NAME: LIC NO: NIC CONTROL.
RCHI'r}�f 'i1NEHR: J�"JO LIC NO: AADDDRESS: ❑
coNTAC1:� N � y �1,PHONE: BUILDING PERMIT IN,
'�` _ _ �-`�Q(�i2 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLE-EC�T� PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECfR IC PERMIT FEE
1 hereby.from that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{qoZ with Section 7000)of Division 3 of the Has mess and Professions Code,am my license is RESIDENTIAL
F q full force and el PERMIT ISSUANCE
CSF L ❑SFDWL [I KITCHEN REMODEL
<U License Can APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF-PIPE
Date Caotmetar
ARCHITECTS DECLARATION PANELS ❑MULFFUNIT ❑STRUCTURAL
Z p r=/t Z I understand my plans shall he used as public raords MODIFICATION
CZ UP TO 200 AMPS q [I INFERIOR ']CHIMNEY REPAIR
Licensed Profewinnal 201-1000A S PROVEMENT
C6 hd ai OWNER-BUILDER DECLARATION OVER IlX10A S
4TH=RF.MODEL/REPAIR DEMOLITION
G' 1 hereby affirm that 1 am exempt from the Contracmrs License Law for the
3 CLU following reason.(Section]031.5,Business and Professions Code:Any city or county SIGNS F.LE OTHER
kFV.a which requires a permit to construct,alter,improve,demolish.or repair any sweturt
F-,qya¢ prior to its issuance,also acquires the applicant for such permit to file a signed statement SPECIAL CIRC IS(,
'�,a.•'.1I
that he is licensed pursuant m Ne previsions of Ne Connector's License Law(Ch;
W X00 (commencing with Section 7")of Division 3 ofthe Business and Professions CW e)or TEMP.METE I COMMERCIAL:
d e y that he is exempt therefrom it the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL, Section^ 7031.5byany applleant for a pert subjects the applicaano a civil penalty of POWER DEVICIS rn mi []TENANT ❑FOOD SERVICE
p., not mom thanrivethundudth,orrm(SSW). IMPROVEMENT
6 wi Lothe owner k,and
pestruct structure
yemplended withwagu as their sole(Sec.tom.Businesson, SWIMMING POOL ELE C
q will do work,Coo the ste Cron is not intended rdfiend Lan,does of apply to an Business []OTHER
1 and Professions Cede:The Convectors License law does not apply to if ..per of lfiLETS-SWITCHES-FIXTUR
lits own who builds or improves Hereon,and who does such work deed or or through
his own employees,e building than such improvements are not year..or offered lar NEW RCSIUEN'1'IAL ELECI'R SQ FT.
mle.ILhowever the building bur ins provcment issoldbe did nsereildori improve for
SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving Nm he did urn build or improve for pur-
I]o as owner of the Sec.70property,am exclusively connecting with licensed convenors to T
cone La d project(Sec.o an Business and Profusions CodeO The Convectors and
nu Lnwdacor suchapply wun own a rofpmlwrswhosedporimpro th thereon,and QTY, PLUMBING PERMIT FEE
who comaucts for such projects with u contractors)licensed pursuant to the Contractors
License law. PERMIT ISSUANCE
loo exempt under Sec ,B&PC for this reason
Owner Date ALTER-DRAIN&VENT-WATER(RA) VALUATION
WORKER'S COMPENSATION DECLARAS'ION BACK FLOW PROTECT.DEVICE
thereby affirm under penalty of perjury one of Ne following accentuate (�v
]Ihave asd is maintain a Cenificnte of Consent to self-irmrc for Workers ComPet- DRAINS-FLOOR,ROOF,AREA,COND,
notion,us provided for by Section 3700 Of the Labor Code,for the performance of Ne STORES TVP[:CONSTRUC'fiON
work for which this permit is issued Xn FIXTURES-PER TRAP
El 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe[.shot Code,for the performance ofthe work for which thin permit is issued GAS-RA.SYSTBM-I INC.40UTLETS
OCC.GROUP qPN
My Work tion}}pp{{yymnce carrier and Policy nuPJQ�,,
Cartier, sI/ 'i' ta !-dNA Policy No.:i ten; - GAS-IIA.SYSTEM-OVER 4IEA)
CERTIFICATE OF EXEMPTION FR KENS'
COMPENSATIO ANCE GRGSR/INDUSTRL WASTE INTERCEPTOR
(This sectio if the
is for o.a hum Dollars(5100) ILDIN IV ION Int
nr leaaJ GREASETRAP PLANCHEC 'rte
Ice ythw inthe perfurattanw ofI swcrkf.rwhi`htI if permi 's issued.l shall SEWER-SANITARY-STORM EA.200 FT.
nm emplo any person in any manner u m m hxome mbjecuo the We kers'Cooper. ENERG
cnation Ln sof Culifomia,Ilene WATER ABATER W/VGNT2LECfR
z 0 Applice GR
(-. � NOTIC TO APPLICANT.IL aR m i t s Certificate of Eaenlpti n,you should WATER SYSTEMMEATING
t^ hewn suhjttt tr the Weaker' Cot c mviaint L,)p r(tie,you most 1[-
fonhw hcooply ith res isi it ,y,'/'�J'�^,},h k re, kW. WATER SERVICE
Uj
ONST�U 110 a')'ftWINC AG NHW RESIDENTIAL PLMIL SQ.Fit PAID
C1.
U0 1hereby it on thvuhcr i.aIn cairn le g agency for the performance of uta Receipttl
Its F the h tar whit this peamit I I.iss W(Sec. ,Civ.C.)
U Len ars Name NAM
DJ [<n er'.Ackinn. 's
f},t, I certre ify that I have is application sultana ded the above info madam is BUILDIN FEE
U ratl en I.I agree m cote nh all city and county ordinancesm state lana relining m QTY, MECHANICAL PERM IT FEE
U `& build consw ,and hereby authorize representatives of rhiact ter upon the SEISMIC(
above- W property far inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep handoss the City of Cupertino against ELECTRIC( .
lobilities,judgmems,costs and expenses which may in any way accrucngaisa said CitygLTER OR ADU'fO MECH.in consequence of the grvming of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO FLOW CFM)
S( C EGULATIONN, MECHANICAL I>
AIR HANDLING UNIT(OVER 10,000C III CONSTRUCTION X
.i anamenl'Applicant/Comractor oat, F.XHAUSI'HOOD(W/DUCF) t'41;e"
MI"�I�ATI FEE
HAZARDOUS MATERI DISCLOSURE
Will the applicant ar furore building occupant stnro orhongle huzallous ma¢nel HEATING UNIT CFO 100.000 BTU) - 11
m defined by the Cupertino Municipal Cede,Chapter 1.11,and the Health and Safety
Cade.Section 25532(.)^ HEATING UNIT(OVER 100,000 BTU) w
C]yes ❑NO VENTII.A'1'ION FAN(SINGLE RHS ID)Will the vpplicantor froom huiltling mcupana use eyuipment or Devices which Data 'pt a
tan hax.Nnus air mntamhiants us defined by the Bay Ates Air Quality Management BOILER-
COMP ONP OR If10,Of10 BTU)
UN
llstrid4
1]ye, CIN. BOILER-COMP(OVER 10LOW HTU) s 0
I have ad the hamooasmchemill requirements under Chapter 6,95 of the Culi- AIR CONDITIONER ISS UA
ford.Health&Safety Cede,Secdans 25505,25533 end 25534.l understand that if flue NEW RESIDENTIAL MECH. SQ.Ff.
building docs not currently have a tenant,Net it is my responsihility to notify Ne occupant
of the requirement,which it,,he mea prior,.iseuanev of a Ceeni Lente nI Occulter,
ICIn-
OwnuoramhunmJagetn Date A ISSUED
OFFICE