28873 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINC-MI!CHANICAL 28873
BUILDING.PROJECTIDENTIFICATION
BUILUIN'GA DRESS SANITARY NO. APPLICATION SUBMITTAL DATI
OWNE 'ISNAMI!: PHONE: I CONTRACTOR'S LIC L
09sVR NIC CONTROL#
CHIT v /ENGINEER: LIC NO: ADDRESS: 07 ❑
CONTACT': r /�/� PHONE:/ /./ BUILDING PERMIT INFO
(may/ 3 DO`11 F-1ConsultantFees Paid by Applicant(Initial) L ELECT PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(coon cnciog JOB DESCRIPTION
O00 with Section 7001B of Division 3 of Ne Business and Profeesions Cline,and mil licenuis
fir 00 o f PERMIT ISSUANCE RESIDENTIAL:
m full force and effect.
QU License Class Lic.p ❑ADWL ❑PLUMBIKiTcHENREMODEL
�� Dme�e 6Ql Commcmr APPLIANCES-RESIDL'NTIAL []ADDITION [I PLUMBING PIPE
y AR i ,CT'S DECLAR ION PANELS ❑MULTI-UNIT CI STRUCTURAL
x Ov�7J. 1 understand my plans shall be used os public record MODIFICATION
OZ JO UPT02MAMPS [2 INTERIOR El CHIMNEY REPAIR
rot-J Licensed Professional 201-1 AMPS IMPROVEMENT
jig
OWNER-BUILDER DECLARATION OVER 1010 AMPS�-+O SSS I hereby affirm that I ten exempt from the Contractor's License Law for the ❑BATH RF.MODF:L/REPAIR 0 DEMOLITION
W4 U fnilowitV reason.(Section 7031.5.Business and Profession,Cade:Any city orcounty SIGNS ELECTRICAL []OTHER
C b' which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance.also requircsthe applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
that he is licensed pursuant to the provisions of the Convenor's License Law(Chapter 9
DO (commencing with Section 7100)o(Division 3 of the Business and Professions Code)or TEMP.METERORPOLEINST, COMMERCIAL:
4 p,a that he is exempt therefrom and the basis for the alleged esemption.Any violation of ❑NEW BLDG/ADDMON ❑DEMOLITION
^,] Section 7(31.5 by any applicant for u permit subjects the upplicunfto a vivil penalty of POWER DEVICES
rn []TENANT El FOOD SERVICE
p., not more than five hundud Perry,
or my
y 10iemployees
IMPROVEMENT
O (] L us ownendtheartpenctures id matueeswithwage.eos theirsolecompensation, SWIMMING POOL ELECTRIC
a� will do the work,and the structure said intended er a w do Resalepply to an Business El OTHER
and Profession,Code:The Comment's License law dors not apply m an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and o does such work himself nr through his own employers,p,, (het su naRmve eats arc not intended or offered for NEW RESIDENTIAL ELELTR SQ Prn
stile.If,however,thebuildingnrimpo t :>� withinomeyearofromplelion,the SQ.FT.FLOOR AREA SISQ.ter
owner-builder will have the huNen of � i did not build o 'e for Eur-
aarsewn ���{{{
I,vs ownerId
1Y• ani ely onwetincon
ucmrsm T
conawm the p1 ,Business fessiuns C :)The con's Li-
seLowdoeun owner''JJ��pr�� ny win be improves thereon,and QTY, PLUMBING PERMIT FEE
cts witheeot}r ¢eaedpurturenno the Contractor's
PERMIT ISSUANCE
,H&P C for this reason
Owner Dom ALTER-DRAIN&VENT-WATER(PA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTETDEVICE
y I 0
/4/7
I have and will maintain a Cardfcme of Consent o self-insure for Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPECONSTRUCTION
section,as provided for by Section 37W of the labor Cafe,for the performance of Ne
work for winch this permit is issued. FIXTURES-PERI RAI'
❑I have and will maintain Workers Compensation Insurance,n required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-PA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Work nu� tioalnsa� erand Pnlicyns
Policy No.: GAS-EA.SYSTIALOVER 4(EA)
CERTIFICAT17 OF 1 EMI'rION IiROM WORKERS'
COMPENSATION INSURANCE GREASWINDUSTRL WASTE.INTERCEPTOR
0 his secliun need not be completed if the permit is income hundred dollars($I00) BU . G ISION PEES
GREASE•TRAP
or less.) PLANCHECK PEE
Icenify drain the pedonnancc oRhe work for which this permit is issued,lshell SEWER-SANITARY-STORM EA.200 FT.
stn employ any person in any manner nom 10 become suhjecno the Workers'Compere- ENERGIFLI
Q ,Z siliou Lawsof Celifornm Ere WATER HEATER W/VENT/ELECTR
z 0 Applicata GRAD G
rA NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM?BEATING
become subject to the Workers Compensation provisions of the Labor Code.you must SOILS
for hwilh comply with such provisions or this Feted,that Inc,deemed revoked. WATER SERVICE
Q
CONhen iso TIONLENDING
ng agony NEW RESIDENTIAL PLMP. SQ.FT PAID
7 z Ihercbyuffimtthauhere isaconswetion lending agency for the Performance of Receipt as
4Uks the work for which this permit is issued(Sec,3097,Civ.C.)
Q U Lenders Name TOTAL:
y WLanders Address TOTAL:
CL I certify that I have read this opal lcal len and state(hut the above information Is BUILDING FEE
rA cortect.l agree to comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE
U4 buildingconnmhod
ctim,rnd hercbyautrareane,nm.ivesuf flakcity to emerupm the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree h save,malcrrifyand keep harmless the City of Caperton against ELECTRIC FEE �.
liabilities,judgments.costs and expenses which may in anyway acme against said City p1aER OR ADD'1'O MIiCII.
in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTAND�WILL COMPLY WI HALL NON-POINT AIR HANDLING UNIT(1010.011s)CFM) MECHANICALFEE
S/OU
AIR HANDLING UNIT(OVF.R IEf1IX1 CFM) CONSTRUCTION TA%
Signature of Appli Commnor Da EXHAUST HOOD(WIDUC) HOUSING MITIQATION FL'E r
IIAZANUOUS MATERIALS DISCLOSURE
Will deapplicant orfoture building occupant store or handle beurdons material HEATING UNIT(TO 110.000 BTU) '
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Coda,Section 2553200? HEATING UNIT(OVER I f0,n(X)BTU) fro
(]Yes E]No VENTILATION FAN(SI NGLE RES ID) PAID _,�
f.fa• Date Recei #
Will the applicant or future building occupant use equipment or devices which 1 ar
ueardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP UNP OR I ORDIDD RTU) yr-
C1T144 r 7 AL:
tstrict?
❑Yes ON. BOILER-COMP(OVER I00.000fO BI U)
I have read No uncommon materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
ramie Health&Safety Cale,Sections 255115,25533 and 25534,I understand that if the NEW RESIDENTIAL MECH. SQ,FT.
building docs not currently breve a retia d,that it is my responsibility to notify de rsccupant
of de requirements which must be met Friar to issuance of a Cenificam of Occupancy.
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE