28687 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL 1'17MMI'I'NO. 28687
NDIVISION APPLICATION/PERMI•T PLUMBING-MECHANICAL
BUILDING
BUILDING PROJECI'IDENTIFICATION
BUILDINGADDRESS: SANITARY N(l. APPLICATIONSUBMITIALDAIF
16 33 - I I u a
'NERS P HONPE: CONTRA�I'O 'S NAME C
IUN /i IC COMI'ROLp
•ARCHITI 'NGINEER: LICNO ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD 'L' PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that l am licensed under provisions of Chspmr 9(commencing NM DESCRIPTION
OOZ diScction]000)af Dimmon3ofthc Busitmssand Professions Calc,and myliccnsc is RESID NTIA -
F12ntfull force and effect. PERMIT ISSUANCE 1
m— ❑SFDWL ❑KITCHEN RHMODEI,
QUU License Class I.icg APPLIANCES-RESIDENTIAL ❑pDORION El PLUMBING RF.-PIPE
HZi Dme Co......
ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
F0v!Z I understand my plansshall usedm ra
public ordv PANELS
Zse MODIFICATION
QZI:p UPTO 20131 AMPS El INTERIOR [I CHIMNEY REPAIR
W LicensW Professional 201.1000AMPS IMPROVFIdENT
G �-J OWNER-BUILDER DECLARATION
C� -t OVER 1000 AMPS ❑BATH REMODEUREPMR
Q 1 greasy.Turco that 1 em exempt from the ContrnsCode:Any c Law o for the
k 3 d U which eq reason.Permit
]D3L5, t,alter, and! l mio demolish,
h,oAny city or counstructure SIGNS ELECTRICAL DOTTER
F. LL N¢� which in i...a permit also re minx tore alcor,improve.,forsudemolish. file
repair any atmm.¢
F•�O.i that he tliceuance,rsuarm to the thoximmarant for such Amnio.icessLawoetement SPECIAL CIRCUHUMISC.
fly that he islittnseJpursuamrothepmvimianxofNeComrecmrsLicenseLew(Chaprer9
(commencing win Section700o.f Division Sof the BusiacoanJ Professions Cale)or TEMP.MFR OR POLE INST. COMMERCIAL:
6 d e oat he is exempt nerefmm and ec basis for rbc alk6dJ exemption.Any violation of O NEW BLDG/ADDITION ❑DEMOLITION
W:2to Section 7031.5 by any applicant for a peroutsubjects the applicant a civil penalty of POWER DEVICES []TENANT ❑FOODSERVICE
not moa than five hundred dollars(S5W).
IMPROVEMENT
❑Lo the work,nth themny.or is of intended woffereesmttt (Sec.compensation. SWIMMING POOL ELECTRIC
F• will dnthesions Codec he cture Contractor's
mots License Law does no,apply
apply .J4,Business ❑OTHER
tail�m and Professions Code:The Contractor's Licenu Tose.ems not apply m an owner of OUTLETS-SWITCHES-FIXTURES
R'3 r property who builds or improves thereon,and who does much work himself or through v sh
his own employees,provided that.such improve rents arc not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
rule.ILhowever.he building or impmvemcm i.s%old Within uncyearolcompletion,the aQRI9 FLQ0yJ.RGA'as� $/SQ,IT.
uiWe will have the burden of proving that he did not builds improve for par- Nor l7 J�JI�
e.f hale.). TOTAL:
r of the potpeny,am exclusively connecting with licensed comma,'..in Ct I Y VI• (,urns I ITV
nn.swm the project(See.704,Business and Pndrsoom Court)The Cantraou,Li-
cense Law does not apply nr an owner ofproperty who huikkor inrpntvcs them,and Q1 Y. PLUMBING PERMIT FEE
Who contracts human ptnjasns wall,,contructons)Iicenxai purs.ant.the Contractor's
License Law. PERMIT ISSUANCE
I con c prerkcr Sec. .II at P C for Thi:rc sr
ALTER-DRAIN&VE (EA) VALUATION
WORKER'S COMPEN. TOTll,",(�),gN
DEC[, BACK]:LOW PRO ,LT.DEVICE
w l hereby affirn under penalty of lxrjury oof thedeclaradon
•n I haveand will maiffen.Ccnir aloof ConsentW..kcr'm Cmpen- DRAINS-F IR,ROOF,AREA,GOND. STORIES TYPPCONSTRUCDON
cation,as provided for by Section 3700 of the Luerformance of the
work far which this permit is issued IIXTU -PER I RAP
❑I have and will maintain Workers Compensation Insurance,us required by Section
37W of the Labor Code.for the perbmnanee of the work for which this Permit is h.wed. G -F-A.SYST - INC Y OUTLETS ti, OCC.GROUT' APN
My Worker's Comperosmion Insurance carrier and Policy number arc:
Career: Poi icy No.: GAS-IiA.SY. E ER4(EA)
CERTIFICATE OF EX EM"ION FROM WOR KERN' GREASE/I . RLWASTEINT
COMPENSATION INSURANCE BUILDING DIVISION FERS
(This section need not smr
c completed ifrhe peit is for onchumdeaddollu(S 10) GREAS P C
m IcsxJ \ PLANCHECK Itifi
I cenify that in the performance ofthe work forwhich this permit is issued.lvh I _SANITARY-S ftME 2W FT.
ern mum
employ amy person n any mer so as m m
becoe subject,,the Workers'Comps ENERGY ILC
O Z sari..Laws of California.Uz,e :R HEATER NE /EL CTR GRADING FE
EZ Applicant
NOTICE.TO APPLICANT,If,after making this Cenificare of Exemption,You shou)J WAT14 SYSTEM INS
Ixcome subject t. he Workers Com tion f the Labor Code,you mutt SOILS PEE
1 ps ort ermiin,,ammas
forthwith comply with wchpmvisions or Permit shall he JttmW rtvuked. WATER SERVICE -
7
ZD Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID D R •i tk
U 0 1 herebyvffirodrad is isacumtruction lendingage.cy for the Performance of p
f~
the work for which his permit is issued(Sec.3097.Civ.C.)
u' I<nAe/s Name TOTAL:
0 UIcndcri Address TOTAL:
} y I cenify that 1 have read this application and state that the above information is BUILDIN
F0 correct l agree to comply win all city and county ordinances and state laws rtfarm,to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authentic mpmmmatives of this city m enter upon me SEISMIC FE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agt.save,indemnify and keep harmCupertino less the City of Cupeo.gains ELECTRIC FEF
eae
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MICH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDER STANDS AND WILL PFISIPLY WITHALLNON-POINT AIR HANDLING UNIT(T010.0110CFM) MECHANICALFE.
SOURCE)iCGJ+[.ATIONS.
Q '� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION AX
.Ignamrco canUContmctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIS TIONf9Hi
HAZARDOUS MATERIALS DI.' SURE
Willtheapplicald nr humrc building occupant st r handle haardmo mvmord HEATING UNIT(TO 1W.IXp BTU)
as defused by the Cupertino Municipal Calc.Chapter 9. 2,und the Health and Safety
Code.Section 25572(.)? HEATING UNIT(OVER 100,000 BTU)
❑Ye. ❑No PAID
VENTILATION FAN(SINGLE RESID) Dare Rc xiprp
Will the applicant or future building occupant use equipments devices which
emir hvaard.us air contaminants us defined by the Buy Area Air Quality Management BOILER-COST UHP OR 100,000 BTI) TOTAL
District❑; Yes ❑Nn
' BOILER-COMP(OVER 100,000 BTU)
I have read the hamrdou.s materials rc a tinder Chaterfie5ofmc Car- AIRCONDITIONER ISSUANCE DATE
quire p
fomiv Deakin&lately Code,S ninny t,that5,Ntoy and 21914,I to notify the
Thor it
NEW RESIDENTIAL MECH. SQ.FT.
building air not,whittly hovel ¢nun,,that itis mry or of it Cony br notify the pansy,
upant
of he requirements wM1icM1 must M nmr prior er ismn:mce of a Cer,iliculc.l lkarp:mry,
Owner or authorized agent Date TOTAL:11 ISSUED BY:
OFFICE