28709 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LF.CTRICAh PERMIT NO. 28709
1 /�
BUILDING DIVISION APPLICATION/PERMIT 1'LUMNINO-MECHANICAL. /Q 7 O 9
BUILDING PROJECT IDENTIFICATION LV �J
BUILDINGADDRESS SANI'IAHY NO. APPLICATION SUBMITTAL DATE
O a'SN MIi: PHON �� CONTRACTOR'S NAME: LIC NO: /-/C 2 6
N/C CONTROL
ARCHITECUENG LEN: LIC NO: A P ❑
s Gat
CONTACT,. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 Am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
C fYZ with Section]IXxq of Division 3 ofthe Mussiness and Professions Code.and my license is RESIDENTIAL,
W 00 PERMIT ISSUANCE
FK Iy_ in full force and effect. ❑SPOWI. ❑KITCHEN REMODEL.
QUtLicense Chex Lic.X APPLIANCES-RESIDENTIAL ❑AUDITION RrPLUMBING RE-PIPE
FFZW Dae Contractor
NG1 ARCHITECTS DECLARATION ❑MUCTLUNIT []STRUCTURAL
F,Nm I uulemandnty plane shall he used us public records PANELS MODIFICATION
pZm UP 110200 AMPS
-�p El INTERIOR El CHIMNEY REPAIR
st 4l' y Lianscd l'nJ'esslonnl 201-1(m)AMPS IMPROVEMENT
`y2; OWNER-BUILDER DECLARATION OVER IINN)AM1tI'S ❑BATH R17MODEUREPAIR 0DEMOLITION
C CW 6 1 hereby uthrm tlmt 1 ant exetnpl Irate the ConOndors License Law for the
Q.V allowing rtavon.(Section 9031.5.Rote mens and Professions Code:Any city car<mmly SIGNS PLEC'fRICAL ❑OTHER
W y which requires a permit at construct,cher,improve,demolish or repair any d ucmre
F��¢ prior toils iswancA.1sorequiresthcapplicant fmwch Permit to Lleasignedstammemd SPECIALCIRCUFUMISC.
N dna he is licensed PAMAAL to the provisions of the Contractor's License Law(Chapter 9 COMMERCIAL
.
L'p0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
Q.0, that that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicantfor a permit subjects the applicant to a civil penalty of POWER DEVICES (]TENANT ❑FOOD SERVICE
not me.than five hundred dollars Wish. IMPROVEMENT
=O ❑I,as owner write property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F. will dath,work...d thesuudureknot imendedorotTemd fm vale(Sec.7044,Business OTHER
W m and Professions Cache:The ContmLicense Law does not apply to an owner of OUTLETS-SWITCHES-FI%TURES
ctm's
d 3 progeny who builds or improves thereon,end who does such work himself or through
his own employees,provided that such improvements are not intended ter offemd Im NEW RESIDENTIAL ELECfR SQ FT.
sal.ILhoweve,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA SISQ.FT.
rowner-hadder will have the burden ofpmving that he did not build or improve for put.
pose ofszle.). TOTAL: A r�
1,As owner,of the Progeny, in exclusively contracting with licensed cmarecrwrs In
construct the project(Sec.744,Business and Professions Code:)The Contractors Li-
censeLaw duesnot apply toanowner ofprogeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE QD
whocontmetefor,mh projats wilt Acnmmdorta)Ilccneod pursuannnthc Cwmmnots Xss_ 5 1996
License exempt
I'LRMI'1'ISSUANCE in in U
exc
Imo nmt under Sec. ,B&PCfor this reason ,
ALIS DRAIN&VENT-WATER IEA) I rel1".1 V DATION
Owner Dam
WORKER rder COMPENSATION DECLARATION BACK Iq,(IW PItOTECf.DEVICE
1 heathy Admaniunderpenahyofpcfjupaneofthe frome fng dreWmact ions:
❑Ihuve anJ will mainutina Cenifcmcof Cnmem mself-insure far Workers Cnmpcn- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
nation,as Provided far by Section 3]1X)cilia Labor Code,for the performance of irea
work for which this Annul is issued. FI%'TURES-PI?H TRAP
1 have and will mainmin Worker's Compensation lucrative,as comired by Section
391%)dth<LuburCode,for the performance oldie work forrpwhich
fthis
Permit is issued, GAS-EA.SYSTEM-1 INCAOUTLETS OCC.GROUP APN
fees �pcnsayup rap - Polcy N..Y'a wa�.,�f�7-qS GAS-P,A.SYSTL'N-OVERJ(EA)
am rCERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFJINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(This section need not to completed if the Permit is for one hundred dollm, S1 W) GREASETRAP
or less) PLANCHF.CK FEE
I certify that in the gerfonvner.0he work for which this permit is ismcd,)shall SEWER-SANITARY-STORM EA.20)FT.
not employ Any Person in any manner w as to Become subject the Workers'Compen- ENERGY FEE
Z cation Laws of Califomia.Date WATEN HEATER WNENMELEM
ZApplicant GRADING PEE
rNi NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING SOILS FEE
F' become subject to the Worker's Compensation provisions of the Labor Code,you muss
Wti forthwith comply with such provisions or this ge wit shall he deemed revoked. WAI ER SERVICE
0
Ox CONS UCT10NLENDINGng agony NIiW RESIDENTIAL PLMB. SQ.FT PAID pate Receiptp
1 hereby uftinn that Ihcre is a conswctian lending agency for the performance of
WO the work for which this pc,an'is issued(Sec.3097.Civ.C.)
C) U Lentos Name 1 TOTAL:
Lenders Address
G 1 cmil' cu
y that 1 have scud IBIS application And state that the above information is BUILDING ISL'
tihcorrect.l agree to comply with all city and county ordinances and sure lows rdAdng n' QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V7
r1- building umsuuctiwn.and hereby nudhorizerepresentative,of this city to enter atom the
shave-mentioned progeny for inspection purposes. IT f ISSUANCE ELECTRIC FEE
(We)Agree to save,indemnify and keep harmless the City of Cupec ian against
liahillties,judgnam.s,costs and expenses which may in any way section against said City ALTER OR ADD TO MECH. PLUMBINGFEt Q O
in nurse eirw,of the grantingof Ihi
APPLICANT UNDERS ND ND rel COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SO CEREG 1
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCIIONTAX
Signau pgl a .new Pat, li%I{pUST HOOD(W/DUCq HOUSING MITIGATION FEE
H DOUS MA ERIAIS DISCLOSURE
Will the applicant or fumm buildingoecupant stem mhandlehazardous material HEATING UNIT(TO IM.000 BTU)
us defined by the Cupertino Municipal Code.Chapmf 9.12.And the Health anal Safety HEATING UNIT(OVER 100.0(10 BTU)
Code.Seemm
25532(x)'1
HEATING
❑Nn VF.M'ILAI'[ON FAN(SINGLE RESID) PAID Da¢ ReceiptX
Will the applicant or future building occupant use equipment or devices which BOILER-COMP QHP OR 100,(X)0 BTU)
mit hauNous air contaminants as define)by the Bay Arca Air Quality Management TOTAL:
District'! BOILER-COMP(OVER 100.000 BTU)
❑Yes ON.
1 have mad the hazardous materials regmimments under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
form.Hath&Safety Cmit,Sections 25505.25533 and 25534.1 uadersmad that if the NI?W RESIDENTIAL MECH. SQ.Fr..
building does not amrectly have a meant,than it is my responsibility tomiry the recupunt
mine re,ir,menu which maxi he aid prior In issmance of a Ccnificate of Occuptmey. wap
Owner,Amahnrtied.gem Date TOTAL: ISSUED BY: V I]F{f
OFFICE