28688 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /►'S5 Q
CITY OF CUPERTINO BUILDING-ELECTRICAL. PF;RMITNO, 28688
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS�-T/ J /� SANITARY NO. APfPLICATION SUBMITTAL DATE
`171l W % e 4
OW EWAME PI{ONE: CONT CTOR'S NA ' LIC NO:
AME
NIC CON'1'ROI.x
�ARCHI'FECT/ENGIN:ER: LIC NO, ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P UM MECH
❑ ❑ ❑
LICMS17D CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am,coaxed ander prswdlon,of Chapter 9(mimnuancing JOB DESCRIPTION
F1W OC)CWZ withSetion]fN10)nf Uivisinn3nithe Business and PndessinnsCedc,and mylicen.a is RESIDENTIAL
_ infull foreeandeRect. PERMIT ISSUANCE
W ❑SFDWL ❑KITCHEN REMODEL
�UU License Class Cmar APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE
hQd Dee CantDECL
ARCHITECTS DECLARATION ❑MULTI-UNIT S AL
F y Z I understand my plans shall be used as public records MODIFICATION
MODIFICADIFlCATION
0 Z 4-0 UP 170 200 AMPS
te I•W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
OWNER-BUILDER DECLARAT ION 2111"1(100 AMPS IMPROVEMENT
2.C W� I hereby affirm that I am exempt from the Commetor's License Law for the OVER P W AMPS El BATH REMODEL/REPAIR ❑DEMOLITION
y3LLF radowingreason.ISeelfrar7031.5,BusinessandProfession.Code.Any city or county SIGNS ELEC'IHICAI. ❑(YI H17R
=� which requires a From,to construct.alter,improve,denadixh,nr repair any swemre
Mor In iU ismance.also requires the applicant for such pcnniuo file asign
ed statement SPECIAL CIRCUITIMISC.
y" met he is licensed pursuant to the provisions of the Caron is License Law(Chapter 9
yG7 COMMERCIAL:
O (commencing with Semion]OW)of Division 3 ofthe Busines and Professions Cade)or TEMP.MEfE:R OR POLE INST
I1.ty m C that M is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m
Section 7031.5 by any applicant for a permit subjects the applicantto a civil Penalty of POWER DEVICES TENANT 0FOOD SERVICE
not mote than five hundred dollars(S5 W).
IMPROVEMENT
Q 0 LmawneroftheproPet,meryemplayees w'h wagex unci,wlecompcnsaion, SWIMMING POOL ELECTRIC
' '=Q will do the work,and theswcutrc is not intendWo Fee tale lSecA094,Buxines [I OTHER
L3� and Pndea�ions Code:The Conuxcuv's Lice 1e i t apply t er of OUTLETS-$WTTCIIIS-FIXTURES N
pmpery who build,,,,impnyIhccuna hwork hi himhis awn employes.Providal u arc t intend se oRe for NEW RESIDENTIAL ELECIRSQFT.ante.If.however,me buildingr. tbin co ton.the SQ.FIFFLOOR ARLA ASQ.FT.ownembuilder will have the b n he J qsy dim vefarpur- o.salol (.as owner of the properta thg wim licensd conwctms mTOTAL:
con. a the projem(Sec.]IIPr essionx Cdc:)The Conwcmr's Li-
cert. Low does not apply to an owner of property whghuilds or improves thereon.anti QTY. PLUM 11ING PERM IT FEE Jk1A
n
e
who contracts for ouch projects with a eontmemr(x)licensed pursuant to the Contractor's
l ase Law. PERMIT ISSUANCE `G~( k/
❑ I am exempt under Sea ,B&PC for this reawn A �„
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby aRrm orale,penalty olpc jury one of dre fallowing declarations:
(have and will maintain a Certificate of Consent to self-insure for Workers Copper, DRAINS-FLOOR.ROOF AREA.CONE. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Coe,for the permrrunce of the
work fit which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37110oflhe1a1or Ctewl'nnI eperl'urmace afthc work forwhinh this permit is isaed. GAS-EA.SYSTItM-I INC.4011TI.E'TS OCC,GROUP APN
My Wor-cr's Compemauoninmrx cu dPnEcy nun,herarc:
mer olicy No.: GAS-EA.SYSTIiM-OVER 4(EA)
mer. CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(Diis,ection need not he completed ifthe permit is for nae hundred dollars IS Earn GREASETRAP
m las.) PLANCHECK FEE
I certify the in the performance of the work for which this permit is issued.Lshall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in any manner in as to become subject the Workers'Campen- ENERGY FEE
Z satin,Law,of Califomia.[)are WATER HEATT I?R WNENRELECTR
7�12 Applicant GRADING FEE
q M NOTICE TO APPLICANT Il;after making this CcNllcate of Exemption,you should WATER SYSTEM/BEATING
a , become.subject to the Workers Compcmuuom provisions of the Labor Core,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
DCONSTRUCTION LENDING AG agency NEW RESIDENTIAL YLMB. SQ,FL PAID Date Receipt#
Its 0 work
wunionhich
that thew isacomwcdon lending agency for the performane of
the work for which this permit is issued(Sec.3097.Civ.C.)
� IsnJer's Name TOTAL:
WiIxndcr's Address 1 L BUILDING EEE
1 certify fibro I Inn,rend this application and sena thin the above infamatore is
o-F.t V1 carat.l agree to comply with all city and county ordinances and state laws relining to QTY MECHANICAL PERMIT FEE
UZ huitding mnswnion,and herehy uuthorizs repre.enmtives nfthis city to en¢r uMs^the SEISMIC FEE
.w mlxme-mentimd proper far imforlion purposes. PERMIT ISSUANCE
(We)agree restive,indemnify and keep hominess the City of Cupertino against ELECTRIC FEE
Iiabilitia,judgments,costs and expenses which easy many way acerueagaiom said City ALTERORADDTOMECH.
in con.¢gaevice of the gaming of this permtiPLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITI ALLNN-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
.ignmure of Applicu^VComme, f5ste EXHAUST HO(P) W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamor future building werrertmoreor handle hazardous material HEATING UNIT(TO 100,000 BTU)
w defied by due Cupertino Municipal Code.Chapter 9.12.and me Health and Safety
Cede.Section 255320)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Raciptat
Will the air contaminants
in furore building occupant use ea Air a or devices which
colt hazardous air comvninanta m AcfincJ by the Nay Area Air Quality'Management BOILER-COMP(3HI'OR 100.000 BTU) TO
Uisumin4
❑Yes C]No BOILER-COMP(OVER 100,"BTU)
I have read the hazardous materials requirements under Chapter 6AIR CONDITIONER95 of the Cali- ISSUANCE DAT
forma Health If Safety Cede.Sections 25505.25533 and 25534.1 understand that if dm NEW RESIDENTIAL MECH. SQ.ET.
Wilding does not currently have a heated.that it is my responsibility to notify the vacupant
of the requirements which most be,met am,.issuance of o Certificate of Occupancy
Ownercr authorized a gent Date TOTAL: ISSUEDBY. VLN
OFFICE