28519 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28519 Q 5 1 Q
BUILDING PROJECT IDEN9'IFICATION L V 1 V
BUILDINGADDRESS: k SANITARY NO. APPLICATION SUBMITTAL DATE.
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ARCHITECIMNGINEER L C O: ADDRESS //^^�� TII aTTAA--
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CONTACT: PHONE: BUILDING PERMIT INFO
/d ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MOH
LICENSED CONTRACTOR'S DECLARAT ION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(e.morstr g JOB DESCRIPTION
O YoZ Ih Section 700(fol Diviom13nfthc liuvinevs and Prnfexsionx Coda and my license ix RESIDENTIAL:
WOO
with PERMIT ISSIIANCE
SUE
in is]]force and cffc 6 � ❑SFDWL ❑KITCHEN REMODEL
QUU ,man Cl s "—Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
W Dme TSDI -
[-.Oval ARCHITEL YS UEChA tATION PANELS - [ MULTIUNIT ❑STRUCTURAL
ZpNZ Iundersmnd my plans shall be aced as public remNs�o-` MODIFICATION
OZ-O UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
r l4tU Licensed Professional 20LIBWAMPS IMPROVEMENT
993 OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR ']DEMOLITION
6 I hereby affirm Ihal 1 am exempt from the Conoanois Licence Law far the
d O i U following mason.(Section 7031.5.Business and Professions Coda:Any city or county SIGNS ELECTRICAL ❑OTHER
IR 3 U y which reams a permit m covsuon,alts,improve.demolish,or apair any nmaurt
F�'O¢ prior to its issuance.also resluimx the applicant for such permit-Glc a signed statement SPECIAL CIRCUIT/MISC.
that he is hentsed persaam-the pmva,ma—f the Cmanctor'x lice nee Law(Chapter 9
�f�p0 (commencing with Section]00)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a aX o that he is exempt IM1erefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^m Section 7031.5 by:myupplicanl fora pmorea objects the...branun a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE.
not more than live hundred dollars(551X)). IMPROVEMENT
=o 01.as owner of the pmpeey.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC DOTTER
(_ will do the work,and the structure is not intended or offered for aole(Sm.]oI4,Business
1+13 and Professions Code:Ure Contrdclnrs License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
q' property who bpi Ida or improves therum,and who d.,,,.,h work himself In donugh
his awn employees,provided he,such iaSome ncns art not intended or offered ter NEW RESIDENTIAL ELECTS SQ FT.
sale.If,however the building or improvement is sold within one year of completion,the SQ.FIT.FLOOR AREA S/SQ.IT.
ser-builder will have the burden of Timing thus he did not build or improve for par-
0'm of sola).
Fl 1,as owner of the property,am exclusively contracting with licensed convacturs lu TOTAL:
consumer the project(Sm.7044.Business and Professions lisle:)The Convectors Li.
nm Law dons nm apply m an owner of property who builds or improves thereon.end QTY. PLUMBING PERMIT FEE
who contractsFaSU01 Projnawilh a cvmtmetar(s)licensed pursuant to the Contractors '
License Law. PERMIT ISSUANCE
I nm ema,q under Sec. ,B&PCjfnr Nis sawn 1 „���
Il g T ALTER-DRAIN'&VEM�WATER ken{ VALUATION
Owner mm ` -
WORKER'SCOMI'ENSATION DECLARATION [A t RACK FLOW PROT[C9'.DCVICP,
I hereby affirm under penally of perjury one of the following declker's ms: - Y
plhave and will for by eCion 3700 of theConsmot to Laor Codc,eua for Worker's Compaq- DRAINS-FT.00R�ROOE AREA, D. I STORIES TYPE CONSTRUCf10N
xntinn,os pmvidW far by Section 3]01 of the Labor Code,for the per4;.rmonee of the
work for which this psmnil is issued. FIXTU ° 31S
1 have end will maintain Workers Compensation losumnca as required by Section I r
370of the laborCade.fon he perforromm.lthe work for which this permit rsjss , GAS-FA.SYSTEM-I INC.4OUTLETS ,ice OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number no: U�
Carrier Policy N..:
GAS-EA.SYSTEM-OVER Y(EA)'+' ""''� -
� 1111...._..
CERTIPICATEOFEXEMPTION FROMWORKERS' +•-- - GREASEONDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEL'.ti
This section realm,be,emnlplemd if the Permit is fortune hundred do[].IS lap GREASETRAP
or less) PLANCHECK FEE
leartifythalind, rmance of the nkfuswht lhispertnaisi...aLlshull SEWER-SANITARY-STORM EA.20 FI'r
not employ any person i dd0 n V"b"Workers'Campers- ENERGY FEE
Z satin Lawn �C 'u�) WATER HEATER WNIiNT/ELECTS
ZQ Applicant 'I GRADINGFEE
ip NOTICE TO APPLICANT: L after making a Certificate of Exemption,you should WATER SYSTEM/TREATING
F•' become subject m the Worker's Compensation provisions of the Labor Code,you must SOILS ItiC
Wforthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Qp'
CONSTRUCTION LENDING AGENCY NEW RF.SIUENTIAI.I'LMR. SQ,17. PAID Date Reccipla
VO Ihemby affirm Nat there isvicaj( tion lending agency for the performance of
D. F" the work branch this permit is issutt(Sec(Scc.J0Z`--q"1
U Irnders Emote--- /�(— TOTAL:
loaders Addrv! /y 1 �-
ly I certify Nat I have mad this aPplmaton and scam that the above information is BUILDING FEE
to e-rea.l agree to comply with all city and county ordinances and state laws relatingto QTY MECHANICAL PERMIT FEE SEISMIC FEE
V building conslructinn,end herebyuwhmornapresentatives of this city to enter upon the
uMwe-metnioned pmpeny fart inspection purluncn. PERMITISSUANCE
(We)agree m sive,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilitiesjudgmenm,costs and espcnses which may in any way accme against said City ALTERORADDTOMECH. PLUMBING FEE a�
ine msequencc oft egmming of this emit
APPLICANTI NI 1.11 NOS ILL COMPLYWITII ALL NON- DINT AIR HANDLING UNIT(TO lo.oXICFM) MECHANICALFFE
SOURCE. EG L MONS. /y /
AIR HANDLING UNIT(OVER IO.a)O CFM) CONSTRUCf1AN YX
Stgnnmre of Appbco vvcan �(/-i/ O"Dlate-' EXHAUST HOOD OxIMUC) GMITIGATION ITH
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant-fuwm building Occupamsmem handle haurdovs motorial HEATING UNIT DO 101000 BTU) A ��
as defined by the Cupertino Municipal Code,Chapter 9.12,uRd the Health and Safety17
Glda Section 25512m)? fIEA'TING UNIT(OVER IdB,U1XI BTU) � log
��
❑Yes t VENTILATION PAN(SINGLE RESID) PAID Receiplp
Will the applicant or future building Occupant use equipment or devices which BOILER-COMP(LHP OR 10,000 BTU)
imil haaardonx air commitments s defined by 11te tiny Area Air Quality Managancnt TOTAL.
Diorrict7❑Ycs ({{Nu BOILER-COMP(OVER 10,000 BTU)
I have adthe hnmrdnus-..trials regairemems under Chapter 6.95 of the Cali- AIR CONUIT'IONER ISSUANCE.DATE
re
femis Health&Safety Code.Sections 25505,25533 and 25534.1 understand Nat If the NEW RESIDENTIAL MECH. SQ.FT.
building it.not cmamly have a mneme Thal it is my responsibility In notify the aupam 1
MIM requirements which must be at prior m issuamc of o Ccgificaze of Oce-Pancy. ,`•�
Owner or authom<J agent Date TOTAL: ISSUED BY:
OFFICE