28589 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28589
BUILDING PROJECT IIIENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
? ,'&e Z-r,'vt C•yo art• yo
OW EWS NAME: PH(INC: -� CON'TRACTOR'S NAME: LIC NO:
N/C CONTROL#
•ARCHITECT/ENGINCER: LIC NO: ADDRESS: ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG CLE P UM MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
I hereby affirm that 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WON thSxlion](1W)of DivisionJoflhc Business tend Professions Codc.xnJ my license is RFSI�NE TIAL:
�ty� ntfall forte and effect. PERMIT ISSUANCE EISFDWL ❑KITCHEN REMODEL
e-u License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N Z W Due Contactor
ARCHITECT'S DECLARATION 0 MULTI-UNIT 0 STRUCTURAL.
{-D m PANELS
Z O V)Z 1 mMerstand my plans shall Nausea]-public mcmds MODIFICATION
OZ=� UP TO 2W AMPS 0INTERIOR 0CHIMNEY REPAIR
E-�2I:u2 Licensed Professional 201-I01UAMPS IMPROVEMENT
xWx IY Q I hereby affirm thatN am OWNER-BUILDER
Cfrom the DECLARATION
License Irw for the OVER IUW AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
R cwUfollowing maxum.(Section]031.5.Business and Professions CWc:,Aartatyorcounty SIGNS ELIiCfRICAI. ElOTHER
F.TF. which requires a permit m con,mai xlmr,improve,demolish,sat repair any ata
aure
f4Q< primo.as ismwcerlm requires theapplic,cm ftrmch Permit o file asigned statement SPECIAL CIRCUIT/MISC.
that he is licenud pursuant o the pawkionx of the Cummerols License Law(Chapter 9
LL�1 tY al)�O (commencing with Section 7")ofbivision J ofthe Business and Professions Coca)or TEMEMEfERORPOLEINST COMMERCIAL:,
a a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
y
Section 7031 S by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
t Than Rve hundred dollars(SSW). EITENANT ❑FOOD SERVICE
!-Z} no moa IMPROVEMENT
Sax ❑1,as owner of the property.or my employees with wages as their sole cempcnmtion. SWIMMING POOL ELECTRIC
�h..� will do the work.and the sttucwreis notimenJeJ ser offacd for tale lSec.]IW1.Beaitaxs El OTHER
Wwe and Professions Cale:The Contracmrs License taw does not apply ns an owner of OUTLETS-SWITCHES-FIXTURES
not who builds or mount thereon and who does such weak himself or through
his own employees,provided that such improvements art not intended or offered for NEW RFSIIIENTIAL CLECTR SQ PT.
sale.If.however.the building or improvement is sold within one year ofeumpletion,the SQ.FT_FLOOR AREA LSQ.FT.
owmar4milder will have the burden of proving that he did not build or improve for put-
you of sale.). T L'0asr
0 I,as owner of the property,am exclusively entrancing with licensed contractors m � C
contact the project(Sec.IDM.Business and Professions CaComm—
Calc:)The Commrs-I-
cense
i- P Z
c selawdoesnotapplytoanownerofpropertywhobuildsorimprovesthemon,and QTY PLUMBING PERMIT FEE till19
who cmmmctsfor such projects with a comracams)Iicen.sed mu
pursnn the Comm ooh95
License law. PERMIT ISSUANCE,
0 I am exempt under Sec. .B h P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VAL'(1 TION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of Perjury one of the following declarations:
O l have and will maintain a Certificac of Consenno self-insure for Work<r's Compen- DRAINS-FLOOR.ROOF, CONU. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Cale,lin the performance of the
work for which This permit is teamed, FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
370amfthe Llmr Coda mrthe performance of the work fur which this pecan,is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS .GROUP APSE
My Worker's Compensation Insurance cattier and Policy number arc'.
Carrier: Policy Na, GAS-FA.SYSTEM-OVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASPJINDUS'TRL WAST F.INTERCEPTOR
COMPCNSA'1'ION INSURANCC �� BUILDING DIVISION FEES
(This section need not he completed ifthe Permit is forone hundred dollars(Sl IAB GRIiASE"BAR
' or less.) PLAN HECK FEE
I ceniry thus in the Perform aneenf thewol,for veh'ahthi.s Permit is issued,Inhall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as to become subject m the WorkersCompen. ENERGY FEE
OZ ration lawsof California.Dmc MINE BE llllNrER W/VI?NT/El-EMR C) Applican GRADING FEE
Z—
NOTICE DO APPLICANT.11,after mak'mg thio Cenilimne of lixempnnn,you shuWd W/O ER SYS'I fiM/I'REA3"]NO SOILS EEE
t"s Inatome subject In the Worker's Compensaion provisions of the Labor Coln,you must
L>t forthwith amply with rush Provisions m Ihia pmmit shill be deemed revoked. WAI Fit SERVICE
Q
Uz CONSTRUCTION LENDING AGENCY NIiW RESII31iNTIA1,PCMB. SQ.IT. PAID Date iptp
B p Ifor by suffinin which
them issue (Sec.i30lendingagency fonhcperformance of
F' Newark for which this permit is issued(Sec.3097,Civ,C.) it
O ULenders Nome l TAC:
Lender's Address
1 certify that I have mad this application and.viae that the above information is BUILD EE
H. pl rosea,l agree Ir comply with ell city and coumy oNinances and slate laws relating m QTY. MECHANICAL PERMIT FEE
UIZ building construction,and hereby aulanize representatives of this city m eater upon the SETS E
move-memion al property for inspection pur{vncs. PERMIT ISSUANCE
(We)name 1. .,a,indemnify and keep harmless the City of Cupertino against ELECTRIC EE
liabilities,judgments.costs and expenses which may in any w���YYf�ggg cans xai City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the gronting of thin permit. /w
APPLICANT UNDERSTANDS AND WILL COMPLY SP''li 1. AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IE(gO CFM) CONSTRUCTION AX
Signamreof ApplicandConnaaor Date EXHAUST HOOD(W/DUCI) HOUSING MITIC ON FEE
HAY.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building eccapant stem or handle hvallous material HEATING UNIT GO I00,W)BTU)
as defined by the 32(x)?ata Municipal Coe,Chapter 9.12,and the Health and Safety
Cale,Sutton 25532(x)? HEATING UNIT(OVER 1 W,Iglll BTU)
[:I Yes 0N VENTILATION FAN(SINGLE RESID) PAID Dam Rwcip,#
Will the applicant or future building ocupmm use equipment or devices which
emit Encomiums air contaminants as defined by the Buy Area Air Quality Management BOILER-COMPOHPOR IW.OUD BTU)
District? TOT
❑Yea ON. BOIL12R-COMP(OVER I011000 BTU)
III I have mad the hazsNous mtedaN raluirernems under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE ATG
forma Health&Safety Code,Sections 25505.2557]and 25534.1 maewmnd that if the NEW RESIDENTIAL.MECH. SQ.IT.
building docs two currently have a tenant,that it is my re.4amsibilay to notify the accupnm
of the aquirements which must be mel prim to issuance of a Certificate of Occupancy.
Owner or xmhoriad agent Data TOTAL ISSUED BY:
OFFICE