28523 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB=-MECHANICAL 15 -3
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SAND'ARYNO. APPLICATION SUBMITTAL DATE
o d2 o�TJ4L_ M0 �_•3OA5
OW HR'S NAME: a PHONE: CONTRACTOR'S NAME: LIC NO:
4 1
NAC CONTROL
AkCHIfECT L'NGINEER: LIC NO: ADDRESS: - ❑ 'r
L G-I&152-
' CONI'ACI': PHONE: BUILDING PERMIT INFO
C I jCy��� ❑ Consultant Fees Paid by Applicant(Initial) LDG CT LUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 bcrehy affirm that I am liceosml under provisions of Chapter 9(commencing JOB DESCRIPTION
MI4Z with Section]00)(H. Division 3.fthe Business and Professions Code,and my licenssis RESIDENTIAL
00 PERMIT ISSUANCE.
yl r ifull force snit elfat. [IS WL ❑KITCHEN REMODEL
U DotLicense Class Conntor APPLIANCES-RESIDENTIAL DITION El PLUMBING RE-PIPE
to ZQQQ e Cnmrac
b.Dy
ARCH ITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
2Ov� lmtderstund my plans shallbeused as public records MODIFICATION
OZ O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4 Licensed Profcasi...I 201-I000AMPS IMPROVEMENT
OWNER-HUILDER DECLARATION
W Q 1 hereby affirm that 1 am exempt from the Convectors License Law Airline OVIiR["AMPS ❑
0 BATH REMODEUREPAIR ❑DEMOLITION
igqp5g4 U following meson.(Section 7031.5,Business it Professions Code:Any city or crow, SIGNS ELECTRICAL ❑OTHER
W a 0 F which requires u permit a construct,slat,,improve,demolish,or repair any swmurc
CI=O prior 10 its issuance,also requires the spliced for such permino file v signed smlersem SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant the provisions of the Contmim's License Law Charity
00 (commencing with Section 90g(0 of Division of the Business and Professions Code)or THMP.MEI ER OR POLE INST. COMMERCIAL:
6 c eG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section 7031.5 by any applicator for a permit subjects the applicant I...ME penalay of POWERDEVICES
❑TENANT ❑FOOD SERVICE
at mora than rise hundred dollars(5500).
Q ❑I,as owner ofthe pmperty,or my employees with wages as their sole compensation, SWIMMING POOL ELELTRI� IMPROVEMENT
0 will do the work,and theslmcmm isnot ineadclmoffeml for sale Sec. 044.Busintaa El OTHER
S and Professions Code: no Contractor's License Law dons not apply to an owner of OUTLETS-SWITCHES-FIXTUR a
r property who builds or improves dureon,and who docs such work himself or Rtrough
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELF.CTR
sole.If,however,the building or improvement is sold within one yarofcompletion,the SQFTFLOORARpA $/SQ.Fr
owner-builder will have the burden a proving thin he did not build m improve for pur- (/■`I1Fly-+(/
pose of awe.). ^fig
C] 1,as owner of the property,am exclusively connecting with licensed contracmra to TO' L' l S I OJ
construct the project(See.Trutt,Business and Professions Code:)The Connector's Li-
ccmeLaw days not apply loanownerofpropeny who builds car impuveslhuromnul QTY. PLUMBING PERMIT FEE
whocontract forsuch projects with ecormsoods)liccnscdpurstrant.the Contmcmrs
License Law. PERMIT ISSUANCE
❑I am esempt under Sec. ,B&P C for,his.ansa
Owner DALTER-DRAIN&VENT-WATER(EA) VALUATION
am att"
WORKERSCOMPENSAI Nquary on DECLARATION BACK FLOW PROTIiCI'.DEVICE
I hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Ceniftcme of Consent to selLinsure far Workers Co.,.. DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
action,as provideil for by Section 3700 of the Labor Code,for the performance of the
work for which this Patent is issued FIXTURES-PER TRAP
❑1 have end will maintain Worker's Compensation Inmomace,as required by Section
3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Workers Compensation lnsumncs,carrier and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSIEM-OV13R4(EA)
C17RTIFICATE 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRE-ASFIINDUSTRI.WASTE INTERCEPTOR
(This section need our he complded oche permit is for one hundred dollars(SIIE) IEk& 'DI I NPEBS
or less.) GREASETRAP PLANCHECK FE
I certify that in the performance ofthe work for which this permit is issued,l shall a
not employ an Person in un manner so as a become suben to the Worked Com SEWER-SANITARY-STORM P.A.200 fT.
p y ype y ) pen- ENERGY PEE
Z sotto.Lawsof Cnlifomia.Date WAIM HRATER WNENT/ELECTR
707 O Applicant GRADING F
Gy NOTICE TO AEI'LICANT:IL nfmrmaking this CcdiGcmt of Cxcdnption,you should WATER SYSTEMfFREAn'ING
a '„^ become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
W r� foMwithcumply with such Provisions or this permit shall be deemed revoked. WATER SERVICE
�z CONSTRUCDONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PC PAID
U1 hereby effort that is a conswction lending agency for the performance of Date
VIP Into
the walk fill which this pennir is issued(Sce.3097,Civ.C.)
C V Lenders None TOTA
W Lenders Address TOTAL:
1 cridly that I have read this application unit state tom the above information is BUILDING FEE s /a
(A cortcct.I agree to comply with all city wall county ordinances and state laws relating,. QTY. MECHANICAL PERMIT FEE
U building construction,and hereby avthodm represenmtivesnfthis city,oenerupon the SEISMIC Mr l�
above.mentioned property,for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harss mlethe City of Cupertino against ELECTRIC FEE
liabilities,judgmena,costs and expense It may in way accrue against mid City ALI lilt OR ADD TO MECH.
PLUMBING PEE
' seyucnce of rhe Granting of lhi- sir.
L CANT UNDERSTANDS WILL ITH ALL N'[0:•P01 T AIR HANDLING UNITITO 10,000CFM) MECHANICAL FEE.
SOI REG ILATI N
S AIR HANDLING UNIT(OVER Iq(ME CFM) CONSTRUCTIONTAX
st
inureApplicardCnmmctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEEHAZARDOUS MATERI LS DISCLOSURE
W the applicant or future building occupant sure.,handle hmamma,material HEATING UNIT(10 100.000 BTU)
m defiled by the Cupertino Municipal Code.Chapter 9.12,trod the Health.id Safety
Code,Section 8532(x)? '/ HEATING UNIT(OVER IOLMM ED U)
❑ Ly
,
Yes mo PAID
VENTIIATION PAN(SINGLH REBID)
Will the applicant or future building occupant use equipment or devices which Uzte/1 (! lRecmpr p
emit harallous air contaminantsins acars defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR IW."BTU)
TOTAL:
Yes
District? BOILBOILER-COMP(OVER I 00,0(d)00,0(d)BTU)
AIR CONDITIONER Ihuve revel,he hacrdnus =50
w unJ apmr695 of the Cali ISSUANCE DATE
fomia Health&Batey Cee.Scelnd riderstand the if the NEW RESIDENTIAL MECH. SQ.FE J IIVV
g domesppl currt OY haves, spa iti ny onmifY the oc p ' (' LmUisvkust he of c ' gum of u U .
Mutiny I judoorucil agent Un TOTAL: ISSUED BY:-�n� �4w70A-UCC'
OFFICE