28892 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N028892
.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL L lXJ tMJ�J,I L
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS j _ �J SANITARY NO. APPLICA ON SUB ITTAI.DATE
V rl�l�e ,(Gt A 2
ONES AME -PHONE: U'a CO RACI'OR:S,NAME: LICN
L 52iC!/� G NIC CONI'RO.p
A CH TECEMNGI CER: - LIC NO: ArS: 5 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
❑ ❑ ❑
LICENSED CONTRd mider S DECLARATION o6TIGN - QTy, ELECTRIC PERMIT FEE
O Z thereby Eoff NalInmlicensed underprovisionsofs Code.and
my license is 70B DESCRIPTION
with Semon]WTI)of Division l of the Business End Professions Cnde,end my license is
Fr,r PERMIT ISSUANCE RESIDENTIAL:
U Lfull farce eml
�FUZF License lass ) �� Lica ❑SFDWL ❑KITCHEN REMODEL
RQ Do¢ Cnnmtnor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECT-SDECLA A ON F1 MULTI-UNIT []STRUCTURAL
l understand m Ins shall he.sed m le
Z0,14 Y plans pu is recotsE PANELS MODIFICATION
p Z.+O - UI'T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
�4Licensed Professional OWNER-BUILDER CLARAI'10N 201-101#)AMPS IMPROVEMENT
E
W 1 hereby affirm at th1 ran exempt from nm the Contremnrs License Law for the OVER 11gX)AMPS � ❑BATH REMODE EPAIR �DEMOLITION
O y U following reawn.(Section 7011.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL OTHER14
which requires a permit to construct,alar,improve,demolish,or repair any structure[-�O�
prior to its issuance,also requires the applicant for such penotto file a signed' tem
staent SPECIAL CIRCUT/MISC.
yW} Nm he is licensed pursuanno the ptoviumsof Ne Conuaators License Law(Chapter 9
5Q� (commencing with Samoan Mother Division 3 ofthe Rdsiness W Professions Cade)or TEMP.METER OR POLE INSL COMMERCIA,
that he is exempt therefrom and the basic for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
.n tL Sauon]031.3 by any vpplicantforopertnil subjars the applicant mncivil penahy of POW(?R DEVICES
111...... y not mare than live hundred dollars(3500). ❑TENANT ❑FOODSERVICE
p6 am
the prapeny,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
C will da the work,and up y,
is not intended orolTeod!for subs(Sec.]M4,Business ❑OTHER
and Professions Code:The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
0.3
property who builds or improves thereon,and who dos such work himself or through
his own employees,provided Nat such impnsventenis arc not intended or offered for NEW RHSIDENTIAL ELECTR SQ I-L
sale.If,he.,.,,the building or improvement is sold within one year efcomplelion,the SQ.IT,FLOOR AREA 3/SQ.Er
ter-builder will have the human of proving that he did not build or improve for pm-
pose of sale.).
I,os minaret the property.vat exel®Ively contracting with licensed common.to TOTAL: (,j p
construct the project(Sea]644,Business and Professions Code.,The ComrecnKa Li- a Y; Q
cenm Law does nm apFllyman owner of prapeny who builds nr impmvcs lbereon,imd Q'rY. PLUMBINGPERMIT FEE
who contracts for such pmjeats with a contrdctons)licensed pursuant to the Contractors ��
1996
License Law.
1 ant exemp under c. � ,IT&P C fowPERMIT ISSUISSUANCEr this remm 1v7v7o
v ALTE?R-DRAIN&VENT- ER III ur VALUATION
Owner Dam IYV
WORKER'S COMPENSA DISCLARATIO PACK PLOW PROTECT, P CE
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate ofConunuo self-insure far Workers Camper. DRAINS-FLOOR,RGOE AREA,C STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Lubar Cade,for the petfood oce of the
mit
work far which this peris issued FIXTURES-PERTRAP
❑I have and will maintain Worker's Compensation Insurance,as acquired by Section
J]W of the Labor e.fnnhe performance olThe work r hich ispamitisimmed. GAS-HA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My WorkersC tion fns nee carrier and Poli rwmM/m:
Cartier. CE/Je���(NF GAS-11A.SYSTEMOVER 4IEA)
CERTIFlCAT P EX. Pl ION FROM E RS' GRI?ASFJINDUS'TRL WAST(?INTERCEPTOR
PENSATION INSl1RANCF.
(This section recd not ba completed iffl a Permit is for one hundred dollars(31 W) BUILDING DIVISION hT?I?S
or Ices.) GRFA$1?TRAP PLANCHECK fEli
(certify that inthe performance my
as
becomeork for
chis peo Woo es'C.Ishelf SEWER-SANITARY-STORM HA.200 Ff.
not employ any perwm in any manner m os to become subject to the Worker Cnmpen- ENERGY FEE
,� Applicant
Laws of California.Data
O APPlicvvt WpIRR BEATER WNF.NT/13LECIR GRADING FEE
tiNOTICE TO APPLICANT:If,afar making this Certificate of Bxempti...you should WATER SYSTEM/TREATING
a ' become object to the Worker's Compensation provisions of the Lahr Coda you must _ SOUS FEE
W fonhwitheompll such provisi .,,nhis permit shall bedecmed revoked WATER SERVICE
Q
CONSem isuc ON LENDING AGENCY NEW RESIDENTIAL PLM B. $Q.PT. PAID
U 0 l herebyichaffirsothis
that there Tissued(See 30 leading agency for the performvnce of Dam Rueipsp
W P the work for which this permit is issued(Sm Jog],Civ,CJ
O U Lenders Name TOTAL:
LSI Lenders Address TOTAL:
yi 1 acuity 01BI I have read this application and state that the above information is BUILDING FEE
V) comet.l onto to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
(..I Z building contraction,and hereby authorim representatives of this city to enter upon the SEISMIC FEE
r above.mendoned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify end keep harmlesrthe City of Cupertino against ELECTRIC FEE
li.ahlies,judg s,costs and expenses which may in any way accmc against mid City ALTER OR ADD TO MECI I.
in ameaqua sof he graming ofthie permit. PLUMBING FEE
APPLIC T DBRSTANDS A' VILL COMPLY WITH ALI.NO -POINT AIR HANDLING UNITno Id road CFM) MECHANICAL FEE
SOU ULATI .
2 AIR HANDLING UNIT(OVER IO.ROCFM) CONSTRUCTION TAX
�Em,V"fmjthCmarachasDa EXHAUSTHOODOMMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthemppliamorfurorebuilding armour storeorhandle haaadmus material HIAT)NG UNIT(TO 100,000 BTU)
as defmW by the Cupertino Municipal Code.Chapter 9.12,and the fault and Safety
Cnde,Section 25512m)'I HEATING UNIT(OVER 100,000 BTU) '
F)Yea; ❑Na
VENT RATION PAN(SINGLE RESIDI PMD Dole Receipt#
Will the applicant or share building the B use equipment or devices which BOILER-COMP(3HP OR IOuNd BI U)
emit hazallous air coam
nliby the nenu as Defined by Roy Area Air Qualify Management TOTAL:
District?
❑Yes ❑Na BOILER-COMP(OVER 100,000 RTU)
I hove seed the hasallous maadals etyuircmems under Chapter b95 of the Cali- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Code,Sections 25505,25533 and 25534.1 undershoot that if the NEW RESIDENTIAL MECH. SQ.IT.
building does not wtrently have a tenant.That it is my responsibilityto mo{ify the occupant
critic requirements which must be and prior to issuance of o Cenificate of Occupancy. /
Owner is,ande nsd agent Data TOTAL: ISSUED
t OFFICE