28570 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. w O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
1 yCl7
BUILDING ADDRE$ SANITARY NO. APPLICATION SUBMITTAL DATE
/ o o�i/e c4 Rod
'S NAME: ,1 PHONE. CO1,%ACIOR'S N - _ • CNPOt
CONTROL#
'IWRCHITECTNGINEER:- LIC NO: ADDRESS:
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CorvTAC71f.nx
TPuorvE: BUILDING PERMIT INFO
7 1-036,0 FE Consultant Fees.Paid by Applicant(Initial) ` gLDG L p UM MCH115-7-itWz�
LICENSED CONTRACTOR;S DECLARATON Q'fY. ELECTRIC PERMIT FI?f: a *by amtta met 1 tats licensed under provisions of Chapter 9(r,mmemcmg JOB DESCRIPTION
OCy700o)of Division 3ofine Business and Professions Codaandm license isand effect. y PERMIT'ISSUANCE � RESIIDENTIAL
V Us Lic.# ❑ FOWL ❑KITCHEN REMODEL
aComrnctnr APPLIANCES-RESIUENTIAI- DITION ❑PLUMBINGRE-PIPE
E„O snGq ARCIII'I'ECT'S DECLARATION - MULTI-UNIT ❑STRUCNRAL
Z O Z I understand my plans shall be usd as public records PANELS �.a
r- V �- MODIFICATION
OZ—O UPT02MAMPS El INTERIOR 11 CHIMNEY REPAIR
'I•� W Licensed Professional - - 3111-1000AMPS IMPRO 1?MI?NT
OWNER-HIIILDER DECLARATION
W 6 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER I000AMPS
CHAT
EMODEIIREPAIR El DEMOLITION
ip5s O d V following reason.(Section 7031.5.Business and Professions Coale:Any city or county SIGNS ELECTRICAL ER
FO~ which requires a permit to construct,alter.improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUI UMISC. 0 r
p. that he it Incanted pursuant mlo
,he IF snsof the Contractor's License Law(Cbap0er9
CC (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEM('.METER OR POLE INST,
d y that be is exempt therefrom and the basis fnr the alleged exemption.Any violation of
tial! ON GJA N DEMOLITION
Senior than 6y any hundred
dollars($5nt far a 0(h.
subjects the applicanuoacivil penalty of POWER DEVICCS ❑T ^I,r�aa, s Cl
not not metre than five hundred dollws($SIN)). M V G T
GO ❑La the worof the propeuct intended
side Sen. 044.Business
SWIMMING POOL ELECTRIC
will dothework,and the The Cure istors Liven Law
for not apply 7B f4,Business ❑OTHER
W 3$ and Professidm Code:The Contractors Licen Inw d not apply ns an
owner of t1Tl.ls'fS-SWITCHES-FI%TURESZeal,
property who builds m improves thereon,an ho does m work himself or through
his own employees,provided Slim such into,tarrocauscoru inrended of maned fnr NEW RESIDENTIAL ELECTR SQ FT.
sole.ILhowever,the building or improve mtisseldwlthinon earot'ermtpinlon,the - SQ.P.FL iHA $/SQ.FI'.
owderbuilder will have the burden of p vin,that he did not b d m improve for par- `O�
pose of owner
I,us owner of the property,am c elusively umtrecrinS with lic sed nsntmdors m
construe the project(Sec.704q sines and Prowho lhnrs Crede:) Cg thenror's Li- ' 1 `+
cnualawdtsforsch plyman terofpPopcny wbotiuildsnrlmpr aeNercon.and QTY, PLUMBING PERMIT FEB
who roareets for such project nth econtracags)licenud pumuemm eConaacmr's
License lsw., PERMIT ISSUANCE!
❑1 am exempt under Se ,B C In rs teas t C_06, R n+
" on ALTER-DRAIN&VENT-WAI'17R(EA)
%xi'don'.'Ponct
ner ate w VALII TION
ORKER'S COMP [ ECLA ON BACK ROW PROTECT'.DEVICE YV
Ihere affirm under ally - creature nllowiagdoelarations �j
I have mail '11 maintain aC m mwernos -insure for Workcr's ComNd- DRAINS-FLOOR.ROOF,AREA,COND. fSTORIF,S / TYPE CONSTRUCTION
d human
cell the Lamm ode,fur the porfomnance of the wink .,which sN it FIXTURES-PER TRAP
] 1 have and will ainti in Worke's ompensaf n Insurance,as required by Section �P Vvrthl
3700o1fNe Labra Cl e,fmflwperfa anceof cworkforwhicb,hisperadismated. GAS-IiA.SYSTCMd INC.4OUTLETS OCC.GROUP pPN
My Worker's Compere ,ionlramareacarroW ro PolicynumMrim:
Carrier: 'olicy No.: GAS-PA.SYSTEM-OVER 4 HA) ,
CERTI- ATEDFH%E 'ION FROM WORKERS'
OMPEISSA ON INSURANCE GRFASRIINDUSTRL WASTE INTERCEPTOR
(Thissectionnecdno becmnpl ed ifthe permit is forunehundred dollws($100) 1/ DI s VISIONFEIS
or less.) GREASE TRAP
Icedifythatinthepedo - eedf,hework Por which thixpmmit is issueJ,lshall PLANCHF.
not employ any per son i ny mer m become subject to the Worker Cumpen- SEWER-SANITARY-STORM EA.200 PT. ENER
Laws of Califo
Z O t'tfcant WATER HEATER WNEN' ELECfR GRAD(
y N e inking this Cetilicute df Exemption,you should
WATER SYSTEM/1'REATINC
a bacon m W km'.Ct tpensatinn provisions of the Labor Code,you must SOILS PEE r.
!Ta forthwith comply withsuchprovisions or this permit shall be deemM revoked.
Q WATER SERVICE
Mz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ.Pf. PAID
L) O l berebyaffrm thatthere lsuconstruction landing agency for the pertimmorce of Dole '5;n
1pt#
wl-•t the work for which this permit is issued(Sce.3097,Civ.C.) -
O Lenders Name TOTAL:
U
Lenders Address q
0.t I certify that T have read this application and state that the above information is BUILDING PGE
V) correct.1 agree m enntply with sell city and roomy nnlinances nnJ nate laws relating m QTY MECHANICAL PERMIT FEEV building consvuctinn.and hereby authorize representatives of this city to enter upon the SEISMIC FF.
sa
abovcmentianed po,,cy far inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of CLpcomm against A ELP
liabilities,judgments.costs and expenses which may in any way accme against said City ALTIiR OR ADD TO MUCH.
in consequence of the grunting of this permit - PI. 1 •RH f
APPLICANT UNDERST DS N ILL COMPLY WITH ALL NON-POINT pIR HANDLING UNIT(TO 10,1X10 CFM)
SOURCE RE ATIO MECH. IC LFEE lit
a
AIR HANDLING UNIT(OVER 10,(Np CFM)
CONSTRUCTION X
gnamre "nittv I Dac EXHAUSTHOOD IW/DUCT) HOUSING MITIG TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will are applicant orfumre building occupant s,oreorhamarlaacardous material HEATING UNIT(TO 100,010 BTU)
as darned by the Cupertino Municipal Code,Chapter 9.12,nod the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100.000 BTU)
❑Yes E]No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or future building occupant use equipment or devices which IW,gp BTU
emrd
it liaeaous it commandants as refund by the Bay Arco Air Quality ManagemBOILER+COMP(IEPORent )
Dls0iei7 BOILER-COST OVEIt 100,000 BTU) TOTAL:
❑Yes Fl No
I have read the materials CONDITIONER t
requirements under Chapter 6.95 of the Cali- ISSUA E DATE
fxnia Health&Safety Cele.Sections 25505,25533 and 25534.1 understand that if the. NEW HLSIDENTIAI.MECH. SQ.tT. ,
building does not carnally have.,count,that it is wry responsibility m notify the rxcupam
of On as,irements which mast he act'n m issuance of a Ceniream of(keupon, `
Of
Owner nr authonzed agent Date -
ISSUED BY:�
OFFICE