28838 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT•PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 28838
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING,PROJECT TDM'IFICA'1'[ON
BUILDINGADDRESS: SANITARY NO. APPLICATION
SUBMITTAL DATE
SN
OWNERS NAMI:: -PHONE: CONTRACTOR'S NAME: LIC NO:
C 9 � n8-C 3 N/C CONIROLN
•ARCHITECDENGINEER: LIC NO: ADDRESS: ❑ -
24
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG E PLUMB MECH
❑ ❑ ❑
LICENSED CONTRd underSDECmas of CON QTY ELECTRIC PERMIT FEE
1 hereby )M.of shut 1 am licensed under provisions of Chapter and
m mmensi is JOB D CRIlaT10N
Poo wird Section]IAlll)ofDivisionJofnhe Business and Professions Cak.anJm license is
r-WO y PERMIT ISSUANCE RESIDENTIAL' -
nNII force and effect.
tF..nLicense Class Licp ❑SFDWL El KITCHEN REMOUEI.
NG Dae Cmtamm APPLIANCES-RESIDEM'IAL ❑ADDITION El PLUMBING RE-PIPR
ARCHITECTS DECLARATION PANELS
I.. rn ❑MULTI-UNIT []STRUCTURAL
0Z ?-1
Z[2� 1 undecswnd my plans shall be used as publicraUPTO 22M AMPS
orJs _ s MMODIFICATION:J
0Licensed Professinal ❑INTERIOR ❑CHIMNEY REPAIR
o 201-1000 AMPS IMPROVEMENT
OWNER-BUILDERmDECLARATION OVER 1000 AMPS ❑BATH RIEMODEIIREPAIR [I DEMOLITION
1 hereby affirm that I L5 exempl from,he Cosions Co License Law for the
L 0G Q following reax..(Section 703L5,Business and Professions Csde:Any city o auuaY SIGNS ELFiCTRICAI. ❑OTHER
3 W Nma which reyuircs n permit re construct after,improve,h pearreh,lir repair unY.gmeure
�w.] priormib issuance,also requires the applicum for such permiuo flea signed statement SPECIAL CIRCUIT/MISC.
}
that he is licensed pursuant to the provisions of the Counsellors license Law(Chapter 9
CSO (commencing with Section70(10)at Divided 3 of Ne Business and Professions Code)or TEMP.METIER OR POLE INST COMMERCIAL:
fL q M eG
that he is exempt Iherefrnm and the basis for the alleged exemption.Any vidalion of ❑NEW BLDG/ADDITION ❑DEMOLITION
fisc) V. Section 7011.111 any applicant fur a permit"bill'the applicant la a civi111,t,of POWER DEVICES
yq} Int..than
fve hand reddollars(S500). ❑TENANT ❑FOODSERVICE
FQS� ❑1,as nwrhrollhe porpHy.or lily employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
wdldothework.andlhestmclure is not intended or offered for sale(See 71W.Business []OTHER0.a and Professions Code:The Co nsinarn
s License law does m apply to an.wrer of OUTLETS-SWITCHES-FIXTURES
property who hnilds or Improves frereoa,and who does such work himself orthrimgh
his own employees,provided that such improvements an,not intended lir offered for NIEW RESIDENTIAL RLECTR SQ FI',
sale.If,however,the building or improvement is sold within one yearofc.mpletion.the %PT,ILOOR AREA 5/SQ.FT.
owner-builder will have the burden of Proving data he did not hudd or improve for put-
pose of sale.). '
1,as owner of the pmpeny,am exclusively contracting with licensed contractors to
amstmcl the project(Sea 7044,Business and Professions Core;)The Contractor's Li.
xLaw does not apply toanowner ofpropeny who hnilds tar improves thereon,unit QTY. PLUMBING PERMIT FEE
who contracts fursuch projects with a c.nnaetorelf licensed pursoaau.the Comramors
License Law. PERMIT ISSUANCE
❑I.m exempt under,Sec. ,B&P C Iia this reasrn
ALTER-DRAIN&VENT-WATER(EA)
Owner Use VALUATION
-WORKERS COMPENSATION DECLARATION BACK FLOW PRO"ITCT.DEVICE
I herehy affirm under penally of Perjury one of the following declensions:
❑I have and will maintain o Certificate of Conaenuoeelf-insure for Workers Contain- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS'HtUCT10N
esaion,ns powidecl for by Section 3700 of the Labor Code,tier the performance of the
ark for which this permitm.sock FIXTURE -P. TRAP
I hove and will maintain WUrkers Compensation Inximp ce,as required by Section
7W.fthe lecher Code,fornhe performance,Rhe work for which,his pemnil is issued, GAS- A.SYSTE -I INC.4 OUTLETS OCC.GROUT' AfN
My Woes Compensation Insurance carrier and Policy number arc
Cance ITA72w 1 a- C6. Policy N.:wC-023904 GA -EA.SYSTEM. VER4(EA) -
CERTIFICA'1'E OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 2 EASEYINDUSTRI,AAST17 INTERCEPTOR BUILDING DIVISION PEES
(This scroonnccdnmbecompleted ifthe,cout is foromchundrWdollars(3100) GREASETRAP
carless.) '
PI.ANCHECK FEE
Loy any plut at the any manner
nce rofthe work for whichthisthe W rissued,lehdl SIEWHR-SANITARY I2M EA, Ff.
not employ any Cason in any manner so as m become subject m the Workers Con ENERGY PER
,Z O of Cvlifomin.Dae
O Applicant
� WATER HEATER W/VE 'LECfR GRADING FEE
ti
NOTICE TO APPLICANT.IL after making this Ccnifcarthe'lor
you should ATER SVS' I2PATI G
abecome subject to the Workers Compensation provisions e,you must SOIfS FEE
forhwith comply with such provisions or th is permit slml l ed ERSE z CONSTRUCGONf:NDING AGFW S/nF.N 1 .PLMB. SQ.F1'. PAID
Thereby affirm than there isuammnmtion lenAingafnrtnuncm Da¢ Receiptitthe workfor which this pcoral is lss
Q U Lemdds Name INV TOTAL:
{gl Leader'x Addresx TOTAL:
a I li fy aha,I have read this application and smm that nth ants a II anon is BUILDING PEE
rA7 correct,l agree to comply with all city and county ordinances anJ am " r sing to QTg MECHANICAL PERMIT FEE
U G building constmetion,and hereby authorize representatives ofnhis c meat ponthe SEISMICFEE
shove-mentioned pnspiny for inspection purposes' PERMIT ISSUANCE
(We)agree to save,indemnify it keep handless the City of '.penin.against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way same ainsisaid City ql-TER OR ADD TO MECH.
in cnaieyuence of the groin,of his permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL JON-POIN AIR HANDLING ON]T(TO IIkWn CFM)
SOURCE REGULATIONS. MECHANICAL FEB
O/Z AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCUONTAX
Signet cafAppiicanUContractor Date EXHAUSTHOOD(W/DUCI'I HOUSING MI'ItGAT10N.FEEy
HAZARDOUS MATERIALS DISCLOSURE
Will We applicant or fsmre building occupant store or handle hazardous motorial HEATING UNIT(TO 100.010 BTU)
as defined by the Captain.Municipal Code,Chapter 9.12,and rite Health and Safety
Cade,section 25!iMbd I HFATING UNIT(OVER IOq000 BTI.))
QYes 7 N PAID VENTILATION PAN(SINGLERESID) W{I Dae Receipt- Recei
Will the applicant lir fuwrt building orcupunt use equipment or Devices which L• . 1 U naP..
craftha...do., it ceman inentsas dented by the Fray Area Air Quality Management BOILER-COMP(3HP0RIW,000BTU)
Disaia'1 � BOILER-COMP(OVER 100.000 BTU) r TOTAL:
L-a.�
❑No
ead the hvallom materials myviremen,s unAcr Cheerer fi 95 of the Gdl- AIR CONDITIONER ISSUANCE
Safely Code,Sections 25505,255]7 and 25534.1 understand that if the NEW RESIDENTIAL.MECII. SQ.FTL
distincturently have a ncnam,that itis my responsibility to molly the osculwn,
ents which must be met prior m issuance of a CeNfcam of Occupancy.
r:sed ager, Date TOTAL: ISSUED BY:
OFFICE