28756 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMFI'NO. 2^ 7 r 6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L lXJ / a�1J YN1
BUILDING PROJECTIDENTIFICAI ION
DINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE AW0
NER'S NA . PI NE: ONTRACI'OR'S NAME: LIC NO:
'J NIC lC�ONfROLM
ARCHIT CI'/ENGINEER: .IC NO: DRESS; ❑ ^�g�n
CONTACT. - � PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - LOG ELE PLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARAI ION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
aZ with Section of Dlvisma 3ofthe Bnome.oaxi Post..bne Code,end my licenseix
O PERMI I'ISSUANCE RESIDENTIAL:
in full force. effect.W� ❑SFDWf. -1 KITCHEN REMODEL
ICU
License Class cent APPLIANCES<L Date Cnmmctor API'LIANCF.S-RESIDENTIAL 1'QIADDITION E]PLUMBING RE8IPF.
I„ ARCHITECTS DECLARATION PANEIS MULTLUNIT ❑STRUCrURAL
Z p n Z 1 understand my plans shall be used as public remo s MODIFICATION
OZ—O UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Pmfesainnnl ,201-INXIAMPS IMPROVEMENT
s ppy� that I. -at111.D1i11 DECLARATION C OVI7R 000AMPS
y❑PC� 1 hereby.uffinn that I um comp from the Conuncmr'x License Law for the ❑BATH RFMODEI/RGPAIR [:1 DEMOLITION
x 3 6 V following remoe(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER p
Y7 O which requires a penult to omr swn,allay.improve,demolish,or repac any swnule �
E' priorm its issuance,also requires the vpplicam fo...ch pemmiuo file.signed statement SPECIAL CIRCUI'VMISG
"y that he is licensed pursuant to the previsions ofthe Conhucmis License Law(Chapter 9
GD (commencingwith Section TODD)ol'Diskme3 ofthe Business and Profcsslons Cale)or TEMP.METER OR POLE INST. COMMERCIAL
this he is exempt therefrom end the huxis forme alleged exemiame Any vw1alinn of - ❑NEW BLDG/ADDITION El DEMOLITION
.n of Section 9031.5 by any applicant for a permit subjects the applicant m u civil penalty of POWER DEVICES' -
} m more nthan Eve hundred dollars(S500).
❑TENANT ❑FOODSERVICE
f30 ❑1.as owner of the propeny.or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC IMPROVEMENT
will do Ne work,sand the swcture is net intended oroRered fur sale(Sec.1044,Business ❑OTHER
W �_ and Professions Cate:The Contractor's License Law does not apply to an owner ofOUTLETS-SWITCHES-FIXTURES
property who builds ter improves thereon,and who does such work himself or through
his own employees,provided that such improvements aro nm intended or oRared far NEW RESIDENTIAL.ELECrIt SQ pE
sale.If,however.lire building or mprovetnenl is.sold within one year ofcmnpletion,the SQ.PC FLOOR AREA - VSQ,PT.
owner nder will have the burden of proving mhos he did not build or improve for par-
seT
1,as owner of Ilse progeny,am exclusively contracting with licensed contractors racL
con. ct the project ISec.1om Business and ory who
Cale:)The es ihector'x
canse dresnotapplytoanownerofprnpens whosedprsuantoves Contractor's QTY. PLUMBING PERMIT FEE fsY
who ennuvns far such projects with a contrecn+Ns)licensed pursuant m the Cmnacsnr's
LirenLos. PHRMI'f ISSUANCE. SEP 2019
❑ lam os. funder Sec. - H&PC for this reason
95
ALTER-DRAIN&VI?NT-WATE VALUATION
ii�
Owner Date C `e ,L. �
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CT.IIB CIT)
1 herby affirm under penally of perjury one ofthe following declarations:
I have and will maintain a Certificate of Consent to self-insom fur Worker's Compote- DRAINS-FLOOR,ROOF AREA,CO STORIES TYPE CONSTRUCTION
attic,as provided for by S fool Ile Labor Code,for the performance ol'the
work for which this peri s ssued. F[X'IU RES-PER TRAP
I] 1 have and will mai in Worker's Ompenssome Insurance,m required by Sermon /
3100ofthe LvbmC ,for Neperfo nceoftheworkfmwhichmislennitisiaeued GAS-EA.SYSTEM-IINC.40UTLETS OCC:GROUP APN
My Worker's Cnm satimn lnaumncec mer end Policy number ere:
Carrier. . I • Policy No: GAS=EA.SYSTIiAbOVGRJ(EA)
-RITTFICATEOFEXF "ION FROM WORKERS'
COMPENSATI NINSURANCE GREASEINDIISI'RLWASTE INTERCF. R BUILDING ISION II?ES
section need noted cam sited Nepermitlsroronahundmddnllars($1110) GREASE TRAP
PLANCHECKFEE
.Airythatin me perform Mahe rk forwhich this permit is izsucd,ishull SEWER-SANITARY-STORM EA.200 Fr..
y mar y my peMas in for s to come subject to the Workers' ete CompENERGY FEE
p xafi.o r9 sof California. •e
C7 O Applicant .r/ I r - - WATER IWATER WNF.Np/ELECTR GRADING
r7 NOTICE APP% (:'otter m Ing this Certificate of Exemption,you should WATER SY$TEM/I'RI?ATING
F becamec fall
it tat rkerTt Gan nsatian.... ieneol't he],she,Code,younmvs SOILS PE
A forthwith (I /snc'c�provivi+ snnhia permit shall he deemed revoked WAI'ERSE:RVICE
f
CONSTR COON LENDING AG Ii CY
7 Z z v NEW RESIDENTIAL PLMB. SQ.FL PAID
LJ olh reb tom thatthe is ronswaion lending agency for the performance of Da Receipt It
the work ,which tits is issued(Sec.3097,Civ.C.)
O U Dmdo's one TOTAL:
Lender's ethics 'TOTAL:
1 dify that 1 sae read this up11iomfen and state that the above information is BUILDING THE �x
h cancels grce roc mply with all city and county iminances and state laws mlating to QTY MECHANICAL PERMIT FEE
building man m,and hereby amhnrizerepresenativesnf thiscity to enteruponthe SEISMIC FEE
above-me property for inspection purposes.
,(We)ogrce to save,indemnify and keep harmless the City of Cupertino against PERMITISSUANCE ELECTRICFEIi
liebilities,judgmema,cnahs and expenses which may in any way accrue again.said Cisy ALTERORADDTOMECH' PLUMBING FE
in mas,..ence of the granting of this pcmnis.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT(501(1,00)CFM)
SOURCE RECTI 'ION / z 2.204 MECHANICAL FEE
AIR HANDLING UNITOVER 10,1100 CFM) CONSTRUCH TAX
Sign ofA cvn ntmnor Date EXHAUST HOOD(W/DUCT)
ZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATIO E
Willi eapplicam or fmure huilAingoccupam aurc or landlehazalloux material HEATING UNIT(TO 100,k)(1 BTU)
m'defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? HEATING UNIT(OVER 100,010 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Date Recta s p
Willapplicantorfurore building t use equipment or devices which BOILER-COMP(3HPOR 100,000BTU)
emit hvN
aoes us air contaminant,as defined!by by the the Bay Area Air Quality ManagementTAL:
District'
[]Vex E]No BOILER-COMP(OVER I00,0h0 BTU)
I V1
I have read the htvaNuus maadaly requirements under Chapter 6.95 of the Cali- AIR CONDITIONER - ISSUANCE DAT
forma Health&Safety Code;Sections 25505,25533 and 25534.1 understand mat if the NEW RESIDENTIAL MECH. SQ.
building does not currently have a tenant,Nm it is my responsibility to nodfy are acupant
of the requtrements which most be mel prior m issuance of a Certificate of Occaptmcy.
Owner or authorized agent Date TOTAL; ISSUEU BY:
OFFICE