28550 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'.
ZosBo N
O 'SSTJGR'S NAME: - PH) ' - CONTRACTOR' NAME: I2250 J Met Lf L�NO:
IIJ--Vriaollp
AWA'
Q SIC CONTROL#
ARCHITECT/ENGINEER: LI NO: ADDRESS:II YT :S ❑
Ofi
CONTACT: PHONE: 3 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL h1-ECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE � / IIdC�l4
I hereby affirthat I an licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
WOO m with Section 7")of Division 3 of the Business and Prefsodmis Code,md my license is PERMIT ISSUANCE RESIDENTIAL
F-1— n full Tome and ec C
='E. (fig ❑SFDWL [:1 KITCHEN REMODEL
Q U Li<enu C Lic,p
at c. Dam Convector_ _.H I-- APPLIANCES-RFSIDEYTIAL ❑ADDRION El PLUMBING RE-PIPE,
ACHITECTS DECLARATION
❑MULTI-UNIT ❑STRUCTURALF �vf PANELS
z O y Z 1 understand my plans shall be used as public records MODIFICATION
Oz-, UPT0 200AMPS
FL—tm Lmemed Professional ❑IMPROVE ❑CHIMNEY REPAIR
�y F,; OWNER BUILDER DECLARATION 201-Ig10AMPE IMPROVEMENT
Q I hereby affirm that I am exempt form the Contractors License Law for the OVER 1000 AMPS ❑BATH R fODEVRIiPAIR DEMO ITIO
X 3 d U following mumn.(Station 7031.5,Business and Professions Cade:Any city merarty SIGNS ELECTRICAL b OTHER T
whim reunites a permit m es maun..lar.impmve,dcmnlinh,or repair any svuaure
� prior to its issuance.also requites me applicant for inch Permit to file asignedsmmmem SPECIAL CIRCUIT/MISE
�
not
That he is licensed pursuant to me provisions oflhe Contractor's License Law(Chapter 9
W 20 (commencing with Section 0000)of Division 3 aria Business and Professions Code)or TEMP.METER OR POLE INST. ICOMMERCIAL'
C.1 c C that he is exempt therefrom and the basis for me alleged exemption Any violation of
X�y Section 7031.5 by any applicant for a permit mhecln the applicanno vcivll ❑NEW BLDG/ADDITION 0DEMOLITION
mw more than five hundred dollars SSW). / ps°ally of POWER DF.VIC[S �TENpNT FOOD SERVICE
=O ❑1,asownerof the pmpcny,ar my empinyees with w.gcxaswheir.mle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
h. willdothe work,andthestmctureis not intendedoruffcrcd formle(Sec.70LL Business ❑OTHER
Wco.3 m and Professions Cade:The Commctors License Law does not apply to an owner of OUTLM-SWITCHES-FIXTURES
property who builds or impmve themnn,and who docs such work himself or through
his own employees,provided that such improvements are not intended or(offered for NEW RESIDENTIAL ELECTR SQ FT
sale If,however,the building or improvement is sold within one year ofcompletion,the SQ.FL IrLOOR�RF'a� EISQ.FI'.
crbuilder will have the burden ofproving that he did not build orimprove lis par' P Au
pose of sale.).
❑1,as owner of the proPcON am exclusively contracting with licensed amtmclom m A .
answer the project(Sec.Will.Bmincas and Proof..ions Code.)The Contrnnnr's Li.
ceJUL i js O s"v�
1Yk4L11!'nse Law does not apply to an of property who builds or improves themr.and QTY. PLUMBING PERMIT FEE
who comrama for such pnsjects with a connucmr(x)licensed pamounuo the Commmors
License Law. PERMI'I'ISSUANCF. CITY OF wt EH I'M
❑ lumexcmpl under Ser. ❑&PCffor this rcuenn
Owner ALTER-DRAIN&VENT-WATER(EA)
Dulc VALUATION
WORKERS COMPENSA I'IUN DGCLARA9'ION BACK FLOW PROTECT.DEVICE
hereby affirm under penally of perjury one of the ful lowing declaratinnx,
❑I M1ave and will maintain a Co,mficmeol Coonan,m1f.insun lire Worker's Compere- DRAINS-FLOOR,ROOF,AREA,COND.
satlan,as provided for by Section 3700 of the Lubar Code,for thi perfumance of the STORIES TYPE CONSTRUCT101
ark for which this pemid is issued. FIXTURES-PER TRAP
1 have and will tourism Works,',,Compemauter Imarmee.n,rerouted by Section
37 ofthe Labor Cede,for the performance of the work lir which this permit ns round. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Work 's Compensmiun Immorace coof and Policy numbh��ff L: OCC.GROUP APN
Carrier. 1R6jj�p�, policy No.: N&YXA-� GAS-EA.SYSTEM-OVER 4(EA)
;I FI T OF :MPU FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed iftic permit is for one hundred dollars IE I W) BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCHECK FEE
Toy my Person
none larany manner of thework for which this themitisir,'CoIma11 SEWER-SANITARY-STORM EA.200 FT.
net employ any person is any Runner m as m become subject es the Workcri Compen-
ENERGY FEE
.�
Applicant
Laws of California.Dam
z Applicant WATF.H HEATER W/VEM'/ELECfR
X y GRADING FEE
NOTICE bj APPLICAM:If,Compensation
this Ci%ions o of Exemption,you should WATER SYSTEWfREATING
? become subject m the Worker's Compcto lois provi shat of the lihaf Cake,you mull SOUS FEE
fIJ
forthwith comply withsuch pmvisians or this permit shall be deemed revoked. WATER SERVICE
a0
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT PE
LJ O I herebyaffimv that them iso consvuction lcndingogery(.,the pfffomuncem a taeipl#
F-' no work for which this .to is issued(Sec.309'1.Civ.C.)
Lmtkes Name
UJ Lenders Address TOTAL: TOTAL:
I--� p, I certify Thal I have mad this application and stere thaw th..bove infomenion is
p) comer.1 agree to comply with all city and county ordinances and sine laws minting to QTY. MECHANICAL PERMIT
L)Z building construction,and hereby aulhorim representatives of this city to enter upon the I FEE
above-memiuned property for inspection purposes. pERMRISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against EE
liabilities.judgment,road. it csN. s which may in any way asrue against said City ALTER OR ADD TO MECH.
in consequence of due granting cifwhis peon I EAPPLI UNDER.TANDSAND W .L COM LY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10'"CEM)SOUR R GULATI S. LFEEAIR HANDLING UNIT(OVER 10.000 CFM) IONTAXignat motApphrionolonwmor Dae EXHAUST HOOD(W/DUCT)HAZARDOUS MATERIALS DISCLOSURE GATION FEEWill the applicantor future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Seedon 8532bd? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RESID)
Will the applicant or future building occupant y A equipment Qu of devices which Dam Receipt
emit hazardous air comuminams us AcfineJ by the Buy Ana Air Quality Management BOILER-COME(3HP OR I00,000 BTU)
District?
❑Yes ❑ 0000
No BOILER-COMP 1 , 0 BTU) TOTAL:
1 have read the bmankn s nmtcrial.v nquirenents under Chupmr 6.95 ol''he Cnli- AIR CONDITIONER
fomia Health&Safety Cale,Sections 25505,25533 and 25534 1 m leca:mJ that if the ISSUANCE DATE
building doesnm cunemly M1ave.tenant,that it is my re,,unchday to notify the recupanl NEW R17SIDEMFIAL MECH. SQ.IT
ofthe nquiranencs which In w be met prior to issuance ofv Canificale al'Occupuncy.
Owner or authorized agent Dam E TOTAL
ISSUED BY:
OFFICE