28989 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAI 28989
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS; SANITARY NO. APPLICATION SUBMITTAL DAT
OWNER'S NAME: PHONE: CON'TRACTOR'S NAME: LICNO.
E C U /� E I/ E O S S 33 Ntc CONTROLN
ARCHITE IENGINEF,R: LIC NO: ADDRESS: ❑
EL C m//J0 - TN•J/
CONTACT; PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ E' ;��
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
WCz with Section 70(t Division 3ofthe Businessland Profession Code,and my license is
F W O in full force and a PERMIT ISSUANCE T
aUl"' LicenselC,�ass - Liax L5 APPLIANCES
SFDWI,
O KITCHEN REMODEL
FZyUj Dam-/�=L= Comracmr APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING REPIPE
coax' ARCHITECTS DECLARATION ❑MULTI UNIT ❑STRUCTURAL
z O y z I understand my plans shall bMODIFICATIONe used as public records PANELS
Oz- UPTO 200 AMPS
❑INTERIOR
Licensed Prof essil
ona0 CHIMNEY REPAIR
Wti4 OWNER-BUILDER DECLARATION 2H1-IIKKIAMPS IMPROVEMENT
q4sd CG W Q I hereby affirm Lha I am exempt from the Co.,...I is License Law folds,hOVER 1gNlAMPS El BATH REMOIlE1JItIiPA1R DEMOLITION
W 3aU following reason(Section]031.5,Businessland Professions Cade:Any city or county SIGNS ELECTRICAL OOTHER
tel u.
pisy which mums a permit to construct.alter.improve,demolish,or repair any structure
n
1pp"' •O�
prior issuance,also re�ryires the applicant perminolileasigned statement SPILCIALCIECUIT/M1SC. �` -�
2�} that he is licensed pursuant to the provisions of the Commusum v License Law(Chapter 9
WCC) (commencing with Section 7")Of Division 3ofthe Business and Professions Code)or THEIR METER ORPOLBINST \ OMM R IA'J
a p,o q that he is exempt danefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION �DEMOLITION
4Xl 4•^ Section 7031.5 by any applicantfor a Permit subjects the applicant o a civil Penalty of POWER DEVICES \ ` []TENANT C1 FOOD SERVICE zz not mo re than fivo hundred dollars(5500). \ IMPROVEMENT
01,as owner Of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
will do the work.and the structure is not intended or offered forxule(Sec.JDit,Business \ ❑OTHER
W^w tend Professions Calc:The Convector's License Law docs nm'.pply ,,an owner Of OUTLETS-SWITCHES-FIXTURES
4'3 property who builds or improves thereon,tend who does such work himself m through \
his own empinyxs,provided that such iinPrevcmenrt arc not intended or offered for NEW RESIDENTIAL.ELECTR SQ IT
sale.If,however,the building or imprmmnenl is sold within one year ofecroplelionthe \SQ.FE FLOOR AREA VSQ.FT.
owaner-builder will have the burden of proving that he did not build or improve for par-
Poe if seleJ. I
0 1,as owner of the property,am exclusively contracting with licensed counselors to TOTAL: \
construct the project(Sm.Alta,Business and Professions Code:)The Contractors U.
cense,Law does not unity Loan owner ofpmpeny who builds or Improves fiction,laid QTY. PLUMBING PERMIT
whocontracts for such Projects with a comlacmm s)licensed pursuanl m the Conlnemrs ` )
License Law. PERMIT ISSUANCE U
0 1 am exempt under Sec. .B'&P c for this reason Z-eta f
ALTILR-DRAIN&VENT-WATER A)
Owner Dale (EVALUATION—
WORKER S
ALUATIONWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 0 C-)
1 hereby aftimt under penally of laTim,one of the following declaatinnx:
O l hesitant will mainaina Cenilicum m'Comem Lo self-insure fill Workers Co.,.- DRAINS-FLOOR.ROOF.AREA,COND.
section,as provided for by Section 3700 of the Leber Code,for the performance of the RIES TYPE CONSTRUCfl01
work for which this permit is isseed IFIXTURES-PER I RAP
0 1 have and will maintain Worker's Compensation Insurance,a re luimal by Section
37M of the labor Code,for the peRnmtanee of the weak for which this permit is issue]. GAS-EA.SYSTEM.I INC.(OUTLETS OCC.GROUP APN
My Werke Co -IioitIry c andl'olicy beroa
Carier: TE C.lIM is 1-Pon,No.:Q 1 Z7 I GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE f ORFASE INDUSTRL WASTE INTERCEPTOR
or less.)
(This section need not be completed if he permit is furnace hundred dollars GREASETRAP ISI00) BUILDING DIVISION FEES
I
1 certify that in the performance of the work forwhich this pend is issued.)shall PLANCHECK FEE
not employ any person in any ommer.so as to become subject to the Workers'Canyen- SEWER-SANITARY-STORM EA.200 IT.
Z '.lion laws ENERGY FEE
a
btu Dae
WATER HEATER W/VENT/ELECfR GRADING PEE
z� App;icxm
In NOTICE TigOPLICANT:ll;.fie,making Nis Ceriifi ExemMin 1,you should WATER SYSTEM/TREATING
a ; hecome subject to the Worker's Compensation provisions of the labor Calc,you must SOILS FEE
forthwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE
ped A
.�T. 2 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. S PT. PAID
L)0 L for by whihthis N0here issued( ectionlenting agency for theFmRormance of Q Date Receipt
Da the work for which this peamit is issue)(Sec.1097,Co,C.)
O U lenders Name TOTAL.
as Lenders Address TOTAL: -OU
p� 1 certify that 1 have rete]this application and nm Lh
aa thove e abintuation
fai' BUILDING FEE
res comma.I agree to comply withal]city and county ordinances and none laws relatingm QTY, MECHANICAL PERMIT
U Z building cmnnmction,and hereby authorize representatives of this city to enter upon the FEE SEISM IC FEE
.bovemcnumned Property for inspection pt r,so, I
1
(We)ug.to save,indemnify and keop harmless[he Cay of Cupertino against PERMIT ISSUANCE i ELECTRIC FEE
liabilities,judgments.costsandexpenus which may in any wayaccroeagainsl said City ALTER OR ADD TO MECH,
in comequence ofthe granting ofihMoral,
rmit. PLUMBING FEE S
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Kidght CFM)
SOU - .ULATIONS. 4-00
MECHANICAL FEE `YP'aJ
AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTIONTAX
fAppliesnUContmcmr Dale EXHAUST HOOD(WOUCT)
HAZARDOUS MATERIALS DISCLOSURE M ' HOUSING MI'HGATION FEE
Will the applicant or future building occupant snore or handle hormtkius materialHEATING UNIT(TO 100,000 BTU)
as defined by the Cuponino Municipal Code.Chapter 9.12,:md the Heahh and Safety
Code,Section 25532(x)] HEATING UNIT(OVER IW,000 BTU)
O Yes ON.
995
VENTILATION PAN(SINGLE RESID) PAID 12-1
Will the applicant or future building occupant use equipment or devices which a`' - Dam Receipt N
mail haraMnus air contaminants as defined by the Buy Are.Air Out ily Management BOILER-COME l3HPOR 00,000BTU)
Dinricty
0Yn ONo BOILER-COME(OVER 108000 BTU) TOTAL: ,
I have read the nostrums mamdals requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER
fomia Health&Safely Cade,Section'25505,25533.121111.1 calernand(hal if Ile ISSUANCE DATE
holdin a not cumenti have a anam, it is est NIiW RESIDENIIAI.MECH. SQ.FT
illy to nOcrr the Mcanant
of y
regal tswmmn tuna - miss ora eertifmme arommxPancr. T
thorisetl.gem Uam TOTAL: 3, �� ISSUED BY: ^m Q/+•a7/ba-/!l` ,
OFFICE