28587 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28587
J O C Q
BUILDING PROJECT IDENTIFICATION L o J v
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL BY
NERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
r SIC CONTROLM
1RCHITEC/ENGINEER: LIC NO: Il ESS: / ❑
o .S.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
oZ
I hereby aRirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Wwith Faction 7lNN))of UivixionJ of the Business and ProfessionvCWe,and my license is
FOO in full force and effect. PERMIT ISSUANCE RESIDENTIAL
Q '
UV License Class Lic.M ❑SFDWL ❑KITCHEN REMODFI
yaw Data Gmtracho APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
p.O rn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z O In z I understand my plans shall he used as puhlie records MODIFICATION
O Z-+C-1 UPTO 2M AMPS
Ed Uarmed Profesameal ❑INTERIOR El CHIMNEY REPAIR
Cy ; 2111-IINNIAMI'S IMPROVEMENT
C OWNER-BUILDER DECLARATION
y C W Q I hereby affirm that I am exempt from the Cnnaacmr's License Law for the OVER Idfp AMPS TH REMODEUREPAIN DEMOLITION
x 3 a LEfollowing reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL - ❑OTHER
W LL which requires a permit to construct,alcor,improve, re
demolish,or repair any structu
Ipp'�O limit to its issuance,alsomquims the applicant for,such permito file a signed statement SPECIAL CIRCUIT/MISC.
i;�(iN• that he is licensed pursuanuo the provi,mnvufthr Contmcmrs License l.aw(C1apter9
��C�O (commencing with Section70(N)pd Division3 ofmc Businesiand Pmfesxions Coul TEMP.METER OR POLE INST. COMM_ FR .IAL
a e that he is exempt therefrom and the basis for the alleged exemption.Any violation of
El DEMOLITION
2N Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of POWER DEVICES I [:)TENANT El
�FOODSERV CE
F z y not more Than five hundred dollars(S5 W).
< ❑Las owner of Ne propery,or myemployees with wages usthcin.lcmnnpcns:nion. SWIMMING POOL ELECTRIC IMPROVEMENT
Sy��O will do the work.and Ne structure is not intended moffrred for sale(Sec.706,Business El OTHER
W 3 and Mofc..tons Code:The Crounwor's License Law Jots not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who build,or improves thereon,and who does such work himself or through
his own employees.provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or iinpmvemem isxold wiihino^eyeurofcnmpletion.the SQ.FL FLOOR AREA 5/SQ.ET.
nervbailder will have the burden of starving that he did not build or improve for par.
'no olsule.4
1,as owner of the property,am exclusively contracting with licensed econometrics to TOTAL:
construct the pmjed(Sec.7f W,Rosiness and Professions Code:)The Cnno-eters Li
cense Law does not apply to an owner of property who build,or improves thereon.and QTY. PLUMBING PERMIT FEE
whocomoud,for such projreta with a eonaadorfs)Iiee^sed pnr,uanl ,,the Conaoemr's
License low. PERMIT ISSUANCE
1.m exempt tole,Sr, ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner are VALUATION
WunderSCOMI of ENSAI
on UE .ARATLON BACK FLOW PROTECT.DEVICE
Ihend wilaffirm
tain a penalty.(perjury on the following it dker's C.r.
ns,as and mai^mina Certificate afC roto selfe,sure fared rkeh Ce of me DRAINS-FLOOR.ROOF AREA.COND. RI "A
satins,as provided for rm Senior JAN) s Labor Gds,for the pert,mance o1 the I STORIES TYPE,CONSTRUCTIC
work far which thizpermit is issu FIXTURES-PER TRAP SEp
❑ 1have and will ma in .,kers Come of
n work
fume,h requir ti Section v r h%I
PW ofthe Labor e,for the performann of the work for which this pe tit is issued. GAS-G.SYSTEM IINC 40l1TLEf5
My WorkersC pensaion lnmmnce carierand Policy number arc: wry OCC.GROUP APN
Curtis,. PalicCERTIFICATE OF EXEMPTIONybROVE W RKERS' GAS-EA.SYSTEM-OVER 4(EA)
wry Ut i"UrLM"NU
COMPENSATION INSURAN GREASE/INDUSTRL WASTE INUrERCEPTOR
(Thi,se tion reel not he completed it a unJred Joll 14100) BUILDING DIVISION FEES
car Ices.) tar GREA'UTRAP
I certify hat in, per rte ne f e -ork hi It this ed Isba11 PLANCHF,CK FEE
mployuny person in wy tear so s et tot _ SEWER
-SANITARY-STORM FA.200IT.
O ,T. satin.Law"d lahhnm' n sect WATER HEATER WNENT/ELECfR ENERGY FEE
O Applicant rs
'z' `q NOTICE:Ill A PLICAN'E If. f'r m k' g thi Car di are of em tion,you should GRADING FEE
P WATER SYSTEM/1'REATINC
a become xcourp n rhe Workers .cope a rmits,ns n e Lobar Glc,you nun SOUS FEE
Da IorthwiN camp with such pnrvisions...his pertnitx deemed invoked. WATER SERVICE:
aQ
CONSTRUCTION LP' ENG AGENCY.•7. Z NEW RESIDENTIAL PLMB. SQ,FT. PAID
L) 0 IMrchy (firm than then isucan nianlrnding agency for the performance of Uam Rec<iptp
w � the work forty ch thispermi'n" (Sec.NNO,Co.C.)
Lander"
me
Lender's AdJres TOTAL:
0. I ccnify t ve read this appliedion and state that the above inl'ommtion is BUILDING FEF.
In comet.I agree to comply with all city and county ordinances and.state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building commuctlnn.and hrebyauthorim rcpresentativesof Nis city toemidepon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(we)agree 1.wve,indemnify and keep harms..the City of Cupertino against ELECTRIC FEE
liubilities.judginenrs.costs and expense.which maymanywayaccme a,doedsmil City ALTER ORADDTO MECH.
in onsequence ofthe granting ofthis permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL IR DANDLING UNIT(TU III,UdO CFM)
SOURCE REGULATIONS. MECHANICAL FEE
A {ANGLING UNIT(OVER Ig00(1 CFM7 CONSTRUCTION TAX
g' a um of Applicanticmi'mcm, Ate EXHAUST HOOD(W/DUCO
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
will theapplicanr or lumen building oecupntumesr handle haemdous material HEATING UNIT(TO I Wjil(INTU)
as defined by ilne Caperin.Municipal Code,Chapter 9.1;and the Health and Safety
CWC.Section 25532(a)? IIEATINC,UNIT(OVER 100,000 BTU)
❑Yes ON.
VENTILATION FAN(SINGLE RESIDE PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt p
emit hamNoas air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP UUP OR I W,000 BTU)
Disoicr? TOTAL:
❑Yes ❑No BOILER-COMP(OVER 100.00 BTU)
I have mad the hazardous materials requircinems under Chapter 6.95 of the Cali- AIR CONDITIONER
forma Health&Safety Coda Sections 25505,8533 it 25534.1 unddsmnd that if the ISSUANCE DATE
building does tarn currently have a recon that it is my responsibility to notify the occupant NEW RESIDENTIAL MECH. SQ.Cr.
of the brima m ins which must hand prior to issuance of a Carificate of 0ceuponay.
Owner or auth.nzed ode^t Date TOTAL:
ISSUED BY:
OFFICE