28493 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO, I1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /8 41 9`3
11UII,DING YROAFCI'IONNTIFlCATION L V J V
BUILDINGADDRESS: SANITARY NO. APPLICAOON SUBMITTAL.DATE
Oro .8TVAP �iRS - L-WA @'zt k07
OW IN I}�I(1 & LCI CONTRACfJ�S N9 C: LIC NO:
� U1 ��, NIC CONTROL
AR HI'I'ECf/ENGINEIiR: LIC NO; ADDRESS: ❑
CONTACT: , PHONE: BUILDING PERMIT INFO
❑ Consultant Fe"Paid by Applicant(Initial) W.QLW
�y yMw MECFI.
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hemby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
aZ with See ..7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL
full force snit eRecl. PERMITISSUANCE
TLII r' 'n ❑SFDWL ❑KITCHEN REMODEL
UzU License Class Contractor
APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
N Q G Date COnlmeCL
h,Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑MODIFTURAL
O
OOrc'Z 1understand my plans shall b<used as public records MODIFICATION
pzt� UPTo 2m AMPS ❑INTERIOR 11 CHIMNEY REPAIR
9W1.�� Licensed Professional 201-1000AMPS L ROVEMENT
- OWNER-BUEDCRDE Ce C.mr ON OVER Ui AMT'S I REMODEL,REPAIR ❑DEMOLITION
L C' 1 hereby nfRrm Nw l am exempt from the Comrnnnrs License Luw mime,
ALL.U following reason.(Section 7031.5,Business and Professions Cade:Any City or county SIGNS IiLECTNICAI. O HER
which requires a poneut to construct,alcor,improve,demolish,or repair any structure
[qq,, prior to its issuance,also requires the applicant for such permit to file.signed statement SPECIAL CIRCUIT/MISC.
2 y That he is licensed pursuer to the provisions of the Commmor'.s License Law(Chapter 4 _
SLL�C�O (commencing with Section 7")of Division 3 of me Business and Professions Code)or TEMP.METER OR POLE.INST. COMMERCIAL;
d c y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^
uA Section]NLS by any applicant for a period subjects In,applicant to a civil penally of POWER DEVICES m ❑TENANT El FOOD SENVICF.
E,Z} rwt marc thanfivethundreddollr (Sem). IMPROVEMENT'
3 6 pLo the wornflhe pmpenctim myemployees dwith wages astheir sole compensation, SWIMMING POOL ELECTRIC
C will Jnthewons ande; xo Com xrc intended m.hared lintvide otapply to an,Rosiness El OTHER
and Professions Code;The Canweloh Lind w law dues not apply to if owner of Ol1TLETS-SWITCHES-FlXTURES
p' property who builds or improves that
thereon,Done who does such work himself or through
his own ow,or the building ohm such imam is old w arc not intended or oecred for NEW RESIDENTIAL IiLECTR SQ FT.
safe.If.owner-bower willhvethe burding or den
is he ithinone ildyear
or
improve Cut
SQ.PT.FLOOR AREA S/SQ.IT.
owner-builder will have the burden of proving that he did urn build nr improve for Aur-
0 1,as owner
'
1,ruownerofct Sec.704, Business
contracting with licensed Ccontmmorsu) TOTAL:
construct the project(Sec.](H4,fluciness unit Professions Code:)'The Contractors Li-
cenu Law does not apply to an owner of pmpeny who builds or improves thereon.and QTY, PLUMBING PERMIT FEE
who concocts for such projects with a contractor(s)licensed pursuant it,the Communes
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C fonhis mews
Owner Date
ALTER-DRAIN&VENT-WATER(LU VALUA I?JD
''• WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE e
I Thereby affirm under penally of perjury one of the following declarations:
Ihnvmnd will maintain.Cenificam of Conserv to self-inwmfor Worker's Compen- DRAINS-FLOOR,ROOK AREA,CONE. 6.
All
rn-s�LS CONSTRUCTION
smian,os puiviJed for by Section 7]m of Ne LnMu Code,for the ITrfommnre of the "T
El
work for which this permit is issued. FIXTURES-PER TRAP ,'
1 haveand will maintain Worker's Compensation Insurance,u required by Section l.V
3700of the Labor Code,for the pcmarme o
nncf lhu work for which din,permit ix issueA, GAS-EA.SYSTEM-1 INC.4 OUTLETS
OCC.GROUT' N APN
My Workers Compcnmtion Insurance caru
career and Policy number arc: - U
Carrier. Policy No.: GAS-LA.SYSTEM-OVER 4(FA)
CERTIFICATE OF EXEMPTION FROM WORK S'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE IN'I'ERCEITOR R1111.DING DIVISION FEES
(ThisseetionneednotWcompletNifthepem(itisf no dollam(Slm)
or less.) .- GREASE TRAP PLANCHECK HE
I certify that in the pedmmurro. tic work for which Is Rmilis issued,Is If SEWER-SANITARY-STORM EX. IT.
ria employ any person in any manner w as to berm hje t e Worker'Co ENERGY PEE
O.7.( cation Luws of Culifomia.Date WAT17R HEAT'F.R W/VFNT/ELHCTR -
Z� Applicant' GRADING FEF.
(n NOTICE TO APPLICANT:If,.pert fINP
Ccnificatccfl a do nu should WATER SYS EMMEATING
1-+ ,~moi become subject to the Wohers Camp. mvixi flhe La C . you moat SOILS FEE
forthwith comply with such pmvixiuns rmits all edeeatteeJ. WpTEk SERVICE
Q
CONhem iso on INGAGL CY NEW RP.SfDENT1AI,PLMB. SQ.FL PAID
V Q kto,wyahthis pnitherc issued(mction lending agency for performance of - Uma i it
[4 E Ne work for which cods permit is issued(Sec.lm],Civ.CJ '
0Lenders Name - OTAL:
WLenders Address
y 1 certify that l have read this application and slate that me above information is BUILDING I LG
(..i'V) correct.I agree to consply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
L 71 building construction,and hereby authorize mprctimunives of Nis city m,enter upon the SFISMICFI
above-mentionW pmpcny for inspection purposes.
(We)agree I.save,indemnify and keep harmless the City of Cupertinoagainst PERMIT ISSUANCE EI.ELTRIG F
liebililics.judgments,coils end expenses wbichmay many way acerucagainsl saidCity ALIERORADDTOMECH.
V.
in consequence of me granting nfthis Aconin. PLUMBINGFEE
APPM'UNDER.TA S AND WILL MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFMI
SOUR C :GU LAT S MECHANICAL s
s e AIR HANDLING UNIT(OVER lO,"CFM) CONSTRUCTION TA
f 7777�____K���`
igm u ( pplicnnUCammMnr Done EXHAUST GOOD(W/DUCI) HOUSING MITIGATION 3L
HAZARD S MATERLAI S DISCL.OSUR
Willmeapplicantmfuw buildingoecupon,amemhan hazaN.morumnid HEATING UNIT(TO I(R."BTU)
as defined by the inn Municipal Codc.Chapter 9,12,unit Ne Ucahh anJ Safety
Code.Saban 25532(e)? HLATING UNIT(OVER I00,IXI()BTU)
❑YesF1 No PAID
VENTILATION PAN(SINGLE RP.SID) Dote Recai M
Will the applicant unions a building by the rn Bay Am.iptrmm or Quality
Mice,which BOILER-COMP UHP OR IM.IH)(L BTU)
emit hazonlous air conmminama as defined by the Bay Arta Air Quality Management )FAL'
Disaicfl 1
❑Yes No
BOILER-COMP(OVER 101IN II BTU)
❑
I have rend the hansom",mencrixlxreairmnenis under Chatar fi.95rf the Cali. AIR CONDITIONER
4 P ISSUANCE DA
four.Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.I.T.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must he met prier in issuance of a Cenific:ae of Occupancy.
Owner or authorized agent Date ISSUED RY;
OFFICE