28627APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING . ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING - MECHANICAL 8[�
BUILDING PROJECT IDENTIFICATION V 6
BUILDI' q� 5: O SANITARY, NO, APPLICATIONSUUBMI MAL DATE.
OWNER'g�YgNy:: `�K[ ^ �a Ct k CONTI�SCT()R:ti NAMIi: - LIC NO
Y�
(� `Y 1# V ( J W N/C =CONTROL p
ARCHITECUENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial) aLpp RhIiCT PLUMB roux
LICENSEDCONTRACTOR 'SDIiCI.ARATION QTY. ELECTRIC PERMIT' PEE
1 hereby affirm the I um licensed under provisions of Chapter 9 (commencing JOB DESCRIPTION
{Q{y00 with Section 7")f Division) of Ne Business and Professions Code, and my license is RESIDENTIAL'
FOG' full force and effect. PERMIT
tY U m ❑ SFDWL ❑ KITCHEN REMODEL
FQ U LC31 License Class " Lic. M
N<d Dam Contractor APPLIANCIS- RISIUENTIAL El DITION L1 PLUMBING RE -PIPE
Fly ARCHITECTS DECLARATIONDLTI -UNIT ❑STRUCfURAI.
I underatandrh plans shall bcusedas blicrxmds PANF.IS
ZO � Y Pu - CHIMNEY OZ O UP,T02W AMPS El INTERIOR ❑CHIMNF,Y REPAIR
Licensed Professional - 201- 10(g)AMPS IMPROVEMENT ,
OWNER-BUILDER DECLNtnT10N
Q 1 hereby affirm thin i am exempt from the Contractors License Law far The OVER 1000 AMPS ❑BATH REMODCIAtEPAIR ❑ DEMOLI'f10N
iq5 O 4 U following reason. (Section 7031.5. Business and Prnfession, Code: Any city or county C1 OTHER
W 34y1"' SIGNS ELECTRICAL which requires a gamut m ennstmet, alter, improve. demolish, or repair any strccture _
qo, primmits iss...ac,also requires the applicant for such pemrino file a signed statement SPECIAL CIRCUIT' /MISC.
that he is licamvd,ammdn0a the pmvisionsof Ne Contmemrs License Law(Canine,9 [ G0O Nummencing with Section 7000)of Division 3 ofthe Business and Professions Code) m TEMP. METER OR POLE INST, f COMMERCIAL'
M C that he is exempt therefrom and The basis for the alleged exemption. Any violation of iP"� ❑ NEW BLDG /ADDITION ❑ DEMOLITION
Y• Section 7031.5 hyany upplicam for. permit subjects the appliecom. civil penalty of POWER DEVICES
t more than five hundred dollars T$500). ❑TENANT El FOOD SHRVICB
6 [,us owner of the t 'IMPROVEMENT
F33F� o
G ❑ pestricor is employees with for sale contpeusiness SWIMMING POOL ELECTRIC �,
will dothewmk, Code: The esurrihninmicense aw does not apply 1. an monr I '°S'a�a ❑OTHER
4 and Professions Code: The Contractor's Libensho di does nut apply m an owner of OUTLETS - SWITCHES - FIXTURE.$ _�pva1j j
progeny who hulls, pr improves thereon, and who dies such work himself m through his own employees, e building that such ment is old w thin nth intended rr offered for NEW RESIDENTIAL ELECDt W. \ iT�
owner-builder the have the bur en ofp improvement is sold did n t build improve put. — SQ. PC Fl.00R AREA S/SQ. FT.
cr 's.it.er will have the burden ofpmving the he did not build o� improve far par- -
pnse of sale.). � �
❑ L as owner of the progeny, um exclusively contracting with licensed con neon, To TOTAL: 1
construct the project (Sec, 71704, Holiness and Professions Coda) The Contractor's Li.
tense Law does not apply to an owner ofpmperty whir builds or improves thereon, did QTY PLUMBING PERMIT FE.
who contracts for such pnijecty with a contramorfsl licensed puesuant to the Gmtmnor's
License Law. PERMITISSUANCE
❑lam exempt under sec. ,B &PCfor this rcuum
Owner Dale ALTER - DRAIN & VENT -WATER fEA) N VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICE l
I hereby affirm under penulty of perjury inte of The following declarations:
❑ I have and will maintain Coniricate of Consent m selfinsure for Worker's Compete DRAINS- FI,OOR, RODP, AREA, COND. STORIES TYPE CONSTRUCTION
notion, as provided for by Suction 3700 of the Labor Code, for the Performance of The -
work for which this permit is'asued. FIXTURES - PER TRAP
❑ 1 have r nd`will maintain Workers Compensation Insum oo,, as required by Section
370fofthe labor Code, fixthinaigiftmaxime, atom work for which This permit is issued. GAS - EA .SYSTEM - I INC. 4 OUTLET OCC. GROUP APN
My WorkerS�a�geyatyR sur ce cardAanit Policy mark, art:
Carrier, CeJJ ///h''��1166 YPolioy No.: - GAS - EA. SYSTEM -OVER 4(EA)
CERTIFICATE. Oil EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASVINDUSTRL WASTE INTERCEPTOR
(This section need not be completed ifthe pernat is for one hundred dollars ($IINB BUILDING DIVISION FEES
less.) GREASE. TRAP PLANCHECK FEE
' IUan vanity that
per inllm any mannero as which uject to the permit Wrkeorcdnall,s l SEWER- SANITARY- STORMEA.20014.
nth employ any person in any manner so as m become subject m the Workers' Cnm1xm ENERGY EEL'
O Z smion Laws of Caifnmia. Date WATER HEATER W/VENf /ELECUR
Z 0 Applicant GRADING FEE �.�
fq
NOTICE TOAPo the Worker., it,, ,h E ate,onle. you should
s, WATER S YS'rEM/rREATING
a � baowithco ply the Workers Compensation provisions No Code. you must SOILS FEE �R
4LJ forthwith comply with such provisions or This permiT Shull be damned revoked. WATER SERVICE -
0
Uz CONSTRUCfmNLENDING AGENCY NEW RESIDENTIAL PLMB. SQ, FT: PAID
.L)O I for Thithanah i isaed(Sea i0lending ugcncyfur the performnnceof Doe ReceipN
LTS F thv work for which This penult in issued (Sea. 3097. Civ. CJ '
O Lenders Nome - TOTAL:
L) Lender's Address TOTAL:
y 1 inanity That 1 have mail this application and state Thor the above information is BUILDING FEE r�
V1 cmrea.I agree to comply with all city no county ordinances and stem laws miningm QTY. MECHANICAL PERMIT FEE
V z building construction, and hereby uuthorizerepmomithives of Nis city to enter upon the SEISMICFEE
ahove- mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We) agree to save, indemnify and keep harmless the City of Cupertino against - ELECTRIC FEE
IT
of he this esanit. may immy way accme againn said City AUH?R Oil A DO TO MECH. IHOUSWG EE
in cm.Cyuen.e of the grondng of thin permit. - '
APPI,I .ANT UNDERSTANDS AND WILL COMPLY WITH ALI NO POINT AIR HANDLING UNIT (TD 10,0X1 CI >M)
SOU EREGULAT ONS. L
9 AIRHANDLING UNIT(OVER 10,000CFM)
-- .- � 3 ( ON• XA p 1
SrgnaTom.(ApP nVCommaor time EXHAUST IIOOU (W /DUCT) 'IG TION FEE
HAZARDOUS MATERIALS D ISCLOSURE Willtheappllcaut m futum building oacapthn murcor handle hazardous mvmnic HEATING UNIT(TO filha" BTU)
as defined by the Cupeninn Municipal Code, Chapter 9.12, and the Health and Safety Gale, SLoon 2553?(a)? HEATING UNIT (OVER 100,001 BTtp ❑Yes ❑No ' �uf
- VENTILATION PAN (SINGLE RESID) 1. Will the applicant or future building occupant use equipment or devices which Date Rae pl V
s
emit hazardous air conmminanm as defined by the Bay Area Air Quality Management BOILER -COMP (311P OR I00j000 BTU)
District? TOT
E] Yes ❑Nth BOILER - COMP (OVER 100.000 BTU) `
I have read the haorinkes matenals P AIR CONDITIONER ISSUANCE DATE
try 25533 asunder , 1 ter understand of the it the
fumia Health &Safety Code, r Sections 25505, 2553) end 25534.1 to unity thus it the NEW RESIDENTIAL MESH. - SQ. FP.
budding does rot s whit immorally have a mouth, that Is my c eoffi C ility to notify the occupant
' of the requirements which must Mmet poor to issuance of Ti Cenifcate of Occupunry.
Owncrcarnalonzedagent Date TOTAL: ISSUED BY:
OFFICE