28628APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
eCITY 00-CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL �
BUILDING PROJECT' IDENTIFICATION
PERMITNO. 28628
BUILDINGADDRFSS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
Ink, OW�4,]ER'S NAME �I'RATOG1 ?
H 07? 76572-
N/C
CONTROL
*ZHGGECTfRNG LIC NO.
/t vN L!
DI ESS:
2r, N •. I r 5 Su
la; Z
DO
U�
�W
o,
C1
G
�;
d U
Cy
a S
cas CO
e'
_ Ir•
o
Q
3
Wation,
Z
y
a
Z
0
f'•'
U
y
h
Z
Eiahilities.judgments,
in
!antis
building
of
CONTACT: PHONE.
z'137-0-50`9
❑ Consullnnt Fees Paid by Applicant (Initial)
BUILDING PERMIT INTO '
B, LDG F P� MECH
�Lijll'•
LICENSE]) CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under Provisions of Chapter 9 (commencing
with Section 700) of Division 3 of the Business and Professions Cale, and my licerm is
m full forces eR'en.
License Class Liap
Dane Contractor
QTY
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. El KITCHEN I2EMODEI.
❑ DDIT]ON ❑PLUMBING RE -PIPE
CfLUNIT ❑STRUCNRAL
MODIFICATION
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
Iunderstand myplmsshollbeusW espubliarcmrds-
PANELS
- UP1100200AMP5
Licensed Professional
OWNER - BUILDER DECLARATION
I hereby affirm that I an exempt from the Contractor's License Law for the
following reusnn. (Section 7031.5, Bosines. and Professions Cole: Any city ... ... only
which ..quires a peat to consumer, alter, improve, demolish, or repair any sbocmre
prior to its issuance, I requires the applicant for such Permit rile a signed statement
that he is licensed pursuant o the provisions of the Contractors License Law (Chaplet 9
(commencing with Section7IXNp of [)'vision 3 ofthe Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑1, es ownentl the prnpeny, or my empinyecawith wugesmtheirxolecompen.wtioe,
will Jo me work, and the strucore is not intended orbited forwle (Sre. 70,44, Business
and Professions Cale: The Contractors License Law does not apply to a owner of
prnpeny who build.. car improves thereon, anJ who does such work himself or through
his own employees, provided that such improvements um not intended or offered for
sale. If. however the Buildingor improvement ismld within one yeunfenmpletion ,the
owner-builder will have the burden of proving that be did nor builA or improve for per-
punt of ulde.
❑ L as owner of the property, am exclusively contracting with licensed commcors to
construct the project (Sec. 7044, Business and Professions Cale:) The Contractor's Li-
moss, Low does not applym an owner of prnpeny, who builds or improves thereon , and
who commons for such ponects with a contmctor(s) licensed pursuant to the Contm.mrs
License Law. -
❑ I am exempt under Sec. B & P C for this reason
201EITMIAMPS
OVER R in AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI'DMISC. CyL
TEMP. METER OR POLE INST.
COMMERCIAL•
❑ NEW BI.DG /ADDITION ❑ DEMOLITION
T�ANT ❑ FOOD SERVICE
IMPROVEMENT
OTHER
POWER DEVICES
SWIMMING I° 001.1?LGCI'RIC
OUTLETS- SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ FU
SQ. !P`f.FLOORAREA
- �L�®
$ /V1sv
1 O
•4 tGa fI[I�
CI 99
I uf. I.( ..-
$ /SQ. Up.
'
TOTAL:
Q'FY. PLUMBINGPERMIT
FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WA'I'Ell (GA)
wner Uea
VALuaTiON
/ ^� /�
/ I (-
Lb—` K
WORKERS COMPENSATION DECLARATION
Ihereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain n Cenificam of Consentm self-insure for Worker's Compere
as provided for by Section 3700 of the Labor Code, for the performance of the
w.rk for which this permit is issuW.
Cl 1 have and will maintain Workers Compenwtion Insurance, as requited by Section
3700ofthe Labor Code far the perfmmunceofthe work for which this permit is issued.
My Workad amia Asa Farrier and Policy number are:
Currieck -�1 �'NaF -d=r Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completad If thepermit is fora. hundred dollars SRO)
mhos.) -
ma
I certify that in the Performance ofthe work forwhich this permit is issued, l shall
oat employ any person in any manner so ate m become subject to the Warkeri Camper-
cation Laws of California, Date
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA. CON [)STORIES
FIXTURES -PER TRAP
GAS - EA. SYSTEM I INC. 4 OUTLETS
-
9YPE GDNSTRDCfIDN
OCC.GROUP
'
pPN
,
GAS - EA. SYST EM-OVER 4(EA)
GREA MNDUSTRI, WASTE INTERCEPTOR
BUILDING DIVISION FEES
-
GREASETRAP
'PLANCIi[CK PEG
SEWER - SANITARY -STORM EA. 200 PT.
ENERGY PEE
WATER HEATER WNLINTAiLECB
GRADING PEG
a�
NOTICE TO APPLICANT.If. after making this Certificate of Exemption, you should
become subject to the Workers Compenution previsions ofthe Labor Code, you must
forthwith comply with such provisions or this permit shallM deemed revoked.
CONSTRUCTION LENDING AGENCY
(hereby affirm that hem is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097. Cis, C.)
lender's Name
WATER SYSTEMORHATING
-
SOILS FEE
WATER SERVICE
PAID
Date R eiptp
NEW IIPSIDENTIAL PLMB., SQ. fT.
'TOTAL:
Lender's Address
-
'TOTAL:
1 .edify that 1 have Iced Nis application and site that the above information is
coven. l agreed comply with all city and county ordinances and state laws relampa.
building construction, and hereby authorize representatives ofthis city to enmr upon the
above - mentioned property lie inspection purposes,
(We) agree to save, indemnify and keep harmless the City of Cupertino against
costs and expenses which may in any way recoe against said City
consequence of the granting of this Permit. n
APPLICANT UND .RSTANDS AND WILL COMPLY WITH ALL ON'OINT
SOL 2CE GUL r'/./'',S
LX —_ -3 (f 96
BUILDING FEE
QTY. MECHANICAL PERMIT
FEE
SEISMICFEE
PERMIT ISSUANCE
FLECI RIC
AUGERORADDTOMECH.
PLUMBING FEE
AIR HANDLING ONI'P U0�10,INNI CFM)
MECHANICALPEL
O`
AIR HANDLING UNIT (OVER Inaba CFM)
CONSTRUCTION X
Sigwmre fAlbflicaunfiCommem, v Hard
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
' ❑Yas ❑No
Will the air cinfinemfuore ildfding by the Day Area Air Quality devices
hazardous nil contaminants as defined by the Buy Area Air Qmlity Management
Manaement
)istrid2
- ❑Yea []No -
1 have mad the hazardous orb. Se bons 2ls 5. Z53 an under Chapter 695 of the Cali-
Health J, Safety Cafe, Sections ,flad i, 25511 um1255341 understand that if the
does nth as whit y bust n repent, trot it is sea c eofa C ility ca notify the p occupant cy.
Ole requirements which must be met prior m issuance ofd Cenificme of Occupancy.
EXHAUSTHOOD(W/DUCT)
HOUSING MITIGA' ON FEE
HEATING UNIT (TO 100,000 BTU)
HEATING UMT(OVER 100,001 BTU)
PAID -'
VENTILATION FAN (SINGLE RESID)
Date Receipt M
BOILER COMP pHP OR IIX1,000 BTU)
TOTAL:
BOILBR- COMP (OVER 101,0X1 BTU)
-
,
AIR CONDITIONER
ISSUANCE DATE
ISSUED RY:
NEW RE5IDENTIAI -MECH. SQ. FT.
'
Owner or authorized agent Date
TOTAL:
OFFICE
I�yr1
w iTn w _
M•a
r YYM
1: