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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PROJECT mISTIEICATION
PERMIT NO. 28763
Q7 /j/j���/^(K�
2 V I V N!
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
`1Q� c C/
1 61 -1 0o biree •sC
O :S NAME: /(] \ PHONE:
C Cf0 N LIC NO:
N/C
CONTROL#
Lcbr' IY,/yJ
❑
fARCHIT�CDFIIGINF,ER: LIC NO:
ADDRESS:
CONTACT: - PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paldby Applicant (Initial)
BLDG E PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nat 1 am licensed under pmvisions of Chapmr 9 (commencing
QTY ELECTRIC PERMIT FEF.
JOB DESCRIPTION
PERM IT ISSUANCE
with Section 70007 of Division 3 afihe I?uvinese and Pmfcssiona Coda. and my hecnm is
Licene fall Classrce deflect.
Date Class Contractor
I Date—, Cnntmcmr
RESIDENTIAL:
❑SEDWI, ❑ KITCHEN REMODEL
[]ADDITION EI PLUMBING RF. -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
APPLIANCES — RESIDI?NTIAL
i ARCHITEC I'5 DECLARATION
I turnaround my plans shall be, used as public me ms
PANELS
Licensed Po4ssianll -
that lam exempt IRLDIERCe ConloON
1 hereby affirm that 1 em exempt from is Contrasts License law for the
Code: Any city or county e
t following reason. (,coal t 7....sm Business and vet demolish,
Which its iseaupermit reannmruet,ulregimpmvgdemolish, merepairannystructure
to for such
also respites previsions
UP TO 200 AMPS
C1 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATA REMODEUREPAIR ODEMOLITION
❑OTHER
201-i WO AM
OVIiR 1000 AMPS
SIGNS ELECTRICAL
SPI7C1ALCIRCUIT/MI$G.
inor
heis]iarnedPn..,,.thesuance.
in.helicensed pursuant min o Contimrmr, LiecwLawdstammem
the Conusinss
TI'MP. METER OR POLE INST.
COMMERCIAL:
of Divinrmof
(commencing with Sation]fxq)of Divinion3 of the Business mA Prnfcssions Cnda)or
nd Professions Code) or
that he is exempt therefrom and the halls for the allegal exemption. Any violation of
NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not marc than fort hundred dollars y emp:
the property or isnoti eluded wiNwages
❑Loxowner work. 11an Business
red for sale their Wall.
will da the work, and the swcmre is not included proffered for salepply
ENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL CLIiCTftIC
and Professions Code: The Contractors License Law does not apply t owner of
OUTLETS — SWITCHES —FlXTURFS
propmy who builds or improves thereon, and who does such work himselfof through
s if
Itis own employees, building that ore not i ed arlcrcJ for
mentis
NEW ItF:5101!N'flAl, i?hECTR SQ FI'.
improvement it sold within one year recall the
prov
however ihave
SQ. PT. FLOOR AREA
SISQ. FT.
owner- the burden at hedid old or improve
,,a of a e.). will have the burden of Arming that he did not build or improve for Aur-
❑ 1, as owner of the property, am exclusively contracting with licensed contractors i.
q11,assowne
_
TOTAL:
conswa the project (Sm. 7PW, Business and Professions Crdep The Contractors IF
ase Low does not apply to an owner of progeny who builds or improves thereon.and
QTY, PLUMBING PERMIT FEE
who contracts mr such projects with a nmuucoor(.v) Bicameral pursuant (()the Contractor's
PERMIT ISSUANCE
License L.W.
C]I am exempt under Sec. ,R&P C farina rtason
ALTER— GRAIN & VENT —WATEll (EA) -
Owner Dare
VALU PION
66 —
WORKER'S COMPENSATION DECLARATION
BACK FLOW PRICED T. DEVICE
1 hereby union under Penalty of perjury one of the following declarations:
1
DRAINS— FI.00R, ROOK AREA, COND.
❑Ihovc an0 will molntalnu Ccrtlfmme o(Consem wselGbsvure for Worker's Compen-
union, as provided for by Section 3703 of Ne Lahr Cade, for to performance of the
- STORIES
TYPE CONSTRUCTION
work for which,his permit is ismal.
FIXTURES— PER TRAP
I have and will maintain W..ka's Compensation Insurance, as manual by Section
3700ofthe Ube, Code, far the vareromme.f the work l'or whichdas perim, is issued.
My Workers Compensation Insurance carrier and Policy munbart er a
GAS— EA. SYSTEM4 INC. 4 OUI' LETS
OCC.GROUP
ANN
Carrier: Policy No :
GAS — FA. SYSTEM -OVER 4 (EA)
CH R'fIFICA'I'I? OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not le completed ifthe permitis mit is for one hundreddollum (SIM)
or less.)
GRI!ASEINDUSTRL WASTE IN'IERCEFfOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEB O
513WCR— SANITARY —STORM IIA. 200 FT.
I certify Nm o the performance of the wmk inewhich this permit rken' Co],bar
not employ nny person in an to b«ome subject the Workers Colors.-
y mannerm as,. ) pen-
ENERGY PI!E
WATER H17NMR WA ENT/ELECTR
sation nwa of Cvlifomia. DataApplic
GRADING FEENOTI
E Exemption, you should
NOTICE TOxt to the Work If, Compensation
this Cisions of
provisions of the Lahr Code, you mutt
become suomp to the Worker's Compeor
WA'1'EN SYS'IEM?NI!ATWG
SOILS FEE
this
fonhwiN comply with such provisions or this pcnnit shall he deemed revokeA.
WAT13ft SF.NVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conswnion lending agency for the performance of
PAID
Date Receipt#
NEW RESIDENTIAL ELME. SQ, ET.
the work far which this permit is ismed (Ses. 3007, Civ. C.)
Landers Name
TOTAL:
Lenders Address
TOTAL:
1 cenify that I have rad this application unit state that the above infarmmum is
BUILDING '.ME
correct. I agree la comply wild all city and county eminences and state laws relating to
building conmramima,end hereby aothorim relm sotbawes of Nis city m enter upon the
QTY. MECHANICAL PERMIT FEE
-P
SEISMIC FEE
PERMIT ISSUANCE
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep to.... ss the City oi' CTerino against
ELEE
ALTHRORADOTOMECH.
liabilities, judgments. costs and expenses which may in any way secret, against said City
in consequence of the granting of this Antral,,
PLUS E
�
AIR HANDLING UNIT (TO 10,000 CFM)
C
I' ANl AI.
APPLICANT UNDERSTANDS AA) WI/ILLLL COMPLY LTH ALL NON -POINT
5 'RC LAT!
AIR HANDLING UNIT (OVER 10,0WCFM)
CONSTNULTION'I'A%
T
�
#�iaj? IIGVwj
EXI IAUSTIIOOD(W/DUCT)
Signvmre of Apphcanuciannemr Data
HAZARDOUS MATERIALS DISCLOSURE.
HOUSING MITIGATION PEE
HEATING UNIT (TO I MJXXI B Hit
Will the applicant or future building occupant store or handle hmadous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25132801
HEA'T'ING ON IT (OV ER It 0.0(u) It FU)
❑Yes ❑Nu
WillDole
the air costa ar future building by the B y A equipment of devices which
emtrict' us air contaminants as def sed by the Bay Area Air Quality Management
forenoon,
District'
❑Yes ['j No
PAID
Receipt#
VENTILATION FAN (SINGLE RPSID)
_
BOILER—COMP (3HP OR IW,drp BTU)
TOTAL:
BOILBR— COMP (OVER 100,000 BTU)
-
AIR CONDITIONER
I have read the hoz Ntms tomcods nts under Chapter M�Ir Cali-
re, p
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. CE.
farads building doesHealth &Safety Code. Satins , that i 25533 and 25534.1 underswnd Na, if Ne
25533
concnth have atenant,thato is ripce
aihllhymnotifythe pancy.
ofradoes a
of the rtquimmenrs which must be ton prior issuance of a Certificutc of Occupancy.
of a
/
ISSUED BY: /
Owner or nn,horieeJ agtoo Date
TOTAL:
OFFICE