28874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /� ^ /N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28 VX
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO, APPLICAl ION SUBMITTAL DAT]
2c+ o S b.
OWNER'S PHONE: R'S NAME:. LIC NO:
saa� NIC _A2>
CONTACT
..ARCHITE GINEE ' SO LIC NO:
ire
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CONTACT: PHONE:
El Consultant
PERMIT INFO
Consultant Fees Paid by Applicant(IBltiep NLDG ELECT' PLUMB MF.CH
❑ ❑ ❑
LICENSED CONTRACIOR'S DECLARATION . QT'Y ELECTRIC PERMIT FEE
I heresy affirm mat 1 am beamed under,ownim s omene
f chapter 9(Containment, JOB DESCRIPTION
QaZ with Section 7a00)of Division 3.1 the Business and Professions Cedc,andm license is
1400 i y PIiRMIT ISSUANCE RESIDENTIAL,
GU Licenlse Class JeRect. LiaN ❑SPDWI. OKITCHEN REMODEL
�7d-4 oat Contractor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
1„Drn ARCHI ITCUS DECLARATION PANELS - El MULTI-UNIT ❑STRUCTURAL
Z p I understand my plans shall M used as public record.. - MODIFICATION
OZ p UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional - 201-I00DAMPS IMPROVEMENT'
a? OWNER-BUILDER DECLARATION
yb C affirm that I am excmpr cemOVER I(10(IAMRS town the Clawraf rs Lie I.uw for the ❑BATH REMODEVREPAIR ❑DEMOLITION
x 3w 1 herebyIS V following reason.(Section 7031.5.Businessland Plnficor...Cole:Any city or County SIGNS ELECTRICAL []OTHER
la O which requires a permit to conswn,alter,improve,demolish,or repair any strucmm t.
prianonsiseuanee.alsom lines theapplicmt bleach pclarith Me asignedsmtement SPECIAL CIRCUITIMISC.
} mat he is licensed pursuant to me previsions of me Contractors License Law(Chapwr9
<0 (commencing with Section TIDO)of Division 3 of the Business and l'rofeasiont Coe)or TEMP.METER OR POLE INST. COMMERCIAL:
Ia c eG xempt that he is etherefrom and the m
hasis lin e allege]exemption.Any violation of El NEW BLDG/ADDITION [2 DEMOLITION
4• Section 7031.5 by any applicant for a permit subjects lie applicant to a civil penalty of POWER DEVICES
rnNANT ❑FOODSERVICE
F Z cl not more than five t h pox, ollars y employees
I OVHMENT
wi Las owner of thepropeny,mmycmplended orowages,their side compensation. SWIMMING POOL ELECTRIC
O andwildame work,andmehe Cco ecuonot intendese I...due,a:'.. (Sec.7(W,Business ❑OTHER
and professions Calc:Therein rem License Ldw]nes am apply a ff r through of OUTLETS-SWITCHES-FIXTURES
property who buil]or improves thereon,one who Jtes such weak
te himself or through
his awn employees,provide mat sock impros...Id s are not intended or offered for EW RESIDENTIAL ELF.ITR SQ Pf. '
sale.r-buil vee have
the bur impmvemenl is haithinon uildarimprovetionthe SQ.PT.FLOOR AREA 'S/SQ,FT.
owner-builder will hove the burden of proving mat he did nm build orimpnrve for par-
, pmsc osale]. T 'f
EJ 1,>owner of the See 70,,am exclusively Contracting with licensed contractors m
construct the project(Su.7(H4,Easiness and Pm(excions Cade:)71te Commences Li-
Cease Law does not apply to an owner of property who buildsor im....C,thereon,and QTY, PLUMBING PERMYI' FEE P A 0 ,41'
who contracts for such projects with a comracmr(s)licensed pursuant fo the Comment's
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER WA) VALUATION
WORKERS COM Ppi3ON DECLARATION BACK PLOW I'HOTEC'I'.DEVICE /-
IherchYamofee
mrunderpenatyperjury oneo(mefollowingaedmatinns:
•❑I have and will maintain a Cenificam of Consent o self-asure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONST RUCTION
section,as provided for by Section 37M of the labor Code,for the performance of the
work for whichthis permit is issued FIXTURES-PER TRAP
❑ I have and will maintain Worker'.Con pensation Insurance,as required by Seelion
3700ofthe labor Ctaie,forme perfaymance of the work for which thispereal is ixlyii GAS-CA.SYSTEM-1 INC.4 OUTLEIX -OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy No.: I GAS-PA.SYSTEM-OVER4(1TA)
CERTIFICATE Oil EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASE%INDUSTRL WASTE INTERCEPTOR
This welanneedirotbecncd nipldil'Bie permit is toy one hundred dollars(Slah) BUILDING DIVISIO 'ETis
• or fall.) - GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work rut which this permit is issued,I.shot]
not employ any person in y manner so nn s becunm subjectpen-to me Walker,' SEWER-SANITARY-S•I'ORM EA.200 Ff.
ENERGY flat.flat.,$ an
satiunlaws of California.Date
Z 0 Applicant WATER HEAT[R WNF.NT/ELF.CB n GRADING FEE,
h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
.haeme subject m the Workers
Worker's Compensation provisions of the Labor Cole,you must SOILS FEE
i� fonhwiNcnmply wltbsueh provisions or this pennhsuch be deemed minted. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCYNEW RESIDENTIAL IL SQ.EL PAID
V O Thereby affirm that is u construction lending agency file the perlhmtmcc of MB, Date ReceiptA
LL E" the work for which this permit is issued(Sec.300.Civ.C.)
0 [enacts Name TOTAL,
(U Lenders Address TOTAL:
fy�
aI Certify that l have red this application and state that the.bove information is
V BUILDING IEE
VV7al correct.l agree to comply with all city and county ordinances and.state laws relating to TY. MECHANICALPERMIT PEE
G building construction.and hereby normal representatives of this city to enter upon me SEISMIC FEE
oboe-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree nave,in
sdemnify and keep hamlets the the City of Cupertino against ELECTRICI7CE
liabilities,julgerenu,costs inactivates which may in any way acme against said City AUMRORADDTOMECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 'h1)
SOURCE REGULATIONS. MECHANICAL HE
- AIR HANDLING UNIT(OVER Fats)CFM) CONSTRUCTION TAX
Signature of Applieant/Contmetor Date EXHAUST HOLD(W/DUCq HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE -
Will the applicant or future building occupant store or handle Inumbaus andainal HEATING UNIT(TO I on"BTU)
as defused by the Cupeninn My iPat Code,Chapter 9.12,and the Health and Safety
Code,Section 2 532of HEATING UNIT(OVER 100,000 BTU)
❑Yes- No VENTILATION FAN(SINGLE.RF.SID) PAID
Date I Receipt#
l Willme applicant or furore wilding occupamaAr.Air Quality Ziceswhich y01LF:R-COMP(3HPOR 100,000 BTU)
mit huardnus sir conmminan's a�aefined by me Bay Arca Air Quality Management TOTAL:
District? Yes I ( f/4 BOILER-COME(OVER 10l BTU)
hove ehvardu xmnterinls AIR CON DITIONER
require sweet.Cr Chapter fi.95 of me Call- - ISSUAt
n is Health A c a S ons 2550 1 l and 2.5534.I utWerstand that if me NEW RESIDENTIAL MECH. SQ.FT
uilAingems ala r rt mmLt this rcspmisibilitymnotify the oeuprm
e tr ttw i nee ora cenifiem t o y.
Ownernrauthorim agent Oats ISSUED BY:
OFFICE y