28631APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO . BUILDING^ ELECTRICAL.. ^` PERMIT NO.
BUILDING DI VISION APPLICATION/PERMIT PLUMBING-MF.CHANICAI.28631
A2R IT ENG EER: LIC :
AD — — - /O
❑
T 1 O
ONT PHONe:
BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG E PLUMB ECH
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❑
LICENSED CONTRACTOR'S DECLARATI N
1 hereby affirm that I am fianxm ander provisions of Chapter 9 (emrtmeneing
tSection]0(gO of Division Sof the Businns and Profneinnx CsMe, and mylicensc is
of fat]force and eRttL
Litems Class o
ctor
Date Contractor
QTY ELECTRIC PERMIT FEF.
-
5 �'Z
,00
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MOWNER-BUILDER
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JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
C1 MULTI -UNIT C3 STRUCTURAL
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
DECLARATION
I herehy affom that 1 am exempt from the Contractors License Law for the
following remon.(Section 7031.5, a and Professions Code: Any city or county
PANELS
Y(p AMPS
201-I000AMPS
OVER If10o AMPS
_
SIGNS ELECTRICALOTHER
4 O ;}
.7
3y
e, demolish, or repair any structure
which requires a permm it const e6 all Ss impmvm
prishi sissuahowemasquir the.p,li mfar such penninn EleasigneJ smmmem
Natheislicensedpursuamt eprovisionsrl the Convector's License Law(Chupmr9
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLF. INST.
COMMERCIAL
❑ W BLDG/ADDITION ❑ DEMOLITION
g<f
yea
(commencing with Seaia 000)of Division tnf NelhamessandlsmfiessichrCaktio
that he is exempt the m and the basis to the alleged exemption. Any violation of
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0
3 ..
Section 7031.5 h y applicant for a pemsii x bjects the applicant to a civil penalty of
not m ve hundred dollars (S500)"
❑ m owner ofthe property, or my employe wit wages as their sole compensation.
will oche work, and thesinicmre is not inteade raffereeforsule(See.7044,Businens
and ofrsome, Code: The CnctoYs en
onu Licens Law Js not apply to mi owner of
pm rty who builds or improves thertan3end w does such work himself or through
his o a employees, pr iJal tgtrsEr improvem as are not intended or offered for
sa1e.1 hosaver,thebui in o ' via is so wilnoune yewofcompletion,the
POWER DEVICESE
ANT ❑ FOOD SERVICE
ROVEMENT
OTHER
SWIMMING POOL ELECTRIC
vWLETS— SWITCHES —FIXTURES
NEW RESIDENTIAL ELECTR SQ PT.
SQ. IT. FLOOR .A $/SQ. PT.
owner uilderwi v •; not pmvmg thed!d'mt build or improve for put-
❑ 1, m w • r as y; am examsi cnmranmg will, Lensed contmar's m
d
Canit_ .i616. Basile ala PmresxionscMe:)The Conunmon, l.i-
ulu - pplyio an owneyq fpmpeny who builds or improves thereon, and
pp
• GY.�
QTY PLUMBING PERMIT FEE
who can such pr"I."with/datmramor(s) licrossd pursuant to the Contractors
Licrnse la .�', /
C]lam eie opt err Sec. ,B&P C for tis rennin
w
`iA
VGi
PERMIT ISSUANCE
.❑Ihuveanl
ALTER — DRAIN & VENT— WATER (EA)
ATION
�Y Ur`��,•r la
1�_ l`., e�
Owner
WOR :R'S COMPENSATION DECLARATION
Ihe. affirm ndat Penalty of perjury one of the following dcclamtions:
BACK MOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF. AREA, COND.
El
it orumdaCmI,.I, art Corson •' Worker's Compen-
satioa, as pro ded r by Section 3]00 o our Cole, for the enhance of the
STORIES T PECONSTRUCIION
work for whit tpermit is issue,
FIXTURES — PER TRAP
❑ I hove and 1 maimnincr's Compensminn Insuruncc, us require by Struma
3]OOofte Labor Code aped'omunce ofthe work for which tis parm 'x issued.
OCC. GROUP APN
GAS—EA. SYSTEM -1 INC. 4 OUTLETS
My Workers Co. tion Imamate carne, ad Policy numberare:
Carrier Policy No.:
GAS — EA. SYSTEM -OVER 4 (FA)
C TIFICATROFEXEMITIONFROMWORKERS'
COMPENSATION INSUR CE
GREASHANDUSTRL WASTE INTERCEPTOR
UILDIN IVISION FEI'S
(This sen mneW not bewmplemd lft epc "far e JnlLsIS )
or lexs)
GREASE TRAP
PLANCHE
O
SEWER—SANITARY—STORM FA. 200 FT.
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{21h
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ULender's
5,)
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Icenifyde in the perfonnarme of the w whit thi. t s a, 1sh 11
rrrr55lhhhrr��lhhh
not employ any on in anYn n R e erS amps -
actual Laws of Cali mit Date rte _
Applicant
ENERGY .
OR DI FEE
WATER HEATER WNENT/ELECTR
NOTICETO APPLI NT. If.n mAin tis a more of P inion, you should
become subject to the mker's C n 1t ^tions of Labor Code, you must
foMwith comply with s It pmvisha he ilia permit aha adamW revoked.
CO TRshom....a AGENCY
Ifrwhich rat mmth use consvuc' len ding agency for the performance of
rework for which this permits'.3(19T. Civ. CJ
Lenders Name
WATER SYSTEMRREATING
WATERSERVICE
S 5 F
PAID m Recciptp
NEW RESIDENTIAL. PLhiB. SQ. FT.
TOTAL:
TOTAL:
Address
1 cavity that 1 have read this application and slate that me above information is
canter. l agree incomply withal]citYsad cauntymditwnces and one laws relming m
buikh ngeonstruction, and hereby authorize representatives ofthis city moderation the
above-mentioned property for inspection purposes.
(We) agate in save, indemnify and kap harmless me City of Cupertino ngaimt
BUILDIN FF.E g ��
SEISMICfE6
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE �,
ELECT IC FEE
PLUM INC FEE
gst said City
IiuN`"es,judgmr,castsand expenses which may loamy way accmeaain
onsequencg/If the granting of this pe
AIXER OR ADD TO MECH.
pIR HANDLING UNIT (TO BLOOD CFM)
MECHANICA FEE r
APPLICA ERSTANDS AN LL COMP .2 . NON -POINT-
SOUR 'C .LATI13NS.
AIR HANDLING UNIT(OVF.R 10,00DU M)
GDNS'TRHCTIDN X
/
EXHAUST HOOD (W/DUCT)
HOUSING MB1GATIUl1kFES
^gram o ApplicanVCantracm Da
HAZARDOUS MATERIALS DISCLOSU E
HFAI'ING UNII'(TO 11X0,000 BTU)
Will the applicant or future building occupant store or handle hazardous material
as defined by to CrNiono Municipal Code, Chapter 9.12, and the Health sad Safety
Code. Section 25532m)?
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
L] Yes 0 N
PAID
Dam Rac t p
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by to Bay Area Alt Quality Managemmn
BOILER—COMP UHP OR 100,000 BTU)
TAI .
BOILER — COMP (OVER IBLOW BTU)
District?
❑Yes ❑No
AIR CONDI'MOSER -
I have read me hmardoue materials reFiremems under Chapter 6.95 of the Cali-
ISSUANCE DA
NEW RESIDENTIAL MECH. SQ. FT.
forma Health & Safety Code, Sections 25505, 25533 and 25534. I understood that if the
building does not currently have a tenant, that it is my responsibility to notify the occupant
of the requirements which must he, met prior to issuance of a Certificate of Occupancy.
ISSUED BY:
Owner or authorized agent Date