28707APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJE NTIFICATION
PERMIT NO.
i O � 0 7
28707
Gv 1
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
taxa 'raw Milt
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O; NER'S NAME; PHONE:
CONT R'S NA LIC NO:
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CONTROL#
to
ARCHIIOVNT11riW/Cf1/{Ivi1NV0IN[EN: LIC
ADDRESS:
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CONTACT. PHONE:
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,LICENSED
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
D ELE PLUMB EC
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G UZ UU
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CONTRA OR'S DECLARATION
I hereby arum that I am licensed tinder provisions of chapter 9 (commencing
with Seetion]lMK)7 of Division3of the Business otic Professions Cale. and mylicense ix
in full force and effete.
License Class List, p
Dcrc Comntcmr
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RFSI,-_� DENTIAL:
❑ SFDWL ❑KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
F -pm
.p=a
ARCHITECUS DECLARATION
l understand my plans shall he used as public records
PANELS
)Z
UPTO20DAMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODEI/REPAIR El DEMOLITION
❑ OTHER3
a�
7 C
O W U
E
Licensed Pmressi mil
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following mount. (Stenon 7131.5, Business and Professions Code: Any city or countySIGNS
211-1001AMPS
OVER IOI(1AMPS
ELECTRICAL
O
� }
I GO
e a
which requires a permit m construct, alter, improve, demolish, or repair any onneurc
prior to its issuance, also requires the applicant for such Permit o file a signed statement
that he is licensed pursuant to the provisions ofthe Contractor's License Low (Chapter 9
(commentingwith Section'!00(pof Division 3 ofthe Business and Professions Cale)or
that he is exempt therofmm and the basis for the alleged exemption. Any violvtion of
5 !CIAL CIRCUIT/MISC.
TEMP. METER OR POLE. )NST.
COMMERCIAL:
❑NEW BLDG/ADDITION ❑DEMOLITION
�w
^6
O
Section 7031.5 by any applicant for a permit subject the applicant to a civil penalty of
no'mare than five hundred dollars ($500).
01, as owner ofthe property, or my employees with wages as their soler, marinates firm,
will do the work. and the structure is not intended oreffeted for %ale(Sec. 705, Business
POWER DEVICES
TENANT 0 FOOD SERVICE
ROVEMENT
❑OTHER
A SWI NO POOL ELECTRIC
a 3 $
°rid professions Cale: The Canari License Law docs nor apply to ..owner of
Property who huilde or improves thereon, and who does such work himself or through
ls�UTLETS - SWAT.CHFS - FIXTURES
his own employees, provided that such improvements an, not intended lir othered for
sale. IL hewevee the have the burden rovemem ithat he ithin t build or orae for the
owner -builder will have th<buNen of proving that he did not buil) or improve for put-
NEW RESIDENTIAL R SQ FT.
SQ. Pr'. FLOOR A
LSQ. FI'.
1, as owner of the property, exclusively connecting with licensed contractors to
con ter the project (Sec. ]DW,, Business and Professions Cale:) The Contractor's Li-
cense Law does net apply m anowner of pusamy who builds or Engraves thereon,end
QTY. PATIM,PERMIT IrEE
whir contracts for such projects with a conrmetor(sj licensed pursuant to the Contractor's'
PERMIT IS CE
License Law.
❑ I out exempt once( Sec. .B& P C for this reason
0i 1
wnc Dam
ALTER - DRAIN&VE WAT I
VALUATION'
JJJ
WORKIiN'S COMPENSATION DECLAMATION
B PLOW PROTE E
I hereby of ire under penalty ofNrjury one of the following declarations:
`JV
DRAINS- OOR,1100'AR D.
F1 I have and will maintain a Certificate ofConsemto self-asue for Workers Compre-
turner, as provided Sir by Sesion 3700 of the Labor Cede, for the performance of the
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
FIXI URES - PER P
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
30W ofthe Labor Code, for the performance ofthe work for which this permit i5 issued.
GAS - EA. SYSTEM -1 INC. I I_I!T5
OCC. GROUP
APN
My Workers Compensation Insurance carrier and Policy number rue:
Carrier, Policy No.:
GAS - EA. SYSTEM -OVER 4 (FA)
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRFASIYINDUSTRL WASTE INTF.RCEPfO
BUILDING DIVISION FEES
(This section rcctl not becompletW Ifthe permit is (orotic hundred dollars (g I W)
orless.)
CREASE. TRAP
PLANCHECK FEE rV611 10
I certify that in the performance mit ofthe work for which this peris issued, l shat[
nm employ any person in any manner so as tobecome subject to the Workers' Compen-
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEC
OZaction
O
f~ ti
Wforthwith
a
UO
Limsof California. Doc
Applicant
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become smbjeeno the Worker. Compensation provisions of Ne Labor Code, you most
comply with such provisions or this pernirshall be deemed Invoked
CONSTRUCTION LENDING AGENCY
Ihereby affirm that Here iss issued 30 [ending agency for the performance of
the work for which this permit is issued ISa. 3f19'I, Civ. CJ
Lender's Name
WATER SYSTEM/TREATING
WATER SERVICE
SOILS FEE
PAID Dare Receipt#
NEW RF.SIDENTIALPWIB. SQ. FT.
TOTAL.:
Lender's Address
TOTAL:
BUILDING EEE �.
1 certify Net I have real this application and state Ihm the above information is
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
ELECTRIC FEE
Vcorrect.
U z
`w
l agree to comply with all city and county ordinances and statelaws reining to
buildingcunnmetratmd hereby aathnrnc representatives ofthie city tomeraprm the
above-mentioned propery for inspection purposes.
(We) agree to save; indemnify and keep hum less the City of Cupetinn against
PERMIT ISSUANCE
PLUMBING FEE
livbilities,judgmenrs, costs and expenses which may in any way accrue against said City
in consequence of the gmndr, of this permit.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT(TO 11,000 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RC _ /
MECHANICAL FEE
AIR 14ANDLING UNIT (OVER IQOp CFM)
��1�
Jw
TAX
EXHAUST HOOD (W/DUCTI
HOUSINGMITIGATION FEE c�4
HOUSING MITIGATION
t^
`I ,
�r wren(ApphcaHAZARrnr la�ie��—
HAZARDOUS MATERIALS DISCLOSURE.
HEATING UNIT jIO I00.000 BTU)
Wll the vppliwnt orfmure building vociferation, or handle hazallous material
as defined by the Capetian Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(v)'t
❑Yes ON.
Will the epglicem to future building usecupam a. equipment in devices which
Demit immolate air contaminants as defined by the Bay Area Air Quality Management
suict?
❑Yes No
aa
PAID
Dare �()Raeipt# O
t
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RFSID)
BOILER-COMPOHPOR 100,000BTU)
TOT
BOILER- COMP (OVER 100,100 BTU)
AIR CONDITIONER
I have read the formation; materials battlements under Chapter 6.95 of the Cali.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
forma Health & Safety Cade. Sections 2.5505, 25533 and 25534. I understood that if the
holding dotes not currently have a tenant, that it is my responsibility in notify the occupant
of etequirementsw ichmust tpnnno issuance of a Cenain."of Or mpancy.
QT'
r euthonred agent �� 1 late
ISSUED BY:
OFFICE