28921APPLICANTTO FILL IN INFORMATION WITHIN REO LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIWSION APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING PROJECT' IDENTIFICATION
PERMIT NO.
28921
BUH.DINGADURESS:! pb /�A`'�`
w 1020' { 09ge NG 1 '� '�r •
SAN ITARY NO,
1
AP/PLICADON SUBMITTALDATE
L �%��`
OWN NAME; PHONE:
G1wcrow
CONTRACTOR'S NAME: LIC NO:
NIC
'❑
CONTROL
' ARCHITF.CT/ENGINF.ER: LIC NU: -
ADDRESS:
tx 9
PHONE:
CONTDA��
BUILDING PERMIT INFO
4�`OA
1 I �� ,
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
-E h/
LICENSED CONTRACT'OR'S DECLARATION
T hereby M. that I Am licensed under provisions of Chapter 9 (cammeacing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Section 7000) of Divinian 3 or Businessand Professions Code,arf my l iciame is
in mu force dad effect,
LicenseClass Lic.p
Dam Contmcmr
PERMIT ISSUANCE -
RESIDENTIAL:
❑SFDWL El KITCHEN REMODEL.
[]ADDITION [I PLUMBING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL
MODIFICATION
APPLIANCES -RESIDENTIAL
ARCHITECT'S DECLARATION
1 understand my plans shill he used as public records
PANELS
UP TO 200 AMPS
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
RF.MODEIIREPAI EMOLITION
.00
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby AM. that 1 am exempt from the Contre,oes License Law for the
following heaven. (Section 703 1.5, nosiness and Professions Code: Any city or county
201-1000AMPS
OVER I(M0AMP5TH
SIGNS ELECTRICAL
which Ac,in,s a,senna, tu consumer,.hest. im'rovc, demolish, or repair any swaure
SPCCIALCIRCUIT/MISC.
prior to its issuance, also requires the Applicant for such permit to file a signed statement
thathelslaansWp.... At to the Provisions of the Cammemr's license Law (Chapter 9
TEMP. MItit OR POLE INST.
(commencing with Section 7000) of Division 3 of the Business and Professions Care) or
that he is exempt therefrom and Ne basis for the Alleged exemption. Any violation of
❑ NE B Cr(Ip''p'DITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to A civil Penalty of
t more than five hundred dollars WON.
❑I,As.wnerofthe property.., my employoos with wages asmeir sole compensalon,
will dmhe w�rk, and iha mmdure is not amended oroffered for aide (Site 7044, Business
POWER DEVICES
❑TENA v ❑ FOOD SERVICE
PROVEME
❑ OT
SWIMMING POOL ELECTRIC
OUTLES- SWITCHES -FIXTURES
and Professions Cale: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If. however. the building or improvement isxold within one year of completion. the
NEW RESIDENTIAL ELECTR SQ R.
SQ.' 17E FLOOR'AREA
$1SQ. ET.
owner -builder will have the burden of proving that he did nm build or improve for pur-
0 1, as owns
I, as owner of It pro. 70,1 ant exclusively contracting with licensed contractors r
consumer the pmJec, (Seo. 7064, Business unJ Pmfeeaiona Gdep The C.ntruq.r'e Li-
OCT 2 4 1995
- TAL:
g
cenx Law does not apply to an owner of property who builds or improves,herson, and
who contracts for such projects with A contractm(s) licensed pursuant the Convectors
QT'y. PLUMBING PE FEE
UP `urt/T
PERMIT ISSUANCE
Law, r!'fll lMpm v!` "—
<xemptJ��u�In y�T s . B & P C for this reavm
I Ulu
ALTER—DRAIN&VENT—WATER(EA)
lrD .
/
(OU0
VALUATION
WORKER'S COMPCNSATION D[CLARAT1.-4
BACK FLOW PROTECT. DEVICE
hereby affirm under penalty of perjury one ofthe following declarations:
DRAINS- FLOOR. ROOF. AREA, COND.
ave and will maintain a Certificate ofConsenin self insum for Workers Campen-
.far. as provided for by Section 37W oI the labor Code, for the penia nines of the
STORIES TYPE CONSTRUCTION
-
Work for which this permit is issued.
FIXTURES - PER TRAP
❑ 1 have And will maintain Wofkers Compensation Irournmes. As ,fuired by Section
37M of the Edam Gde, for the performance of the work lin which this permit is issued.
GAS -EA.SYSTEM-I INC.4 OUTLETS
OCC. GROUP APN
My Workers Compensation Insurance currier and Policy number Art:
Carrier: Policy No:
,
GAS -EA. SYSTEM -OVER
CERTIFICATH OIt EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Act becompleted ifthe'ermit is for one hundred dollars (SIM)
or leve.)
GRRASIVINDUSTRL WASTE INTERCEPTOR
BUT )I D ISION S
PLANCHECK FEE
GREASE TRAP
SEWER -SANITARY -STORM EA .2f0 FT.
I certify that in the Performance ofthe work forwhich this permit is issued, l shall
not employ any Person in any manner sn as to become subject the Workers Compen-
ENERGY FEE
sa,ion Iowa of CAlifinno. Dote
Applicant
WATER HEATER W/VENT/ELECTR
ADING FEE
NOTICE TO APPLICANT: If, ufit, making this Ccallictie of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cale, you must
WATER SYSTEMRREATING
ILS PEE
forthwith complywi,h such provisions or this Permit shall be doomed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm Nor, is Ac.astaximn lendingag..cy for Ne'e,fammnceof
a Receipt#
NEW RESIDENTIAL P1,1. SQ. PI'.D
the work for which this permit is issued (Sec. 3197, Civ, CJ
NJ
Landers Name
TOTAL:
Lender's Address
TOTAL:
ILDING FEE
1 certify that E have read this application and stem that the above information is
QTY. MECIIANICALPERMIT
SMIC FEE
correct. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of ibis city to enter upon the
PERMIT ISSUANCE
ECTRIC IE
above-mentioned property for inspection purposes.
(We) agree misuse. indemnify and keep hamless the City of Cupertino Against
ALTERORADDTOMECH.
IPA
UMBING E
liabilities,judgments, carts and expenses which may in any way accrue against said City
in consequence of the granting of this permit,
AER HANDLING UNIT Iq(11111 CFM)CHANIC
LFEE
APPLICANT UNDERSTANDS AND WILL rO LYWITHALLNON-POINT
SOf1RCF. REGULATIONS.
HANDLING UNIT (OVER I0,000 CFM)NSTRU
ONTAX
,WqAIR
EXHAUSTHOOD(W/DUCI)USING
MUI ATION FEE
afApplic.AVCommmor Dam
' HAZARDOUS MATERIALS DISCLOSUREWill
HEATING UNIT(TO IRBit)BTU)as
the Applicant or farm. building occupants,nrour handle hazardous material
defined by ,he Curtino Municipal Code. Chapter 9.12, And the Health and Safety
Code, Section 25532(a)'I
HEATING UNIT (OVER I MOMBTU)
❑Yes ❑Nn
Will the applicant or future building oecupant use equipment or devices which
nit hazardous air contaminants as defined by the Bay Area Air Quality Management
D
Date Receipt #
VENTILATION FAN (SINGLE RPSID)
nO1LF.R-COMP UNEP OR 100,M) BTU)
BOILER - COMP (OVER 100,000 BTU)
District?
❑Yes MNn ,
AIR CONDITIONEIntonationsISS
1 have read the Intonations materials requirements under Chapter 6.95 of the Cali-
N E DATE
NEW RESIDENTIAL MECH, SQ. pT.
fomin Health & Safety Cole, Sections 25505, 25533 and 25534. 1 understand that if the
building does mo, currently have A mnant,,hat it is my responsibility to notify the bccupont
of Ne requirtmenu which as, he met 'do, to issmnce of a Cendiewr of Occupancy.
1
ISSUED BY:
TOTAL
Owner or authorized agent Date
OFFICE