28819 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPE11IVRTINO BUILDING-ELECTRICAL. PERM]'1'NO.
BUILDINGISION APPLICATION/PERMITPLUMBING-MECHANICAL 28819
BUILDING PROJECT IDENTIFICATWN
OUILDING ADDRESS etSam arJh o Qry�p —m6�� JOt 14J3 SANITARY NO. APPLICATION SUBMITTAL UATI
OW Rga E.lilti eM \Jt,- 08 98x'-6400 CONTRACTOR
WP-es .c a?tV0N .
BIC CONTROLM
ARCHITECTMNGINMR: LIC NO: AD RMS 13W1011-$''a z 19 �i /tv
CONTACT: PHONE: BUILDING PERMIT INFO
tee /',0� �r y� O6/ El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
(�
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
COC'tat Z wirdllforcnndefecDivision3ofthe Business and Professions Cale,and mylicenx is
�O in full fore and effect PERMIT ISSUANCE
aVzU� License Class Lica DWL KITCHEN RIODEL.
N6 Uam Contractor APPLIANCES-RESIDENTIAL ADDITION 0PLUMBING RE-PIPE
I„ ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
7.O v�� IunderswnA my plans shall heisedmimblic records MODIFICATION
O Z— UP TO 200 AMPS
P 4 Licensed Pre exsional ❑INTERIOR [I CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 2111-I000AMPS IMPROVEMENT
C I hereby uifom that 1 me exempt from the Comractor's License Law for the OVER 1000AMPS ❑BATH REMODEI/RL•PAIR EI DEMOLITION
ip�06 V following reason.(Section]031.5.Business and Professions Cade:Any city carcounty SIGNS ELECTRICAL ❑OTHER
F �I"' which requims a permit m consumer,cher,improve,demolish,or repair any structure
prier to its issuance,also requires Ne applicant for such Permit o filen signed statentem SPECIAL CIRCUIT/MISC. p
that her is licensed pursuant to the provisions of the Commences License Law(Claapter9
300 (commencing with Secuinn]Wt))of Divisinn3ol the BusinessanJ PrafesninnsCode)nr TEMP.METERORPOLEINST. COMMERCIAL:
a q=pt that he is exempt therefrom wen the basis for the alleged exemption.Any violation of W BLQG/lkIIp1TIQN ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES �I�JU LV:
y A FOOD SERVICE
Gnot twre Nan five hundred dollars(f500). IMPROVEMENT❑I,as owner of the property,or my employees with wages as their sole comicmttion, SWIMMINGPOOLELECTRIC '
wall do Ne wmk,and the swcture isnot intcroN orolTered for sale(Sce.]Dbl,Business F]VT0 HCRUr"L 1
and Professions Code:The Contractor's License Law does not apply to hn owner M OUTLET'S-SWITCHES-FIXTURES V I V
property who builds or improves Hereon,and who does such work himself or through
his own employers,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however.the building orimprovemenr is sold wiNmone ywrefcnmplerion,the r SQ.FT.FLOOR AREA 5/SQ.FT.
owner-builder will have the burden of proving Nat he did not build or improve for pur-
1a salen.
[1 .
I,as owner of ct properly,am ndusivan contracting with licensed coact Is , TOTAL:
consumer rM1e Project f5<c.]lW,1,Business and Professions Cnden 91to Cnnvaunr'e LL
cense Law does not apply to an owner ofpropeny who builds or improves mention,and QTY, PLUMBING PERMIT FEE 390
whocontracts fmsuchProjectswitha c°nrmrunhi)licensed puts uanrmthe Coannovi is
License law' PERMIT ISSUANCE.
I nm exempt under Sec. ,B&P C for this mason
Owner pate
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION - BACK FLOW PROTECT.DEVICE
baffi !l l—I�zOO
I hem y rm under penalty of pc jury one of the following dami
deal 7 7r'w.7 '
❑IM1ave and will meimaine Certificate of Comenuo self-insure fm Worker's Cnmpen- DRAINS-FLWR,ROQBAREA,COND.
xtion,as provided for by Section 3](MI of the labor Cade,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
gl have and will maintain Workces Compensation Insurance,as mnuired by Section
3700 ofthe Labor Cole,for the performanccof the wok for which this Permit is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Worke acro station lnsumn ecarrier and Policy nuyherarc:, b�
Carrier. 44k Policy Nn.: ��A , Iffy GAS-EA.SYSTEMOVER,1(EA)
•tR I'ICATE OFPfION FROM WORKCRS'
COMPENSATION INSURANCE GREASFIINDUSTRI.WASTE INTERCEPTOR
(This arnica need not becomponcul if Ne permit is Barone hundreddolisrs($100) BUILDING DIVISION FP. S
or lcssJ GREASE TRAP PLANCHECK FEE QaW
1comfy that inthe anymmeweo as to
whichthis tomtitisers Car shall
natant In an SEWER-SANITARY-STORM EA.200 f'f.
employ y person in any manner ser as to he[ome subject to the Workers'Cnmpen- ENERGY FEE
Z satmnlawswf CrIifmrnm Dma WATER HEATER WNENT/ELECTR
O Applicant GRADING FEE
V2 NOTICE TO APPLICANT:IL aper making this Certifies¢of Exemption,you should WATER SYSTEMIUMATING
a '�^ become subject to the Workces Compensation provisions of the Lahr Code,you most SOILS FEE
forthwith comply with such provisions or this pewit shall he deemed revoked. WATER SERVICE
z
CONST RUCHON LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.IT PAID `r
U 0 (hereby a(fren that hem is a construction lending agency for Ne perfommnce of to - Receipt#
W F the work for which this permit is ismed(Ser.TOO,Civ.C.)
O U Lender's Name U TO'T'AL:
W Lender's Address TOTAL-: �1/
CL. I certify that I have read this application and state that dm above information is RELE�RTC
EE / 6 A.
(AA correct.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U� building conswction,and hereby aumenze representatives of Nis city m enter upon the E
aMwe-co ndoned property for inspection purposes PERMIT ISSUANCE
(We)agreem save,indemnify and keep harmless the City of Cupertino againt EE 173AS
liabilitics,judgments.costs and expenses which may in any way acme against avid City ALTER OR ADDTO MECH.in cmr equence of the granting of this permit. FEE
APPLICANT INDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) AL HE 1`-t#,f
E.RF CATIONS�� � AIR HANDLINGUNIT(OVERMOOCPM) TIONTAXJ (� (>Signnm odA� pplicanUCommnor Date EXHAUSTHWD UNMUCT) ITIGATIONFX.
HAZARDOUS MATERIALS DISCLOSURE
Will the APPlicanl or future building weather store or handle hauudons material HEATING UNIT TI'O 101.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cole.Section 255320)7 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN PSI NGLE RESID) PAID -
Date Reeeip
0011 Ne applicant in nus a building by
B y A equipment or devices which BOILER-COMP QHP OR 11X#010 BTU)
emit harardoue air contaminants as defined by the Buy Area Air Quality Management T A
Denton^
C]Yes r-1 No BOILER-COMP(OVER I01(00 BTU) d
I havcrnad the hamNousmaterials requirements under Chapte,695 of the Cid. AIR CONDITIONER ISSUANCE DATE
(wait,Health&Safety Code,Sections B505.25533 and 2553,1.1 undersand Har if Ne NEW RESIDENTIAL MECH. SQ.FT.
buildingdoesm currently have a tenant.that it is my responsibility to notify the occupant
offlue ennui nn which m mer priorm issuance of a Ced�fiCpla of
rauNcnzed t,gem Date TOTAL: ISSUED BY:
OFFICE