28784 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. a.a ^ a
BUILDING DIVISION PPLICATION/PERMIT PLUMBING-MECHANICAL 28 4
BUILDING PROJECT IDENTIFICATION
BUILDING DRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
� � F
OWNER' '
� PHONETTO . AQ LIE M O ma/yN/C CONTROLp
ARCHITECTENGINGC LICNO:
❑
Q
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMBMECH
❑ ❑ ❑
LIm that IDCONTRACnOR S rproviConsof CON- QTY ELECTRIC PERMIT PEE
1 hereby affirm Nts I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O00 with Section7000)of0ivision3oft Business and Pmfessiom Cad,and my license is �-
�OO PERMIT ISSUANCE RESIDENTIAL:
n full(areae t. I
FV j Lice Claz r Lic g ❑STD HH ❑ C BIN REMODEL
N<S Dm�'� Contracmr APPLIANCPS-RESIDENTIAL ❑ADDITION BING RF.-PIPE
I„•py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z O ttj Z I understand my plans shop be azW as public accords MODIFICATION
'Oz- UPT0200AMPS [I INTERIOR ❑CHIMNEY REPAIR
F(3 Licensed Professional 201-I04aAMPS IMPROVEMENT
EEEF OWNER-BUILDER DECLARATION O OVER Ifx1I1AMPS 1 hereby affirm that l am exempt form the Contractor's License Law far the ❑BATH REMODEVREPAIR ❑DEMOLITION
F LLV following reason.(Section 1011.5,Business and Professions Code:Any city oreminty SIGNS ELECTRICAL ❑OTHER I
Ca which requires a pemm m cmvwm,alter,improve.demolish,or repair,any swaurc
mJ prior to its issuance.also requires the applicant for such Permit o file a signed statement SPECIALCIRCUIT C.
} that he is licensed pursuant o the pmvisions of the Contractors License lmw(Chapter9
00 (eminuencing with Section 7000 of Division 3 of the Business and Professions CWP )R Code) TEMP.METPOLE INST. COMMERCIAL:
6 e C shut he is exempt thcrefrme end the basis for the alleged esemption.Any......tinct of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pemtlty ofPOWBN DEVICES ❑TENANT [I FOOD SERVICE
N nmmnre than Eve hundoxidollars(55110).
eS6 1,as ownerof the ten,orm employees with wages IMPROVEMENT'
O ❑ pop y yemp y ge frsaleirwle c04L nosiness
SWIMMING FOUL ELECTRIC
will do the work,C d the swcmrc i nmee LiceW malfercJ for sale(Sec.]044,liusincss []OTHER
63 and Profesaioro Code:The Commmor's License Law Joes nm apply to an owner of OUTLETS-SWITCHES-FIXTURPS
properly who builds or improves thereon.and who does such work Marott art through
his awn employees,provided Bad such improvements are ort intended or offered for NEW RESIDENTIAL ELECIR SQ IT.
'We.If.however.the building or improvement is sold within one yearo(completion,the SQ,PT.FLOOR AREA $/SQ.FT.
owner-builder will have the harden of pmving that he did not build or improve for par,
powofsalcJ. , R�
❑ 1,as owner of the Property,em exclusively comments with licensed commetors m TOTAL: r
consumer the project(Seo.7044,Business and Prolessions Code:)The Contractor's LI-cense Law does not apply to an owner of property who builds(it improves thereat,and QTY. PLUMBING PERMIT FP.E ��� ��
99y
1
who contracts for such projects with a contmou ds"licensed pursuant m the COntmchas
License Law. PERMIT ISSUANCE 99V5
ElIamexemptunder Sec. ,138,PCforthisremon
Owner Date ALTER-DRAIN&VENT-WATER(EA) t V ATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby Wflon under penalty of perjury One of the following declorvtlons: - ..
❑ Ihave and will muinminnCenificme of Cnnsennnsdf-inwrc for Worker's Conmmt- DRAINS-FLOOR,RODE AREA,GOND' STORIES TYPE GDNSI'RHCfIDN
anion,as provided for by Section Tutu Of the Labor Code,for the performence of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Cale, mthe performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Works ompen. In ane carierand Pnlic
Cartier. Policy N GAS-P.A.SYSTEM-OVER 4(EA)
17 CERTIFICATE OF EXEMPTION FROM WO KE S'
COMPENSATION INSURANCE GRHAS+UINDUSTRL WASTE INTERCEPTOR
(Hda section meednm hearmpleted fifth on sforonehundreddolbtrs($100) BUILDING D :ION FEES
or less.) GRF.ASE'I'RAP PLANCHECK I'EI?
I unify that in the performance of ework for whid ispennitislsxucd,lshall SEWER-SANITARY-STORM EA.20017.
not employ any perwn in tory m:mner c m henme w hjeet the Wmkers COmpen- ENERGY FEE
O z sedan Unes of Calif stun.Dore WATER HRA'I BE WNENT/ELECTR
z 0 Applicant GRADING FEE
fq
NOT ICE'TO AP PLICA NT aftermaking this Coal to of Ex prion,you should WATER SYS'TEM/rREATING
I"! became subject to the r ars Cnmpcnsatign p.Ojsi., d me La r Cale,you must SOILS HE
forthwith cont suchprnvismomNis rota SII e n rooked. WATER SERVICE
Q
QQQ]... CONS'TIIUCTIONLE OhNCY ��/ NRW RESIDENTIAL PCMB. SQ.pr. PAID
U n "hereby affr thouherc isuc di ndiny ug� ceperfnrmnnce of Data Receiptp
C1ti Il:-•yt thew rk for which N- pemtit 097,Civ.C.)
0 U Lends sNeme' TOTAL:
Lender Address TOTAL:
y certify that I cad this Joh au,th a above information is BUILDING FEE
rA emrect. agrem comp th slfsn and atnty.thin es and slam loss mlmingm QTY MECHANICAL PERMIT FEE
V building .ninon,et rtbydPa epreum ea of this city m enmr upnnthe SP.ISMICFEE
abovcme boned prapeny for inspeEtian purynse PERMIT ISSUANCE
( agree m save,indemnify and ke nnlexs the City Of CopeninO egoinct ELECTRIC FEE
liahilities,j dgan costs nnJ expensesw hmay in any way accrue egninst suit City ALTER ON ADU'I'O MECH.
in cnbwqua ce Of the grunting of this nit. PLUMBING FEF:
APPLICAN 'UNDERSTANDS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT O'U W.000 CFM"
SOURCE RE iULATlONS. MECHANICAL FEE
AIR HANDLING UNIT(OVE ."CFM) CONSTRUCTION TAX
lignmureof Ap icanO nuuetor Date EXHAUST HOOD(W/ ) HOUSING MITIGATION FEE
AZARDOOS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle baardous material HEAPING UNIT100,1100 BTU)
us defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Snl'ety
Cale,Section 25532(x)7 HEATING UN OVER IMAW HTU)
❑Yes ❑No VENTIL ON FAN(SINGLE RFSID) PAID
Will the applicant or future building accupant use equipment at devices which Data Receipt R
•strut hamrdaus air contaminants as defioeA by the Bay Area Air Quality Management BOILER-COM"'UNP OR IOE"BTU)
TOTAL:
District?
E]yes 0N BOILER-COMP(OVER WE"BTU)
I hale read the h:rmrdous mmenolx requimmcnts under Chaprer 6.95 of the Cali- AIR CONDITIONER ISSUA D
fnmia Health&Safery Code,. ions 25505,]5513 and 2.1534.1 undersand thin T the NEW RLSH)F-NTIAL MECH. SQ',FI'.
- huilding dcesnotearre ly .meant.Nat it is my roponobility to notify theoccnpum
Ofthere irement^ - et nn ceofa Ce 'tate nf0 cupaapy.
Own rorautho ecdagent Date TOTAL: ISSUEDB
ag
'OFFICE