28790 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. ^ ^ 7^O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL' LIXJ lJA
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
OWfiR AME: PHONE C � CONT Cf 'S NAME: LIC No.Is NIC CONTROLM�J
e J 1� ❑ J r� /
ARCHITECT/ENGINEER: LIC NO: NI?'
CONTACT: PHONE: BUILDING PERMIT INFO
A L� T ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
V ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ROzZ with Sectionnssniti'Division ofthe Business and Professions Code,undmylicense is RESIDENTIAL:
0o in, 11 forcetnde r PERMIT ISSUANCE
klC a 'G G�j Q� Q ❑SFDWL ❑KITCHEN REMODEL
Q,ULiceme Cl
Z Lic.p APPLIANCES RESIDENTIAL
tDam Contrenur - []ADDITION ❑PLUMBING R&PIPE
p-py ARCHITECTS DECLARATION ❑MULTIUNIT ❑STRUCTURAL.
1 understand my plans shall he used as bl' PANELS
ZO �j pu mrttnrds MODIFICATION
UP10200AMPS
O - ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional - 201-I000AMPS IMPROVEMENT
J Ron I Out
DECLARATION
Connector's
I hereby affirm Nm 10m uempt from the Contructor'e Lianm Law for the OVER IfXIB AMPS ❑BATH REMODF.VREPAIR 0 DEMOLITION
W a 6 U following reason,(Suction 7031.5,Business and Professions Code.Any city or county SIGNS ELECTRICAL 1-1 OTHER
ul
0 which requires It permit m contact,elm,improve,demolish,or repair anystmemre _
F 1j0 poor to its issuance,also requires the applicant for such Permit o file a signed statement SPECIALCIRCUIT/MISC.
} that he is licensed pursuant a the provisions of the Convectors License Law(Chapter 9
&01
(commencing with Secdan 7..011)ofDivision 3 ofsheBuonessand Professions Code)or TEM P.ka:rfiRO .111 S
1T. COMMERCIAL
06 r,0 LL tent he is exempt therefiom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION ❑DEMOLITION
ao Section 7031.5 by any applicant for a permit subjects the applicant to u civil penalty of POWER DL'VICES CTFNANT ❑FOOD SERVICE
F-ZY not more than rive hundred dollars($500). IMPROVEMENT
pT60 01,asownerofshepropeny,Or myemployux with wugesns their sole compensation, SWIMMING POOL ECTR -
�+,CGL� wllldo the work,and thextmaimelstud iurml,vornffered Ln,me(Sec.7044,Business COTHER
and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCH FIXTUR
property who builds or improves thereon.and who does such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW RESIDI?NTIA 1 : SQ 1'.
sale.If,howeventhe building,,,improvement k oild within oneyear of completion,the SQ.FT.FLOOR AREA E/SQ.IT.
nwncrhuilder will have sure burden of proving that he did not build or improve for pun
you ane❑Las oner of ct property,.n sinesand cotracting with:)TheeCcomracmrs mcomate e pryem(Sea]OMs,I{usiness moil Professions Calet)TTc Cnmmctor'e Id.
�reo"ato
LowJoe;nm apply to unownerof pmpeny who hulIJ,or improves therm,,,0 1 QTY PLUMBING PERMIT FEE
who ts for such projects with a contractorb)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. •B&1'C for this reason
ALIVE-DRAIN&VEN'T-WATBR(EA) VALUATION
Owner Date
WORKER'S COMPENSA'1'I ON DECLARATION BACK FLOW PROTECT DEVICE
re
1 Imby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Comentto self-insme for Worker's Compete DRAINS-FLOOR,ROOF.AREA,COND STORIES
TYPE CONSTRUCTION
Union,as rovidcd for by Section 371X1 of the Luhnr Gyle,for te hpf,finu unce al the
wor hich[his permit is issued. FIXTURES-PI!R TRAP
I have and will maintain Workerranc
Workers Compensation Insurance,u required by by Section
37Mof[he labor Code,for the Performance of the work for which this permit is issued GAS-EA.SYSTEM-]INC.4 OUTLETS OCOGROUP APN
My Worker umpensnp Into a carrier and Policy nyys
Carrier, s Pol icy No.: /V`IS'TZZ% GAS-EA.SYSTEM-OVER 4(EA)
ERTIFI'ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This amnion need nos be completed ifthe permit is fortune hundred dollars($100) BUILDMG DIVISION Il?FS
or less) GREASE TRAP PLANCHECK FEF.
Ininify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2W PT.
not employ any permn in any manner so as to become subject subjeco the Worker Campen- ENERGY FEE
OZ satiun laws of California.Data WATER HEATER WNENTA?LECR
Applicant T GRADING FEE
t•-1 r�ry NOTICE TO APPLICANT.If,after making this Cenifiewti or Exemption,you should WATER SYSTEMOREATING
become subject to the Worker's Compensation provisions Of the Labor Code.you must SOILS FEE
{il forthwith comply with such previsions oribis permit shall be deemed rovol WATER SERVICE
Q
0 CONSTNUCTLONLENDINGAGENCY NEW NPSIDENTIAL PLMIi, SQ.FT. PAID
U
U O I hereby which
that[here issued(Sm.construction lending agency for Ne performance of Date Rccei M
O(•+ L e work for which[bis permit is issued(Sm.30f)7.Civ.CJ
Lenders Name T
I<nder s Address 'TOTAL:
P. 1 certify but I have read this application unJ state that tura above inhumation is BUILDING FF.E
V) correct.I agree to comply with all city and county ordinances andstate laws relating to QTY. MECHANICAL PERMIT FEE
U Z buildingconaaucdon.md hereby uubmine reprexcntativesofibisciry tnen¢rupon she SEISMIC FEE JcD
above-mentioned property for inspection purposes.
(We)ego.,.save,indemnify and keep hurmles;the City of Cupertino aaninst PERMIT ISSUANCE ELECTRIC FEB
liahilities,judgmenhs,costs and expenses which may in any way sector,against said City pLTF.R OR ADD TO MCCII.
in consequenm of are granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT CM 10,000 CFM) MECHANICALME
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,0(1(1 CFM) CONSTRUCTION TAX
Signature of Applicant/Contrector Dom EXHAUSTHOOD(W7DUC1) HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOSURE
Will theapplimmt or foram huilding occu,mIstoreor handle homrdnusmnmriul HEATING UNIT'(TO 100,003 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532(0)7 1 HEATING UNIT(OVER I00.0h)BTU)
❑Yes ON. PAID
VENTILATION PAN(SIN01.1?RESID) Date n Receipt#
Will mt or faun building occupant use equipment or devices which
mitharallous us airit co comaminanu as defined by she Bay Am Air Quality Management BOILER-COMP ORP OR I00,000 BTU)
istrim1 TOTAL:
❑Yea ❑Na 00IL[!R-COMP(OVER 100,000 BTU) ,
I have rail the hamNoua nationals requirements der Chapter 6.95 of the Cali AIRCONDITIONF.R
9 p ISSUANCE DATE
form a Hwlsh&Safe Cede Se SJ4.1 understated Net if the p(/a
buildin does carrel h entenunk titi;m- ry y oIiW RESIULNTIALMECI{. SQ.FT.
g n y yresponsibili mnotif he Pontt
of Ne req ' mote hicht ;t ntd e fi Cunlfiwteyf yup J
j,Ktura honmed agent 5 DI/ TOTAL ISSUED BY:
OFFICE