28854 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILMNG-ELECYRICAL PERMIT NO. 2 8 8 5 q
BUILDING DIVISION APPIACATIONLPERMIT PLUMBING-MECHANICAL. VX VX 4
BUILDING PROJECT'IDP.NTIFICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW #AMB;
Cj�TRACfORS NAMBINO
N/C CONTROLpHO —� '
A I'PECUENGINEER: It NO: ADD F ❑
CONTACT: /f• PHONE:Ir BUILDING PERMIT INFO
` ❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
A1C/LICENSEffCo Rn RT nECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
a2 with Section Ma)of Div" 3nfaha Buslnessond Professinms Co e.as tlicamc is
00 i mcclic--7� y PERMIT ISSUANCE RESIDENTIAL:
tX LL n full force dice s.
QUU Liunse s Lic.# ❑SFDWL ITCHEN REMODEL
W Dam Cnntr "% -RESIDENTIAL []ADDITION ❑PLUMBINGRE-PIPE
AR iITECI'S C 1
PANELS [IMULTI-UNIT ❑STRUCTURAL
z O ror Z I undersand my plans shall be used as public records MODIFICATION
024, UP'1'0200AMPS - [I INTERIOR ❑CHIMNEY REPAIR
I" I' Licensed Professimul 201-IWOAMPS g�sIMPROVEMENT
4 OWNER-BUILDER DECLARATION OVER IM) ATH RHMODBUREPAIR �DCMOLRION
yL 1 hereby afOrm that I an exempt fns.the Connector's License Low forma
x 0 a V following reason(Smion 70)1.5.Business and Professions Code:Any city or coumY _ SIGNS ELGCfRICAL D OTHER
47 3 LL which requires a Permit to convect,slant improve,demolish,or repair any scrucam
ISti prior to is Issuance,also requires The applicant for such penot to rile a signedsatement SPECIALCIRCUIT/MISC.
Y That he is licensed pursnanno the provisions of the Convenors License Law(Chapter 9
(commencing with Section 7")of Division 3 of the Business and Professions Cape)or TEMP.MAZER OR POLE INST COMMERCIAL:
m ca oC Nffo
at he is exempt aherens and the basin for the alleged exemption.Any violation of D NEW BLDGIADDITION D DEMOLITION
"y Smtion]UJ1.5 by any applicant Bre a penniasubjcets Ne applicant o a civil penalty of POWER E []TENANT []FOODSERVICE
ZZ mtholl .
a mom than five hundred d $5WI. IMPROVEMENT
O ❑1,as owner of the property,or my employees with wages as their sale compensation. SWIMMNC OL ELECN14C
_ 011de Nework,end the structure,is not immndedo,ffered far.1.(S.70,PI Business []OTHER
and Professions Cade:The Commodes License Law does not apply ro an owner of IITLETS-SW CHBS FI% ES
6 a^ propeny who build,or improves there.,std who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDL1i)\AL`n1LECI R SQ IT.
sale.If,however.the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA S/SQ.PIl
owner-hudder will have The harden of proving that he did not build or improve for pur-
poseofsale).
❑stua owner ofthe property,amexclusively contracting s wirdlicensed commcton i- I L:
centum d project(Seepplly]040,Business end ity who
Professions Code:)The Cnnhermos Li- IT / �••yr//J/s[-/y`///
whocoawdoesnaappr manownerilhcofpmpcnywcesedprsds improves Hereon and Qty, � UMHING PERMIT FEE
Lha coaster for such projects with a commcmr(M licensed pursuant the Commmors
C ensel.aw. PER 1 C�
I am exempt under Sec. ,B&P C fo duo nd.son
Date ALTER
FLOW PR \ ATaaER� (EA) VALUAON�
Owner WORKERS COMPENSATION DECLARATION BACK FLAW PROTIiCf. OTCR\
• I hereby affirm under Penalty of Perjury one of the following dealamtions:
1 M1ave end will muimnin aCenificam of ConservmselGinmrcfnr Worker',Camper- DRAINS-FI.00 , OP REA,CO STORIES TYPE CONST CfION
saaion,as provided for by Section 37M of the Lehr Cole,for the performance of the
workforwhichdin,mitisissued. FIXTURES-PER �A
[:] I have and will maintain Worker's Compensation Insurance,as requord by Section
37M of the Lotions Code,for the performance of the weak for which this permit is issued. GAS-EA.SYSTE .I INC. Mlt �
OCC.GROUP APN
My Workers Cnmp<nwtionlnsurance c.rrierand oliy N.,numberurt: GAS-EA,SYSTEM-OVER4IA
Corsica Policy No:
CERTIITCAI B OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE IN
(This section need not he campleTed if the permit Is Ion one hundred colors($10q - BUILDING DIVISION FT,E9
GREASE TRAP
or less) ♦♦ PLANCHECK P�E
(cenify ah a Qerf, nonce ework far which Nisp timlasuedlshall SEWER-SANITARY-STORM EA.200 Fr.
not employ an
n fi eT hexane.n tat he�ys�s y.� Workerx'Cnmpen- ENERGY PER '
Z cation la �- n ^a
70 0 APPIic¢ WATER HEATER WNENTIELECfR G
q NOTICE T�PLICANT:If,afar mu ung thTe Cennfcum of Cxcmpuon,you should WATER mSYS'fEM/1'REATING
ai becoe subjecno the Workers Compensation provisions of thm
e labor Code.you thus
L$I forthwith comply with such provisions or this permitshallM deemed revoked WATER SERVICE t.
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hereby affirm that there is a construction lending agency for the performance of Data Receipt#
L) F0-T aha work for which ahlsp�fmils iss 1 .JN)].Civ.CJ
QF Lantern Name �// � TOTAL...Lender's AdJres= e T ��
I cenify that 1 isciel6d this application and state that the above information is BUILDING HE
(02 comet l agree tocomply withal]city and county ordinances and state laws relating to QTY- MECHANICAL PERMIT FEE O
V building construction,and hereby ailhoriae representatives ofthisciay to emerupon the SEISMIC FEE
.hove.mentioned propeny for inspection putpnsms. PERMIT ISSUANCE-
(We)agree Io save,indemnify and keep harmless the City of Cupertino against ELECIAIC PER
d
liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEB ,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,"CIN)
SOURCE REGULATIONS. MECHANICAL FEE �#
AIR HANDLING UNIT(OVER 10,010 CFM) CONS'TRUCTIONTAX
Signature ofppplicam/Contractor Data EXHAUST HOOD GVMUCF) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occup.t store unbundle harnrdous materiel HEATING UNIT(T0100,000 BTU)
as defined by the Cupertino Municipal CMe,Chapter 9.12.and the Health and Safety
Cade,Sxtion 25532m)'t HEATING UNIT(OVER 011,000 BTU) `
El Yea NRE
JNNo VENTILATION FAS NGLE S ID) PAID
`� Dam Receiptst
humorous
the applicant or contaminants
building huse equipment or desires which
emit hadnus air aminsms es defnM by by the
Bay Area Air Quality Management BOILER-COMP(3HPOR 1!0,000 BTU)
TOTAL:
Oianlct]
❑Yes BOILER-COMP(OVER I00,00013'1'U)
1]('n
AIR CONDITIONIiR
(have read hgha,. maials remem,under Chaim,695ofthe Cid- ISSUANCE DAT
fomia 1 h&. 2 ,25533 and 25534.1 understand Nat ifNe NEW RESIDENTIAL MECH. SQ.FT.
buil ' due c tit' y nesponsibilirym notify abeocuparaoniuani Cenificau of Oce m
i
O ror authn ed agent Date TQT ISSUEDBY,
OFFICE '