28956 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, ^8^ 5
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. L lx!Vy 4/FV•
BUILDING PROJECT IDENTIFICATION
1NGADISRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
TJWOSZ W/LLow /ZpVE Lf}-N�. 'l.a I��
NER'SNA E: PHONE:/ p� 'TRACTOR'SNAME: LIC NO:
NIC CONTROL#
ITECGENGINEER: LIC NO UDkE55: ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
❑-Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ , ❑ ❑
LICENSED CONTRACTOR'SDECLARATION QTY ELECTRIC PERMIT FEB
1 hereby affirm that 1 am licensed under adl Proops of Chapati 9(commencing JOB DESCRIPTION
O1Z with Sefull ction
eand pec Division the BusinessnnJ Profexsions Cale,intim license is PERMIT ISSUANCE
�uyl00 wr y \ RESIDENTIAL:
�F U,� LiceneClass and effect.
U{FFk,.,..)l License Class Lic.x CSFDWL El KITCHEN REMODEL
F�W Dute Convector APPLIANCES—RESIDENTIAL. []ADDITION C PLUMBING REPIPE
h
NI—�Oy ARCHI'1'ECT:S DF.CLARA'TIUN PANELS ❑MULTI-UNIT CSTRUCURAL
Z p YPLL 1 understand my pians shall be used os public reconls MODIFICATION
OZ p UP TO 200 AMPS CINTERIOR 0CHIMNEY REPAIR
Licensed Professional - 201-1"AMPS IMPROVEMENT
Oai I am exempt R DECLARATION ConTION - OVER I"AMPS C BATH REMODEUREPAIR C DEMOLITION
0 ooEf 4L'1 I hereby affnn that I am exempt from the Cnntmaorx License Law far the
3 d U following reason.(Section 40365,Business end Professions Code:Any city or county SIGNS ELECTRICAL C OTHER
0 which requires a Permit to construsel,alter improve,demolish,or repair any suumurc
vylI
prior o its iswance,also requires the applicant for such permit to Bic a signed statement SPECIAL CTRCUIT/MISC,
ry>Qg that he is licensed pursuant to the provisions of the Commao's License Law(Cleapter 9
❑0 (commencing with Section 7")of Division 3 of the Business end Pmfessinns Cale)or TEMP.ITT OR POLE INS"E AMM .R IA
d q q that he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW SLOG/ADDITION O DEMOLITION
zC Y.
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of POWER DEVICES
[]TENANT CFOOD SERVICE
?6
not mare than five hunJrW dollars($500).
O , IMPROVEMENT❑ SWIMMING POOL ELECTRIC -
II Jothework,andthe he Co cisnotintendedoroffe d not
a(Sec.)044,Business []OTHER
�_ and Property
who
Cade:The oyes Counselor's Land w I.S.does not apply s if owner of OUTLETS—SWITCHES—FlXT11RG5
3 his own who builU,or improves t such i,and who docs such work hiatal(or through
his own employees,building that such mens is old within arc on intended or olieud for NEW RESIDENTIAL ELECIR SQ F1'.
sale.ILhowever r willThe h vette burdenprovcment is Soldddonb ild rfromPletlot the SQ,PL FLOOR AREA $ISQ.F'f.
owntt-M1uildcr will have the burden of proving that he did not huild or improve lot poi-
orsale.).
ns owner of the property,am exclusively convecting with licensed contractors to 'fU
con St the project(Sec.]01-1,Fiusiness and Professions Code:)The Contractors Li.
U a law rows not apply in an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEB q
who nnnmers fur writ Pmjecta with u c.nvacmKs)licensed Inns antro the Contme�n's M
License Lnw. - Plitt Mrf ISSUANCE
❑I am exempt under Sec. .B&P C lin this reason
asci Dm ALTER—DRAIN&VENT W (EA ION
WOR ;S COMPENSATION Dnr
ECLARATION PACK .O Ut'ECC)
ihereby aflion under penalty of perjury one of the following declarations: e17Y a ., ,
•C l huveund willmornme a Certificate of Consent to self-insure for Worker's ComPen- DRAINS—IlLOOR,R HA,CO STORIES TYPE CONSTRUCTION
sotion,as provided for by Section 37(k)of the Labor Cale,for the performance of the
work for which this permit ie ikwcd. - FIXTURES—PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3000ofthe labor Code,fartheperformarmof the work for which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUTLETS OCOGROUP APN
My Worker's Compensation Insurance comer and Policy number am:
Carrier: Policy No.: GAS—EA.SYSTEM OVER 4(EA)
CERTIFICATE..OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEF/INDUSTRL WASTE INTERCEPTOR
.(This section need not ta completed if the permit is foronehundred dollars($ato) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work fmwhich this permit is issued,l shall
not employ any person in an annerso US m become subject t.the Workers Can SEWER—SANITARY—STORM EA:200 FT.
any 3 pen- ENERGY PEG '
z Sam laws of California.Date
7 WATER HEATER W [NT1LFCRAPPlicant
GRADING FEEGy NOTICE TO APPLICANT.IL tanking this Certificate of Exemption youmtld Wp'1'ER SYSTEM?kEATiNG
become subject to the Worker's Compensation provisionss of f the Lahr Code,youu most
S"L5 PEE
Com
[Ia forthwith comply with such provisions.,this pemut shall b•dwmal revoked. WATER S17RVICII
;IsQ
.7z CONSTRUCTION LENDING AGGNCY NEW kFSIDGNTIAI.PLM1I B. SQ.PT. - PAID
V 0 k for by which
that Permit i issued((Sec.
30l Civ.
agency Tasha perfomrance of pace Receipt
H
the work for which this permit is issued(Sec.309'/.Ci¢C1
Q U lenders Name TOTAL:
{k1 lender's Address TOTAL
0. 1 certify that 1 have mad this application end state that the starve information rehation is BUILDING FEE
N correct,ldingcgreemmmand with all ucity
riz countyordinancesof and nmela r Upingm QTy, MECHANICAL PERMIT FEE
V z building constructions and hereby authorize representatives of this city 1.enterupsn the SEISMIC FEE
above-mentioned property for inspection purposes. - PHRMIi ISSUANCE
(We)agree to sale,indemnify and keep harmless the City of Cool against E L B C r R I C IrEE
liahilities,judgments,costs andexpenses which may m mly way City ALTER OR ADD TO MF,CIi.
in consequence of the granting.(this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,000 CFM)
SOI CE REGULATIONS. MECHANICAL FEE
9� AIR HANDLING UNIT(OVEN IU,oUOCFM) CONSTRUCTIONTAX
Signamrco[Aliffieurt/C.04,111irr I/ Data EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will thcapPlicamar Team buildingoecupantemm or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the CUper ino Municipal Code,Chapter 912,and the Health unit Safety
Code,Section 25532(a)'1 BEATING UNI E(OVER 10TO p BTU)
❑Yes ❑No t
., VENTILATION PAN(SINGLE RESID) PAID
Will thea applicant or future building amateurs use Data Recap,#
pP g cup ea Air usury Management
BOILER—COMP(311P OR 100,01(0 BTU)
Dist hazardous air cnnmminants ns defined by the Boy Area Air Quality Management
Disl(iCl4 TOTAL:
❑Yes I]Nn BOILIiR-COMPOVER100,0fail
I have real the hazallous materials requirements Under Chapter 6.95 of the Cali- AIR CONDrDONER ISSUANCE DATE
(antis Health&Safety Code,Stations 8505,25533 and 25534.1 nndecnunJ that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not
cormantly have U mount,Nat it is my responsibility to notify the eecopmn
of the requirements which must be met prior issuance of a Certificate of Occupancy. ,
Owner or authorized agent - Dam TOTAL: ISSUED BY: �s�`s�`- •
OFFICE