28876 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. a.. ^ w
LVA
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BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING •2-MECHANICAL l8
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O S3 7465 c�TI
OWNF. 'S E: ' I, Q 1 PFJ(1NE_ _ CONTRA OH'S E: LIC O: NAC CONTROL#
AR H CfIENGINEER: N LIC NO: ADDRESS: - ❑
CONTACT FF{p�E. I❑ Consultant Fees Paid by Applicant(Initial) B,��pf(L' BUEELECT PER NFO
PLUMB
MECH
❑ ❑ ❑
L EN lD CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ,f
I hereby offrm Nut 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�0Z NSection7WH of Division 3 ofthe Business and Professions Cade,and my license is RESIDENTIAL:
O can PERMIT ISSUANCE RESIDE [_1 KITCHEN REMODEL
in full force enJ effect.
�F,Vz License Class Liaro APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
N p
Data-Cammnor
p.Dm ARCHITECTS❑ ,bliKTION PANELS OMULTI:UNIT ' ❑STRUCTURAL
Z p f/1 Z I undersmnd my plena shell be used as public records MODIFICATION '
pZ UPT02MAMN ❑INTERIOR [:1 CHIMNEY REPAIR
Licensed Pmv(essinnel 201-I000AMPS IMPROVEMENT
')t OWNER-BUILDER DECLARATION
Q i hereby affw that 1 am esempt tram the Contmnm's License law far Ne OVER 111(0AMPS O BATH RF.MODFLREPAIR DEMOL I N
a2 Vfollowing reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL L3OTHER
="H F which requires a pornat to consuucl,alter,improve,demolish,or repair any swctme
poor to its histamine.also real the applicant for such Permit rile a signed statement SPECIALCIRCUIT/MISC.
0
�Iy Nath<is licensed pursuanothe ,.vision,of the Cmdowors License Law(Chopter9
apo (commencing with Section 7") Division 3 of the Busincssand Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: t
a pr K Nu he is exempt therefrom and the basis for the alleged exemption.Any violation of O NEW BLDG/ADDITION ❑DEMOLITION
iC r4/.
Section by any applicant permit subjects the applicant toacivil penalty of POWER DEVICES EITENANT ❑FOODSERVICE
WF„Zisr not more Nan rive hundred dollars($500). IMPROVEMENT
O i.ns owner of the property,or my employees with wages ns their cats compenmurn. SWIMMING POOL ELECTRIC
will do the work,and Ne structure is not troubled oreffered(oriole(Sec.7614,Business []OTHER
and Professions Code:The Convector's License Law does not apply to an owner of OUTLETS-SWITCHES-FIX
property who builds or improves themor,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR FT.
sale.If,however,the building or improvement is sold within one yeurmfcompletion,the SQ.VC FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or impmve for par,
Lou of selene O 6I, -
❑I,asow rot the property.am exclusively cmnmmting with licensed contractors 1(DTn1 ^`
crnsweI the project(Sec.]0M,Business and Poiesume,Code:)The Con oscers Li- {I/ 1
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBINGPERMIT Ve
FEE 6199
who court for such Projects with a contmputs
ctm(s)licensed uanno the Commaetods
me Lit
Ocl uresmptunder Sec. ,B&PCferthismason PERMIT ISSUANCE Vp Vup,CyI/
IVp
ALTER-DRAIN&VENT-WATER IRA) VALUATION
Owner Date - ,
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under pemlty of perjury one of the following declamtiuns:
❑I have and will maintain a Cenitiibt,of Consent to self-ireure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND,
cation,as provided for by Section 3]001 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
.,it for which this permit fs issued FIXTURES-PER TRAP
O I have and will maintain Worker's Compensation Insurance,as required by Section -
3700 of the Labor Code,for the Performance of the work for which this permit is issued. GAS-BA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wurkels Compensation Insurance carrier and Policy number art:
Carrier: 'Policy No.: GAS-EA.SYSTEM-OVER 4(EA) .
CERTIFICATE OF EXEMPTION FROM WORKERS' "
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the permit is for hundred dollars(Ei00) GREASE TRAP
or Ins.) PLANCHECK FEE
Tcertify that in the performance orwhich this Permitsuissued shall
not employ cy person in tiny mannerim to to become subject m the Wtkex'ComPc.-- SEWER-SANITARY-STORM EA.200P
ENERGY HE
Z senior laws of0difomia.Date WATER HEATER WNENTIELEC R
Applicant GRADING FEE
g' NOTICE TO APPLICANT If,after makin this Cer ificme of Esem t -h IJ
g p ion,you s oo WATER SYSTEM/TREATING
become subject the Workers Compensation provisions of the Ichor Code,you man SOILS FEE
{il forthwith complyy with melt provisions orr this pewit shall he deetseJ revoked. WATER SERVICE
Q
7z
CONSTRUCTION LENDING AGENCY p NEW RESIDP.M'IAL PLMB. SQ,FT. PAID
V n I far whi h his pe there is ned(Seeconstruction30 lending agency for the perfrwnttce of Date Receipt#
V. pF:+y thewmkfnr whichhis pewit is issued(See.309],Cie CJ
Q Lender's Name TOTAL:
LUk1
Leashes Address TOTAL:
1
1 certify that I have real this application and seas that the about information is BUILDING FEE
taq cumber,l agree to comply with all city and county mrdinn ccs and state laws belo ng m QTY, MECHANICAL PERMIT FEE
V building crmwctim.and hereby authorim repreunatives of Nis city m emerupon the SEISMIC ME
above-mentioned property,for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep huwless the City of Cupertino against ELECTRIC FEE
liabilities.judgments,toss and expenses which may in any way accrue againd'sud City ALTERORADDTOMECH.
in coeqce uenof the granting of this pewit. PLUMBING FEE
ns
APPLICANT UNDERS ANDS NOW ,COMPI WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFXD MECHANICAL HE
SOURCERF "L 5.
AIR HANDLING UNIT(OVER(Root CFM) CONSTRUCTIONTAX
Signe I IwaM ace Dae EXHAUST HOOD(WMUC) HOUSING MITIGATION FEE
HAZAR99 1AT'ERIALS DISCLOSURE
W 11 the applicant arj6'one wilding oecupom norc nr handle hamrdnua mamrial HEATING UNIT(TO 100,000 BTU)
u defined by the Cupenin66Municipal Code.Chaper 9.12,and Ne Health and Safny
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BT'U)
Dyes 71 No VEX riLATION FANS INGLE RESID) PAID •! .
Dem Receipt#
Will the applicant or(mum building by the Bt use equipment lor ily Management
which BOILER-COMP(3HP OR Inagua BTU)
emit hazardrue air contaminants m defined by the Bay Area Air Quality Management TOTAL:
District?
O Yeg Ills. BOILER-COMP(OVER 100,a0a BTU) 16
I have mead the harandmis maerids requiomenrs under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Snfny Code,Sections 25505,25533 most T55O4,1 understood Nat if the NEW RESIDENTIAL MECH. SQ.PT.
building does not currently have a tenant,that it is my responsibility to notify Ne occupant
of the mluiremens which must he mer prim to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE