28464 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY,,
CITY OF CUPERTINO IBUILDING-ELECTRICAL
PERMIT NO 2 8 4 6 4
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGGPROJECT
T IDENTIFICATION `
tlUlIA1NG PROJECT IDENTIFICATION
BUILDINGADDRESS. - - SANITARYNO. APPLICATION SUBMITTAL DATE
_ �64.'S
OW R'S AP
ME: HO CONTRACTO 'S NAME: LIC NO:
N/C CONTROL
It I
ARCHITECT.AI1NGINEER: LI NO: ADDRESS:
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) L ELECT PLUMB MECH
1-1 El
❑ ,❑ e
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT FEE -
I hereby dorm that I om licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OZiL with Seclion]000)of Division3ofthe Business and Professions Crile,and mylicense is
{{y 00 PERMIT ISSUANCE
I-� RBSIDENTIA
W r m NII force and effect. ❑SFDWL ❑KITCHEN REMODEL
U License Class- Car
Data Con"'wou APPLIANCES-RESIDENTIAL C1 ADDITION ❑PLUMBING RE-PIPE
.
7y ARCHITECT'S DECLARATION PANELS - ❑MULTI-UNIT []STRUCTURAL Y
ZO y)Q I understand my plans shall be used as public records MODIFICATION
:t 'UP TO 2M AMPS 'C INTERIOR ❑CHIMNEY REPAIR.
r {y Licensed Professional 201.1"AMPS IMPROVEMENT
S y la-J OWNER-BUILDER DECLARATION OVER["AMPS ❑BATH REMODEL REPAIR [-I DEMOLITION ,
S K•'` I hereby affirm that 1 sm exempt from the Contractor's License Law for the
ip5,O y U following reason.(Section 7031.5,Business end Professions Code:Any city or county SIGNS ELECTRICAL ❑0TH
which requires a permit to construct,altee improve,demolish,or repair any structure _
prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC
,> that he licensed pursuant to the provso'softhe Contractors License Law(Chapter 9 - `
GO
(commencingwith Sect 7") fD"son3ofthe Business add Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: i
dyx c C that he is exempt therefrom and the bans for Ne alleged exemption Any violation of ❑NEW BLDG/ADDMON ❑DEMOLITION
00'0.y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES _ ❑TENANT [I FOOD SERVICE
f+l not more than five hundred dollars(S500). IMPROVEMENT
[Q. Q (]1,as owner tithe property,or my employees with wages as their sole compensation, SWIMMING POOLELECTRIC ",).
will do the work,and the structure is not intended reoffered for sale(Sec.]044,Business []OTHER _
r�rE 6b6b6b and Professions Code:The Contmclors License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES .
-' property who builds or improves thereon,and who does such work himself or through
I
his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL ELECT? SQ FT
sale.If,however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.EP.,
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale): ,
❑1,as owner of the property,em exclusively contracting with licensed commands to TOTAL:
concoct the project(Sec.7044',Business and Perfesslonc Cade:)The Commene's Li.
cense Law does not apply to an owner of propeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects wit a conuuctor(s)licensed pursuant o the Contractor's _
License Law. PERMIT ISSUANCE 4
❑I am de
exempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER HQJ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE n
I hereby affirm under penalty of perjury one of the following declarations:
�❑I have and will maintain a Certificate ofConsenuo self-insure for Workers Caroni DRAINS-FLOOR,ROOE AREA,COND. - STORMS - TYPE CONSTRUCTION
/ sation,se provided for by Section 3]00 of the Labor Code,for the Pa forounce of the S
work for which this permit is issued. HXTUV� 7 P&'TRAP , • 44 _f "
❑1 have and will maintain Worker's Compensation harmonica,as required by Section I f - •/I
377 of the labor Code,for the Performance of the work for which this permit is issued G -EA.SYSTEMI INC.4 OUTLETS ` C gOUP ,. APN .
My Worker's Compensation Insurance carrier and Policy number are: - „ 6•
Cartier: Policy No.: GAS-EA,SYSTEb].0'VER 4(EEA) _
CERTIFICATE OF EXEMPTION FROM WORKERS' ('O
COMPENSATION INSURANCE <" GREASEIINDUS STE INTERCEPTOR
(Thio section need mtbe completed if the pemtit isfmone hundtN dollars($100). GREAS ' � BU DIVISION FBES
or[a..) - (� s PLANCHECKI�E
I cenify Nat in Ne performance of the work for which this permit is issf(2d,Ishell EW -
ANITARY-STORM EA.200 IT. ENERGY FEE
not employ any Per0rn ste in any manner so as to become subject to the W kers'Compen-
.`� eaLaws of California.Dam ' W R HEATER W/VENT/ELECTR
OO Applicant GRADING FEE '
hNOTICE TO APPLICANT:If,after making this Caribbean,of Exemption,you should
WATER SYSTEM/IREATING SOILS FEE
abecome subject to the Worker's Compensation provisions of Ne Luber C.lead a m,^ust
Lit foMwith comply with such provisions.,,his permit shell be deemed revoked Vk WATER SERVICE
Q
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID Da Rec ' R
V O I hereby affirm that there is a construction lending agency for the pahmaa.n'of'' ' -
the work far which this permit Is issued(Seo:3097,Civ.C) "
fL 'Lender's NameTOTAL:
O LJ Lenders Address - TOTAL:
T� W I certify that 1 have read this application and sicle that the above information is - B IN
tO correct.I agree to comply with all city and county incidences and state laws relating in QTY, MECHANICAL PERMIT FEE
L) building construction,and hereby authenze representatives ofthis city to enter upon the SEE
above-mentioned propeny for inspection purposes. -
PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELBCTR B
f Iabove,PNTU
,mstsand pe sea which may in any wayaccmeagainstsuid Ci
ALTER OR ADD TO MECH. PLUMBING FEE
in ronu s permit: e I
APPL e S LC Y LN NT AIR HANDLING UNIT(TO 10,000 CPM) MECHANICALFE
SOU ( AIR HANDLING UNIT 10,000 CFM) CONSTRUCTION 1AX
Signetore of ApplitudlCodtrzemr Data EXHAUST HOOD(W/DUCT) HOUSING MITI TION FEE
HAZARDOUS MATERIALS DISC SURE -
Will the applicant orfuture building reaction store or handle hazardous conterial HEATING UNIT(TO thin"BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)^ - HEATING UNIT(OVER 100,000 BTU)
E]Yes 7N VENTILATION FAN(SINGLE RESID) PAID
Date Receipt p
Will the applicant or furore building occupant use equipment or devices which BOILER=COMP OH[P OR 100.000 BTU)
emit hazardous air contaminants as defincA by the BayrAma Air Quality Management IOTA :
District^ -
El Yet FN. BOILER-COMP(OVER 100,000 BTU) ^
I
I have read the bazzNous materials writ inexam s under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUAN
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. '
building does not currently have a mount,that it is my responsibility to notify the occupant _
of the requirements which must be met prior to issuance of a Certificate of Occupancy. - 6
Owner or malunzed agent - ' Dale TOTAL ISSUED
„OFFICE