28679 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPIACATION/PERMITPLUMBING-MECHANICAL 28679'
BUILDING PROJF.C'1'IDENTIFICATION
B��ADDRESS: ^ � SANITARY ND. APPLICATIONSUBMITTALDATI
GK � OONTRACTOR'S NAME: LIC N��
CQJ � CONTROL
�fl1l@fITLLT/ENGINEER:
LIC NO: pUDRFSS:
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
A El ❑
LICENSED CONTRACfOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hemby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWZ Li,..with Section Division 3afthe Business and Professions Code,and my license is R GIF D�FNTIAI;
F�O in full force and effect. '�� PERMIT ISSUANCE ❑SFDWL [IKITCHEN REMODEL
�U
U License Chis APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Dote Contractor
ZO= ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
I understand my Inns shall he useJlys public records MODIFICATION
OZ -Sd///M E J=TiYLI 4/"� UPT02W AMPS
r4INs Licensed Pro essoml6� CI INTERIOR [I CHIMNEY REPAIR
201-I WO AMPS IMPROVEMENT
OWNER-BUILDER m Ce Contractor's
ON OVER]"AMPS ❑BATH REMODELREPAIR ❑DEMOLITION
K I hereby affirm that I am exempt from the Carron,Cos License Law for the
3 O U following reesov.(Secdon]o3L5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑ ER
<L which requires a permit to construct.alter,improve,demolish,or repairany swttum
2 prior m its issuance,alsomquires the applicant far such permit file asigned stammer SPECIAL CIRCUIT/MISC.
;!�N thus tim es licensed pursuion 700eprovisions of the Commdor'snd Professions
ro (s Code)
)or
pthame,is(commencingwith Section the basis for
do theeged siiminJ on. nisnsGsdc)nr TIiMP.METEROR POLE INST. COMMERCIAL:
dtxy e C that he is exempt @ertfrom and the basis for the alleged esem on. ny violmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wro
Section]031.5 M1y any applicom for apennit subjects the apple nnouc it penalty of POWER DEVICES
y 1 ❑TENANT ❑FOOD SERVICE
F, y not mom than five hundred dollars(15W). IMPROVEMENT
6 ❑I,ns owner oftheprnperty,ormy employees with wage stheirsolecom motion, SWIMMING POOL ELECTRIC
w.11 do the work,and the suuctumisnotimm�dedoroff ormle(Ses.]0J4, sins ❑OTHER
and Professions Came:The Conuactor's License Law s not apply to an ow r of OUTLETS-SWITCHES-FIXTURES
�' progeny who builds or improves thereon,and who J such work himself or th gh u
his own employees,provided that such improveme are not intended or offered NEW RESIDENTIAL ELECTR SQ FT. n ^ ^�
mle.lf.however.ihehuildingurimpmvementissol within one year ofcompletion,t r - SQ.'FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden ofproving th e did not build orimpmve torpor
❑spas awverofthe property,amexdusivel nnuacting wird licensed cantmcmrs to TOTAL: NOV2U 19��
nsWcnbe project(Sec.]fM4,Buxinea, Profess ions Cndc:)'th Cnnuamor's Li
cele law does not apply loan owner of Deny wM10 builds mimpmv<s thereon,and 'Y PLUMBING PERMIT FEE C17Y
wnnrnntractaroraacl,pmjecNishhaeo m<mrta)Ea<naedpnnmammmnenntm<mra Uh ��r�HTINO
License Law' PERMIT ISSUANCE
❑lam exempt underSac. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT ( Z VALUATION
WORKS COMPENSATION DECLARATION ACK FLOW PROTECT.DEVICE
Ihcrtby affirm un rpenahy ofprjury one ofthe fello ng mthpn� b
❑I hav<andwill matin neCmiticiteof Conxsuoself-insure r �ompen. U AINS-FLOOILROORARB&OND.'4, TYPECONSTRUCTION
sation,as provided for Sor 3]W of th bur Cr ,fo «of c C STORI
work for which this penitis hued FIXTURES-PER TRAP ^�
❑I have end will main 'n Workers Compass 'i required by action y -
3]WofNeLam
daCoic, Itheperfnrance f ichdid panni sssced. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Comperach Insuddromemon umberore:
Carrier. 'Polk o.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICA 'OFEXEMP ION MW ' '
CO PENSATIONINSU NCE GREASEANDUSTRLWASTRINTERCEPTOR
BUILDI GDIVISI NFBFS
(Thissaction rcednot repleted if the permit is for
6hed JslHrs($1 W) GREASETRAP O
or less.) - �' PLANCHECK FEE
Ioyanythiin inary sof the bsecomesiork d,1 t isissuedlshollV 175
SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any man n r vs m hacome aubje Co.,..o- ENERGY FEE
vino laws f e.Do WATER HEATER WNENT/ELECTR
Applicant FZ444 33, GRADING FEE
y NOTICETOA PLICANT:IL aRerm mg Nis Cer neem of Exemption.you should WATER SYSTEMITREATING
became subject to the Worker's Camper.
on
P_/,
ro ions of the lab.Cede,you must - SOILS FEE
Wforthwith comply with such provisions ort mit shell be deemed menked. WATER SERVICE
Q
U0 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID ReceitN
V Ihercbyaff that it.
..ed(Set.309ending agency for the perfomuntt of p
the work for which thin permit is issuW(Sec.3W],Civ.C.)
I1n E" lender's Name TOTAL
LJ Lenders Address TOTAL:
y1 certify that I have mad this application and state that the above information is BUILDING FEE ��
VJ comet.l agree to comply with all city and county(a iwnces and state laws relating to QTY, MECHANICAL PERMIT FEE
V Z building amswetinn.and hereby authorize represenmtives of Nis city wenterupon the SEISMIC HE
r above-mentioned property for inspection purposes. PERMIT ISSUANCE. ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities.judgmems,costs and expenses which my in any way seems against mid City ALTERORADDTOMECL PLUMBING FE
in nmquence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POIPZ AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL E
SOURCE i .
REGULATIONS.
,
�� �.�CC��lG(�,�FY /Ca AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIO
SiHa��pllcan/Contractor Data EXHAUST HOOD(W/DUQ}
HAZARDOUS MATERIALS DISCLOSURE, HOUSING MITIGATION F
Will theapplicanl or future building occupantsmre m handle hamrdous anterial HEATING UNIT(TO IM."BTU) '
as defined by the Cupertino Municipal Codc.Chapter 9.13,and me Heald.and 5a1ay
Code,Section 25531(a)? HEATING UNIT(OVER 1 W,WO BTU)
E3 Yes L]No VENTILATION PAN(SINGLE RESID) PAID
Will thea licom or froom buildin m uu mem or devices which Dam Boccip N
pp bthey egmy BOILER-COMP(3HP OR 000.030 ROLE
mit hazardous air contaminants use defineddbyy the Bey Area Air Quality Management - AL:
District?
❑Yes ❑cut BOILER-COMP(OVER 100.0110g10 BTIE -
l m
have read the hardous materials requirements under Chapter 6,95 of the Cali. AIR CONDITIONER - ISSUANC
foods Health&Safety Code,Sectiorzs 25505,25533 and 25534.1'undcrstand thin if the NEW RESIDENTIAL MECH. SQ.Fm
building does not correctly have a tenant that it is my responsibility m notify the occupant _
of the remiremnts which must be net priarto issuance ma Certificate of Occupancy.
Ilz
Owner or outhorixed agent Dam TOTAL' ISSUED BY: /
OFFICE