28865 (2) -711
MMEE-
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLr
<` CITY+OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERrT PLUMBING-MECHANICAL. 28865
BUILDING PROJECF IDENTIFICATION
BUTLDINGADDR' S: SANITARY NO. APPLICATION SUBMITTAL CALL
/Ob CoRLoovA R.o. 6--11
OWNHR'S NAME: - PHONE: CONTRACTOR'S NAM LIC NO.
ebw Cory k�-II�� `��l:" Iva
NIC CONTROLM
ARCHITECT/ENGINEER: LIC NO: - ADDRESS:
- ra"a" ❑
Vj
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB,• MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby aRum Nat 1 am licensed under provisions Of Chapter 9(commencing JOB DESCRIPTION
F�O0z with Section 7000)Of Division 3 ofthe Business and Professions Code,and my license is PERMIT ISSUANCE. RESIDENTIAL:
O O U in full force and e
<L ffu y j Zy ❑SPDWL 11 KITCHEN REMODEL
� �U
j LicenseO Lic.N pppLIANCES-RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPE
yUete ss ` Contractor 4 •,
¢ ARCHITECT-S DECfARATI N ❑MULTI-UNIT ❑ N
STRUCRAL
Z O rn q I understand my plans shall be used as public mccords PANELS. MODIFICATION
O'Z—a UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
f-� u1 Licensed ProfessionalID
201-IgAMPS IMPROVEMENT
W W Q•.1OWNER-BUILDER DECLARATION OVER IOlM1AMPS El BATH REM HP I ❑D•M IjTiQN
I hereby affirm that I am exempt from the Contractors License Low for the �/
itSOyU follo%ingmason(Section703L5,Businessand Professions Code:Any city or county SIGNS ELECTRICAL THEIR
sRµ0 which repulses v permit to construct.alter,improve,demolish,or repair any structure sax
�T{sa
....JJi priuno'o,issuance,alsnrequite,theappliram fnrsuch Permit o file u signed statement SPECIAL CIRCUIT/MISC.
} that haus licensed pursuant m the provisions of the Connectors License Law(chapter9
QO�O (commencing with Section 7000)of Division 3 ofthe Business and Professions Cmc)or TEMP.METER OR POLE INST. COMMERCIAL:
a c ag Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^,y Section 7031.5 by any applicant for a Permit subjects the applicant a civil pertalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than Eve hundred dollars(55(X0.
Z Y IMPROVEMENT
€Q I,as owner
evomk,ofthe gropcny,amyemployees d with wages
rsale(See.sale cam,Businun. SWIMMING POOL ELECTRIC
3m will do thewok,andthesnenureixnot imendeJnroffered forsale(Sec.7B4,Business []OTHER
elm
and PromWons Cale:The Convector's License Law dues not apply N an owner of OUTLETS-SWITCHES-FIXTURES
�• progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or oRered for NEW RESIDENTIAL ELECTR S
sale.IL however,the building or improvement is sold within one yeerofcompletion,the SQ.FT.FLOOR AREA QSQ.FT.
wnerbuilder will have the burden of proving that he did not build or improve for pur-
immofsale.). -
1,as owner of the property,am exclusively connecting with licensed contractors to OTAL:
construct he pmjmt(Sm.7044,Business and Professions Code)The Cmiumcmrs Li-
conewLawdoesnotapplytoenownerofpropertywhobuildcorimprovesthereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant lathe Contrac m s
License Law. PERMIT ISSUANCE
❑I um exempt under Sea ,B At P C for This rcmon
ALTER-GRAIN&VENT-WATER IEA) VALUATION '
Owner Data
WORKER'S COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
go
I hium will
under penalty of perjury one of the fallowing J 'kr,"Cor
Ihove andwill main mina Cenificam of me Laterite
Code,
for Workman Ce of the DRAINS-FLOOR,ROOFAREA,COND. - -
muan.m provided fm by Section 3]00 of Ne Inbar Code,for the perfomnwce of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of she Labor Code,for the performance ofthe work fort which Lthhiis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
C Wnrke' Compo mm'On lot ncgami Poky No.and m++�wV[.L— GAS-EA.SYSTEM-OVER 4I EA)
Ca riec Q
ERTIFICATE IF EXEMPTION FROM WORKERS' .
COMPENSATION INSURANCE GREASDINDUSTRL WASTC INTERCEPTOR
BUILDING DIVISION EELS
(This section need not he completed date permit is for one hundred dollars F$100) GREASETRAP
or lcss7 PLANCHECK FEE n
I modify that inthe perfannicamofthe weak forwhich this permit is issued,Txhall SEWER-SANITARY-STORM EA.200 FT.
on
not employ any persin any manner so as to hmeme subject to the Workers COmpun- ENERGY FEE
0 Z sation Laws of Califomia.Date WATER HEATER W/VFM/ELECTR GRADING FEF.
rz Applicant
. NOTICE TO APPLICAN'P.IL after making this Cenificam of Exemption,you should a WATER SYSTEM/TREATING -
� become subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
�O CONSTRUCTION LENDINGAO agency NEW RESIDENTIAL PLMB. SQ,14. PAID Data Receipt#
I for whalRrnthatrMrtissued( ec.3 7.Cgency for the performance of
W F the work for which this permit is issued(Sea 11197,Co,lv.C.)
O Lenders Name - TOTAL:
IsnderAddress TOTAL
I certifymity Net 1 have real this application ani statement Ne uMwc Information ix BUILDING FEE
Ncomer l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT Mn
L)z building commotion.and hereby amhodm representatives of this citym enter upon the SEISMIC FEE
above-mentioned pmpeny fur inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE _
babilams,judgmentIrostsand expenses which may iamy way accrue vgvinst said City ALTER OR ADD TO MECH. PLUMBING FEE I
in consequence of a loading mf this permit.
APPLICANT D RSTANDS AND WILL COMPLY WITH ALL NON-POI �yq rIR AAN�.INFr`UMT TO 10,000 CFM)
SOURCE RF,UL IONS. _ ` •� S MECHANICA
,� ISSO'UNIT LOVER 10.00(1 CFM) CONSTRUCTION A
SiBnmureo ApplicvalContmcmr Date EXHAUST GOOD(W/DUC) HOUSINGrh9'I'IGATI)1N�FF�r-
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accepts store orhaalte bamrdoun material HEATING UNIT CTO 10J00 BTU)
as defined by the Cupenlnm Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 1553200? HEATING UNIT(OVPR 100,W0 BTU)
❑Ye ❑NoPAID
VENTILATION FAN(SINGLE RCSID) Dem Recciptp
Will the applicant or future building Occupant use equipment or devices which BOILER-COMP(3HP OR IW,000 BTU)
mit himallous air contaminants as defined by the Bay Area Air Quality Management
District? _ BOILER-COMP(OVER I WAW BTU)
/1 ❑Yes 'F-1Nn
/ AIR CONDITIONER �'pp
Ihove reSafet Limeade.,odea materials 5,25533 cand nder LTapurt memmdvaThai Cali- ISSUANCE
fmmia Reales n Safety Cade Sections 25505,25533 end 25534.1 to nota fod Net if Ne NEW RESIDENTIAL MECH. SQ.FT.
building fess oro iscurrentlywhich have a mount,p that n o my responsibility to notify the ancy.
of The requirements which most be met prior m issuance of a Certificate of Occupancy.
Owner of authmimd agent Data TOTAL: ISSUED BY:
OFFICE