28776 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 2,8776
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BUILDING DIVISION APPLICATION/PERMIT ' PLUMBING.MECHANICAL' 2,g 7 7 6
BUILDING ADDRESS:
BUILDING PROJECT IDENTIFICATION 1 IIJJ
' SANITARY NO. APPLICATION SUBMITTAL DATE
Pis
OW NAME: PU NE: )NT • DR'S Mli: LIC NO: —J� +
N/C - CONTRUL#
ARC ECT iNGINF.:R:
_DC NO, ,g
CONTACT. PHONE: -
BUILDING PERMIT INFO
0 Consultant Fees Paid by Applicant(Initial) PLUMB MECH
LTC' EDCONTRACTORBLDG ELECT'SDECLARATION r 0 0
1 hereby aRinn that 1 am licensed-Mer provisions of Chapter 9(commencing QTY ELECTRIC PERMIT FEE
QRZ with Section]II(IOIafDivision 3 close Businessand Professions Code,and my license is JOB DESCRIPTION
CZ)
in full force and effect. I PERMIT ISSUANCE RESIDENTIAL
`UU License Class Lic.p OSFDWL ❑KITCHEN REMODEL
M D?m Cmanutou ZAI
RESIDENTIAL4 []ADDITION ❑PLUMBING RE PIPE
II--••tian ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
024—
2 4 Q I understand my pWu shell be used as public recoNs MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
�� W Licenso PrOPosemnel IMPROVEMENT"
XaOWNER-BUILDER DECLARATION{y KK 1 herebyuffirm.that Icon exemt fromthe Comrucmis Li ' ❑BATH REMODEUREPAIR []DEMOLITION
x 3 dU following reason.(Section]0715,Business and Pmfesaiore Code:Any city or county CAL ❑OTHER
Y1 OFyQ., which requires a permit m consumer,aper,improve,demolish,or repair any structure
h..] prions its issuance,also requires the applicant for such perinh m file a signed statement SPECIAL CIRCUIT/MISC.
�a£ that he is licensed punuannn Ne provisions of the Compactors License law(Chapter 9
�q0 (commencing with Section)000)Of Division I Of the Business and Professions Code)ar TEMP.METER OR POLE INST COMMERCIAL,
ti n pt that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a penou subjacta the applonnt to a civil pem lly of. POWER DEVICES
h P not mart than Eve hundred dollars($500). OTENANT 0 FOOD SERVICE
❑ I,as Owner Of the properly,or my employees with wages as their sole compensation, SWIMMING POOL EEIRIC IMPROVEMENT
will do mework,and the common is not intended reoffered forsale(SN.]044,Business OOTHER
a and Professions Code:The Contrncimrs License law Jens not apply to an owner of OUTLETS-SWITCH
pmpeny who builds or improves thereon,and who docs such work himself or through _
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL Fr.
sale.IL however,the building or improvement is sold within are yearofcompletiun,me FT.FLOOR ARE PSQ.FT.
s ner-builder will have the burden of proving that he did not build or improve fur put-pose of sale.).1,es owner of the pmpeny,am exclusively contracting with licensed contmemrs to TOTAL:construct the prones(Seepply o an wneBusr off and Professions Caleb The Contadora Li- J�SQ.
r 2who clawdoeoatapply teen owneroftaccou icebuildsorimprove thereon and 1]TY. PLUMBING PERMIT FEE 9(yy.who cse Lo u for such pmjens with a comrecmr(s)licensed puisuum to the Commctols {/A".License Law. PERMIT ISSUANCEem exempt under gee. B&P C for this reams C UUrt' 1
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VA ATIO
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
sat
I hemby affirm under penalty mf perjury one of the following dedamtions:
❑lhuve and provided
for by
netio37W of Has,
Lagam Cush.sure for Workels Compen-. DRAINS-FLOOR,ROOF,AREA,COND. '
work as provided for mi Ss issued.
3)W of the Labor Calc,for the performance of the S IFS I TYPE GGNSTRGCTIDN
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will oda,fon Worker's Come of he w Insurance,h required by Section
My of the yokes Car Codgfonthe
surancmence ofthewark for which this permit is issued. OAS-FA.SY$TCM-I INC.4OUTLETS OG APN
My Workels Compensation Insurance Cartier end Policy number arc:
Cartier. Policy No.: GAS-RYSYSTBMOVER4(EA) .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(This section need not becompleted Hoge permit is forms,hundred dollars Li IW) BUILDING DIVISION FEES
or less.) GREASE TRAP
I certify that in the perfnnn:mce ofth work for which this permit is issued,Ishall PL CHECK FEE
not<mploy any person' any men h- p the WaRem'Com _ SEWER-SANITARY-STORM I' IT.
O Z soon laws .Date �` t P<n ENER FF.E
y O0 Applicant WATER HEATER W/VENT/ELECfR GRADING E ,
ay NOTICE TO P NT.IL after making this Cardficme of Exemption,you should WATER SYSTENVIREATING
become subject e,Ne Workeh Compensation provisions of Ne Labor Code,you most SOILS FEE
(onhwith comply with ouch pmvisimns or this permit shall he JeenmJ revoked.
Wy Q WATER SERVICE.
] Z - CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L) Q Thereby affirm that them is ucoularelionl ndm,.,car,fabe,,mpnmpcc.f Date re t
us f•+ the work for which this peromt is issued(Sec.3097,Civ,C.)
0 ,` Lendels Name A
y L4L Under's Address' TOTAL:
[-, y I certify that 1 have read this application and state that the above information is BUILDING r
�r f0 correct.l agree to comply with all city and county ordinances and state laws relmingm QTy. MECf1ANICAI.PERMIT FEE
r'V Z building construction,and hereby authorize reprawnmtmves of this city to anter uponthe SEISMIC FI
above-mentioned property for inspection purposes. -
PERMIT ISSUANCE
(We)agra m save,indemnify and kap harmless the City of Cupertino against ELECTRIC FEES
liabilities,judgments,rostsand expense which may manyway.,mae against said City A
LTER TO MECH.
'n camequence of the granting of Nis pema. PLUMBING FEE
APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT UNIT LTO 10,"CFM)
S UI 'E R�GIL INS. MECHANICAL PE
UNIT(OVER 10,000 CFM) CONSTRUCTIO X
Si a mof pplic bnmeh Dm D OVIDUCT)
'HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION E
Will the applicant or future building Occupant store or handle hazardous material HEATING UNIT(TO IW,000 BTU)
as derimed by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. _
VENTILATIONFAN(SINGLE RESID) _ PAID '
Will the applicant or forum building cecupam use equipmchl Or devices which Dem Regi t p
mit hozmdoue air courtrooms as defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR D0,0DMTU)
District?
❑Yes Fl No BOILER-COMP(OVER II0,00 0BTU) A '
I have iao the bezallois materialsm3uiremeon under Chapter 6.95 of the,Cali- AIRCONDITIONER IS TE
forma Health&Safety Code,Serious 23503,25533 and 25534.1 anteroom,that if the NI!W RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant.that it is my respmsoolity to notify the Occupant
Of the requirements which must Ise mel prior m issuance of o Certifies,of Occupancy.
i
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE