28588 (2) APPLICANTTO FILL.IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO _ BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 28588
BUILDING ADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
o I �yqS
OWry'/p'R' NA PHONE: COMPACTOR'S NA LIC NO:
i s! - S as �' N/C CONTROL 0
RCya,E l/ENGINEER: LIC NO ADDRESS. ❑ "
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) L P uM MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
C o wr I hereby acorn,that I am Rcensed anger provisions or Chapter 9(aomnrendng JO b DESCRIPTION
th 5cdinn7afl(1)of0ivision3of the Business and Rnfessions Code,and mylicensc ie PERMIT ISSUANCE RESIDENTIAL:
n roll force and of ear.
FUZV License lav LiC.M � �� � ❑SFDWL ❑KITCHEN REMODEL
NQS Date Conmkmr X47--- APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING R&PIPE
Z a„Oq ARCHITECTS DECL \TION PANELS ❑MULTI-UNrr ❑STRUCTURAL
b ra Z 1 understand my plans shall be used as public records MODIFICATION
O Z—o UPTO 200 AMPS
P M F' Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
¢y+ 2 OWNER-BUILDER DECLARATION 201.1000AMPS IMPROVEMENT
g+ 1 hereby affirm mol 1 am exempt from the Contractor's License law for the OVER 1000 AMPS ❑BATH REMODEIIREPAIR DEMOLITION
31 V following resson.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LL which requires a pmout to construct offer,improve.demolish,or repair ony ammumS in
�O Rod heor to is
pursuanclan t
to
are for such Commumriuoicenssigned statement SPECIAL CI0.CUIT/MISG ��� k�
i metre is licounic,rsmnuo Ne are Vonaot me Con Permitofile a nwstate erg
p p0 (commencingwith Section7000)of Dividm13afthe Business and Professions Code)or TEMP.METER OR POLE INST.
p� e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
i� t4 Section 703L56y soy apPhcam forepennit subject the applicanuoacivil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not marc Nan five hundred dollars($500).
�p< I,mawner of Ne IMPROVEMENT
f G ❑ pe some n myemployees withwagesasthei(See compertation, SWIMMING POOL ELECTRIC
will do le wort.Code: he Concis to's Livens Law do s int a(Sec. r and Business ❑OTHER
W�� and Pmfessians Code:The Contractor's License law does not apply m rn owntt of OUTLET'S-SWITCHES-FIXTURE$ . �
3 his own who ogees,or improves Hereon,end who rices such week himself or through
his own employees,provided that such improvement an,not intended or offered for NEW RESIDENT IAL CLECIR SQ FT.
sale.If.however,He building or improvement is sold within one year ofcmnpletion,the SQ.FT,FLOOR AREA §/SQ.FT.
owner-buildcr will have Ne burden of proving that he did not build or improve for put-
pose of sale.. '
❑h as owner of the property,and exclusively contracting with licensed eontndors to
construct the I mjms(Sec.]UW.Business and Professions Code:)The Convenors Li-
cause Law does net apply to an owner of property who builds or improves brand.add QTY. PLUMBINGPERMIT FEE
who commi for such prejectn with a contractors)licensed pursuant o the Contractor's
License Low. PERMIT ISSUANCE '
I am exempt under Sec. B&P C for this reason'
Owner
ALTER-DRAIN&VENT-WATER(EA)WATVALLA-ION
� D.m �•�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby effum under penalty of perjury one of Ne following declamtiom:
I have and will maintain a Certificate ofConent to self-ivure for Wmkers Comped- DRAINS-FLOOR,ROOF,AREA,COND.
cation,as provided for by Section 379)of the Labor Code,for the perfommnce of the STORIES TYPE CONSTRUCTION
aaakforwhichthispermi oissued. FIXTURES-PER TRAP
- []1 have and will maintain Worker's Compensation Insurance,as required by Section
37o0 of Ne Labor Code.for the perfamunce of the work for which Nis permit is issued. GAS-P.A.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are: \
Carrie'. Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(Thissecdon need not bawarpleted ifthepermil isforbnehundmidollav(§IW) BUILDING DIVISION 'q
or less.) I GRP AP
PLANCHECK FEE
Icmify that in the Performance ofthe work fnrwhich this permit is issucd,Ishall SEWER-SA ITARY-STORM EA.200 FT.
not employ any person in any conn hu bjecf no He Workers'Comped- ENERGY FEE
'z cation lawso fornie.D �� -yrpasu
z O A licent73 HEATER WNFNT/ELECfR
- ' �C'RF7:Il�Bcr making His Ccnifcam df Exemption,you should GRADING FEE
fA NOTICE TOA PU WATER SYSTEM/T0.HATING
(^, become aubject to rhe Worker Compensation provisions of me Labor Code,you must SOILS FEE
{fif7 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
az CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.FT. PAID
Ihereby a(f that Here is a construction lending agency for the performance of Data Receipt
U
U f+ Ne work for which this perm (See .
it Is bused(S 3097.Civ.C
0 U lender's Name TOTAL:
D.l Carrier's Address TOT
Ty, 1 certify that 1 have read this application and seem than the above information is BUILDING FEE ro
VJ correct.Ingree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U 4 building construction,and hereby authofiae representatives of this city to enter upon the SEISMIC FEE
above-nmntioned property for inspection per exce. PERMITISSUANCE
(We)agrve
ee fa sa ,indemnify and kap hamlesa Ne City of Cupertino ignites, ELECTRIC FEE
liabilities.jud,romm,cdsu and axile.which may in any way...against aid City
in consequence of the,trading of this permit - ALTER Oft ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CPM)
SOURCE REGULATIONS. - MECHANICALFEE
- AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of AppHournVontractor Data EXHAUST BOUD(WMUCI') HOUSING MITIGATION FEB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhaMle Interfaces material HEATING UNIT GO 100.000 BTU)
as defined by the Copenino MunjjjGGGipal Code,Chapter 9.12,and are HW N and Safety _
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) 64 T.✓
❑Yes No r.
VENTILATIONPAID
FAN(SINGLE RESID) Dine ovei to
Will me eppiicent orfutum building occupem use cgoipmem or devices which BOILER-COM 100,000BTU)
t harentous air conmminan�defined by the Bay Area Air Quality Managemen114V V — 11.111
t
District? BOILER-COMP(OVER tOLO1)BTU)
❑Yes
AIR CONDITIONER oil Y Ur UUrtt+ sn/
I have mad the harurdous material;requimments under Chapter 6.95 of He Cali- ISSUANCE DATE
fomia Health&Safcty Cade,Stations 25505,25533 and 25534.I understand Hal if Ne NEW RESIDENTIAL MECH. SQ.PI'.-
b'Id' gdnca ern currently hooe.maant thin it is my responsibility innotify the occupant
fifth filaments bemetprormisuontt
y
. / 1i' _ s
are
F . � r
s agent Dam TOTAL: ISSUED BY:
OFFICE