28883 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 28883
/8 8$3K
BUILDING PROJECT IDENTIFICATION L V lJ
BUILUINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
SLS H`fDE "At1E • �� ���
OWNU44AME 70NE�j�aIG� CONI CfOR'$NAME: , 1^ LIC NO:
1Y N NIC CONTROL a
❑.
ARCHITECT/ENGINEER: LIC NO ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing lOR ESCRIPTION
wo, with Seen 170)of Division 3ofthe Bunnensand P oficsions Colcml my license is R IDFNTIA
FSB 'n full foreaand effca. PERMIT ISSUANCE �L
C h r ❑MIWI. ❑KITCHEN REMODEL
aUU License Class Lica
vF)6i Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION 11 PLUMBING RE-PIPE
I, Iz)On ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p n Z 1 understand my plans shall he used as public records MODIFICATION
O Z—QQ UPTO 200 AMPS
(•:�,I'-W LicensN Professional ❑INTERIOR [I CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-I000AMPS MPROVFMENT
4 W1 hereby allirm that I am exempt from the Contractor's License Law for the OVER 11100 AMPS TH RFb10DEUREPAIR DEMOLITION
6 following reason.(Section 7031.5,Business and Professions Code Any city or county SIGNS ELECTRICAL. _ ❑OTHER
w0 y which requites a porndt to construct,.Inas improve,demolish,or repair any structure
poor to it issumrce.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Y that he is licensed punume nrnhe pn Inionsol Inc Contra,mrs License Law(Claque,I
(cunmencing iN Section]000)of i;iswn3of eBusincss and Prof"winm Cedr)or TEMP METER OR POLE INST. COMMERCIAL
a o that he Is en p 'eichom and th h ollegnl exemption.Any violation of ❑DEMOLITION
x Sstion]OJ n a I' to Iso jean thea applicant a civil ❑NENANT ADDITION
��N pp penal of POWER DEVICES
^Zp, nm mors tha ndr ( . q, ❑TENANT ❑FOOD SERVICE
�Ip ❑Las owns the propert.m mYanployeeswlth wages.,theirmlecompenzmiun. SWIMMING POOL ELECTRIC IMPROVEMENT
al 1" wJl do the wo an the not ntr�nntmten a rroffertd for sale(See,7011,Business ❑0'THER
ad and Prolcsaoma Co,le:'Ihc mrtsL c La tnTapply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds nr imp art d xk M1im- nr throe
his own employees,provided that sucb imps emcn`s grand al m offered or NEW RESIDENTIAL ELECTS SO Ff.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FK FLOOR AREA SNQ.FL
owner-loolder will have the burden of proving that he did not build or improve for par- B r'
posemf sale.).
I,m owner of the prolmny,unr exclusively contouring with licemed eon owous an
construct the pmject(See 7fHy Business and Professions COdep The Contzaors Li-ase OCT l Y �g 1k9as95
Law docs not apply m an owner of property who bei Ids or improves thereon. Q7'Y, PLUMBING PERMIT FEE ,{�
who contracts for such projects with a Conuaaor(g licensed pursuanua Ne Contractors /s
❑License law. - PERMIT ISSUANCE r COY Ur VVf CITIIN,
l um exem f under Sec. ,H&P C for this reason
ALTER-DRAIN&VENT-WATER(EA)
Owner Dam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑Ihave and willmaintain eCenifiwm Of Conserv to selGinsum for Workers Compcn- DRAINS-FLOOR,ROOF,AREA,CoN D.
saiioq as provided to,by Station 3700 of te ,forhLahur Codethe performance or the STORIES TYPE CONSTRUCTION
work for which Nis pcmrit is issuN. FIXTURES-PER TRAP
I s and will maintain Workers Compensation Insurance,as required by Section 15
37fthe LaborCWe,fonhe perfonrvance ofthe work forwM1i<h this permit is issued. GAS-EA.SYSTEM-IINCAOITLETS
Workers Cam .inn lamarm lamer and Polis OCC.GROUT' APN
pens. ynumber ere:
urrier: popsy No,FROM
GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATEOMPE SATION'IINN FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This station maxima beeam11etr4 ifthepemrit a fnronc hundred dollars(S I B0) BUILDING DIVISION ITiP.S
/ or las.) GREASETRAP PLANCHECK FEE
Loy any Imofen nthe Perhouany
so thework fill becomewhich this ChemoisirsuContuarl SEWER-SANITARY-STORM EA.200 FT.
nor employ any Califon in any manner so as to become subject the Workers'Compen' ENERGY IRE
.2 r laws of Cdifomia.Dae
O mt
WATER HEATER WNIiNT/ELEC'1'R
Z N A,
NOTICNOTICE TO APPLICANT:IL after making this Cisions or of Exemption,Cod,y should GRADING FEE
become subject WorkerLs Compensation WATIiR SYSTEM/1'REATING
J petro provisions shag of the Labor Coda,you must SOILS FEE
forthwith comply with such provisions or this permit shall he deemed re SOILS
WATER SERVICE
0. Q
'Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAIN. SQ.FT PAID
C.7 0 I herebyaffirmthi that is col(Set.3 lending agency for performance of R eipta
D. (•' Nc work for which this permit is issued(Set.3W7,Civ.C.)
Leach No.
W Lender's Address OT111
TOTAL:
ly 1 certify that I have read Nis application and state that the above information is BUILOIN
V? corecL I agree to comply with an city and county ordinances and state laws rclmiag to QTY, MECHANICAL PERMIT FEE
U Z building construction.and hereby authorim representatives ofthis chym enter upon the SEISMIC
abuse-mmdoned propeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEG
liabilitia,judgmass,costs and expenses which may in any way accrue againnxaid City ALTER OR ADD TO MECH.
'neon. quenccof Negramingofthoperon. PLUMBING FE ,
APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL.NO '-POI R HANDLING UNIT(TO 10,000 CFM)
GULATIONS, D �I MECHANICA FEE
v` AIR HANDLING UNIT IO,BW CPM) CONSTRUCrI NTA%
Sigwwre.1 Applemm-ontmcmr, Dale HXHAUSTHOODMIDUCT)
HAZARDOUS MA'1'BRIALS DISCL(ISURE. I HOUSING MITIGATI E
Will Neapplicant or future building occupant store or handl haaallons material HEATING UNIT(ID 100,IX1011TO)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cal,Section 255321.)? HEATING UNIT(OVER 100,00D LOU)
E]Yes No
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupwn use equipnsnt or device.,which Date Receipt M
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP OHP OR INLON)BTU)
10,LN,Idmgdiv �[CLUeut1yhxVC
TOT
s F-1 No BOILER-COME(OVER IW,IIOOBTU)
read me hamrdous materials rcquimmems under Chapter 6.95 of the Cali- AIR CONDITIONER
&Safety Code,Sections 25505,25533 and 25531.1 understand that if the ISSUANCE\\�DATE
nomuoeutlyhave a tenant,that iti.sany rcapnosibilitymt notify NeOccupmnNEW RESIDENTIAL MECH. SQ.FT.ment which must be sect ptlnr to issuance of a CcniGcate of O cupan,
hnnr.agcm Date T
ISSUED BY:
OFFICE