28498 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OFCUPERTINO -" - BUILDING-ELECTRICAL PERMIT NO. 28498
1 ^' q /S/N
BUILDING DIVISION APPLICATIONTERMIT PLUMBING-MECHANICAL L VX 4 JV VX
BUILDING PROJECT IDENTIFICATION 4
., BUILDINGADDRESS: . , SANITARY NO. APPLI ATION S)MITTAL DATI
L2002g�229J
OWNE 'S NAM _,PHONE: - CONTRACTOSr(ffA,;hV/ _ LIC NO:
- NIC CONTROL#
RCHITECT/ENGINMR: LIC NO: ADDRESS:
CONTACT: ' PHONE: - BUILDING PERMIT INFO
44g 2 Consultant Fees Paid by Applicant(Initial) BLDG: ELEcf P uMB Ec
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERMIT FEE
I hereby aorto that I am licensed under provisions of Chapter 9(commencing JOB_DESCRIPTION
with Section]0sadir Dlvlsloo3ofthe Business and Professions Code,and my license is RESIDENTIAL:
H W r in full force and effect. - PERMIT ISSUANCE -
�U[[--.. License Class Lie,a ❑SFDWL ❑KITCHEN REMODEL
�•' Date - Conir ter APPLIANCES-RESIDENTIAL ❑ADDITION
El PLUMBING RE-PIPE
E Dc, ARCHITECT'S DECLARATION. PANELS
El MULTI-UNIT ❑STRUCTURAL
OZ n a 1 understand my plans shill be used as public records MODIFICATION
952 UPTO 2IX)AMPS ,0INTERIOR' El CHIMNEY REPAIR
Licensed Professional. 201-1000 AMPS IMPROVEMENT
CCC777 OWNER-BUILDER DECLARATION
[hereby affirm that I em exempt from thdre e Comrmctor'e License Law for the OVER IOW AMPS ATH REMODEUREPAIR D DEMOLITION
yO6U following reason. Section]031.5.Businessand Potassiums Code:An t
y ci y or county ❑OTHER
W 3 y,F g ( SIGNS ELECTRICAL .
O which requires n permit m cocas the aloe improve,demolish,or repair any swment
or
ts
t�a
that he
slice sedpurlso uantto the thovisiappo antsof for such Contra for Livenso file a Law ned(Chapter
SPECIAL CIRCUIT/MIS
n!Q� Nat he is licensed pursuant the provisions of the Commetor'x License Lew(Chapter 9 '
GCo (commencingwith Section7",.IDiviaionlofthe Businessand Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
n a Net he is exempt therefrom and the basis for Ne alleged exemption.Any violation of - NEW BLDG/ADDI'f10N DEMOLRfON
{°• Section 7031.5 by rimy applicant fora permit aubjuels the applicant m n civil penalty of POWER DEVICES
r„ } not more than five hundred dollars($500). . O TENANT s D FOOD SERVICE
60
El 1,as owner of the poper,or my employees with wages as their sole compensation, SWIMMING LELE 'IMPROVEMENT
will do theand work, the sBucmre is not intended oroffered forout a(Sac.,]044,Businessiss ❑OTHER
and professions Cede:The Contractor's License Law does not apply to as owner of OUTLETS-SWITC -FIX 11
R' .. property who builds of improves thereon,and who does such work himself or through
his own employees,pmvidcl that such improvements are not intended or offered for NEW RESIDENTIAL ELE SQ FT. _
sale.If,however Ne building mimprovementis sold within mayearifemapiction,the SQ.FT.FLOOR AREA VSQ.Fr.
owner-builder will have the burden of proving Nat he did not build or improve for put-
,pose of sale.).
❑Las owner of the property,em exclusively connecting with licensed tors TO�: /'. _
conswc[N 44,e project(Sec.]0Business and Pro@salons Codc).TTa Conteratmmctor's Lo.o.r
e law does not apply to an owner or propery who builds or improves themon,and QTY, PLUMBING PERMIT FEE
cam
commucts for such proeas with a evaluated a)Bcams dpum antto the Como tors
License Law. t
❑I em exempt under Sec. ,B&P C far this reason PERMIT ISSUANCE —�
Owner ••• ALTER-DRAIN&VENT-WATER T,k) ,
VALUATION .
WORKER'S COMPENSATION DECLARATION BACK FLOWPROTECT.DEVICE OOO.
1 hereby affnm under penalty of perjury one of the following declarations: / -
Ihave and will mainminmCerificateofConunitoself-insure for Worker's Crupper. DRAINS-FLOOR,ROOF,AREA,COND, n
737W
ion,as provided for by Section 37M of the Labor Code,for the performance of the STORIES' TYPE CONSTRUCTION
rk for which this permit is issued. FIXTURES-PERTRAP
El I have end will maintain Workers Compensation Insurance,as required by Section "
of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN i
y Worker's Compensation Insurance carrier and Policy number arc:rtier. Policy No.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATROF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FBES
(Thissatlan nwd not be completed iFlhe permit is Tumor hmnsdred dollars(E 100)
cilias.) CREASE TRAP
PLANCHECK FEE
I certify that in to perfoimnceeof the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 Fp.'
not employ an�P9Js n many manner s n become aubjecuo the Workers'Co.,.- ,` ENERGY FEE -
O Z sation LawCCli ofnft,�a'.pa WATER HEATER W/VENT/ELECfR -
Z 2 Appiican[ (f'� GRADING FEE -
.w In NOTICE TO APPLICANT:IL after making Nis ' cam of Exemption,you should WATER SYSTEM/TREATING
F- become subject to the Workers Compensation provisions of the Labor Cade,you must SOILS FEE,
forthwith comply with suchprovisioasorthis permit shall be deemed revoked. WATER SERVICE -
CONSTRUCTION LENDING AGENCY
Z' NEW RESIDENTIAL PLMB. SQ.FT. 'PAID
V O l for
rwhichirm that issued((See.3097.
agency for the performance of Data Receipta
w F the work for which this peemb is issued(Sac.309],Civ.CJ -
O Lender's Name - TOTAL:
Lender's Address TO
a 1 certify that 1 have read this epplica[ion inti state lhm Ne about inPormation is i , BUILDING FEE
ycorrect.l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U building construction,and hereby authorizerepresematives of this city to enter upon the SEISMIC FEE
mouse-mentioned property for inspection purposes. - 1I
(We)agree to save,indemnify and keep harmless the City of Cupertino against ` I PERMIT ISSUANCE ELECTRIC FEE .
liabilities,judgments,costs and expenses which may in anyway sceme against said City ALTER OR ADO TO MECH.
in consequence of the granting of this permit PLUMBING FM' Gql
APPLICANT UNDERSTAN ND WILL COMPLY WITH AI L NONPOINTAIR HANDLING UNIT(TO 10,000 CFM) —
SO ' I;
R LNTT
,NS. O' - MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM)„ CONSTRUCTION TAX,
Srgriamreof Applicant/Cmdommir _ —Date EXHAUST HOOD(W/DULT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous rnatenal HEATING UNIT(TO 100,000 BTU)
as defined by Ne Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Seetioo 25532bd? ``�� - HEATING UNIT(OVER 100.000 BTU)
❑Yes xrvo VENTILATION FAN(SINGLE RESID) PAI
Will Ne applicant or future building �j t p
pp 6 by the Bay A a Air ant or devices Management,
BOILER-COMP 3HP OR 100,000 BTU
�mh hazardous air contaminants az define)by the Bay Area Air Quality Management' ( ) '
isMaP e _;11-y U TAL:
Uyes BOILER-COMP(OVER Ifq,000 BTU) t
ctljon
VN j O
I have mad the hazardous materials p AIR CONDITIONER - ISSUANCE DAT
requirements under Chapter dt at Carie
forma H &Safety Cade,Sections 255(15,25531 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FF.
boil ' mtc n he ei pNat it is my responsih'litym notify cxcup t
which ormiss ttnf mificnr(� n � .
ror authnrizW agent. b Dme !. TOTAL: ISSUED BY:
OFFICE '