28705 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANT TARY NO. APPLICATION SUBMI'fTALDATE
OW'NER'S NAME: PHONE: ONTRACfO SNAME: LIC NU:
PIC -� NIC CONTROLM
ARCHITECDENGINEF,R: LIC NO: ADDRESST ❑
2&74 Tue i-6 Vel q 17
CONI'ACI': PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) MAG ELECT PLUMB MUCH
LEY ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W Op
,oZ with SPERMIT ISSUANCE L
tection 0(X0)of Division 3ofthe Business and Professions Code.and my license is RESIDENTIA
1-.1Wr in full Forrestal effect. DSFDWL [I KITCHEN REMODEL
Fa�UZU License Clan Lic.p APPLIANCES-RESIDENTIAL [I ADD]] [I PLUMBING RE-PIPE
NQL Date Cannaewr
FDh ARCHITECTS DECLARATION PANELS El MULTI-UNIT El STRUCTURAL
Z p m Z I understand my plans shall be used as public records MODIFICATION
OZInO UPT0200AMY5 []INTERIOR El
CHIMNEY REPAIR
F=tW LicermalPrnfirlinnal 201-1010AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
C 6 I M1erehy affirm that 1 am cxanpl Iron the Commaors Liccrne Law loathe OVER 10(s)AMPS [I BATH REMODEL/RCPAIR DEMOLITION
iW5 R 6 U following reason.(Section 703 L5.Resines trod Pndaasions Civle:Any oily a eaumY SICNS IH.I!C'1'RICAL D OTHER
I WI` which require o pe m mm�mn,ulmr,impnwc,demolisM1,or repair any,wclurc
F"u'Og' priormilsisspeareaha rcyuircslM1e applicant for such pemnino lileasigned statnnem SPECIAL CIRCUIT/MISC.
)hatheislicensedpumuuttothepmvisionsofthe Conuaanr's License w(Chapicr9
WCpOy (commencingwith Scaion7B00)of Divisinn]ofthe Rusinessamc Professions Cale)m TEMP.METER OR POLE INST. COMMERCIAL'
0.L e 4 Nm he is exempt thcmfmm and.4he basis or the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
Section 7031.5 by any applicant rape subjects the npplica� civil pendty of POWER DEVICES DTENANT El FOOD SERVICE:
�56�In )m ore than five formed call $ ) IMPROVEMENT
Las nwneral'Ihe property, it t c. N 6ea' t pcnsotion, SWIMMING POOL ELECTRIC
Q
ps will Jathewor nndim. a ns tended em rsnl irvro.71li' ucmc,e. DOTHER
W as and Profession. al:' c t mos Licen x mm apply to an owner of OUTLM S-SWITCHES-PU PUT
a 3 property,who bu i spr vr.the Jy�h such wad,himself ur tbmagb
his own emp ye tried N°��' niinvements are not intended or offered for
NEW RESIDENTIAL ELECTR SQ PI'. fw n B �^
eale.1fh.wev .d, suildingm 4 t is sold within one year ofeompletion,Ne SQ,FT.`F100R'AREA 5/SQ.FT.
owner-builder will the burden proving that he did not build or improve for pur-
poxeafsale.). TOTAL: OCT 311995
EI 1,as owner of the propany,am exclusively nlmrzcdng will IicenmJ eommetnn to
construct the project(Secs 7044.Business and Profession,Code:)The Contractor's lis
cense law docs not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE 111. Ur
who conducts for such projects with a contraaogs)licensed puua
rsn to the Contractors WI-EHfM
License lase. PERMIT ISSUANCE
D 1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATEM(EA) VALUATION
Owner Date /[ i
WORKE'R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herchy nffirrn under penally of perjury ane of the following declarrinew
)have and will maintain a Certilicam of Consent to self-insure for Workers Compete DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION
cation,as provided for by Section 3700 of the labor Code,far the performance of the
..,it for which this permit is issued. FIXTURES-PER TRAP
D I have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe labor Code,for the performance of the work for which this permit is issued. GAS-G.SYSTEM4 INC.4 OUTLETS OCCGROUP APN
MCurriey Wmrr:k, .Cmr9wnsWW Insurancyamcr and Policy u{ v'O�('
GAS-Eh SYSTEM-OVER 4(I!A)
CIiRTIPIC Op
COMPENSATION
IN FROM WORKIiRS'
COO MPENSATION INSURANCE GRFASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifthe permit is formic hundred dollars(Slgq GREASETRAP
or le".)(This
FEF.
I ccnd doe innieferformuccof0mvinak farwhichdinpcnnit isiscued.lehall SEWER-SANITARY-STORM EA.200 FT.
not employ any Persian in any manner so as In become subject m the Workers'Cooper- ENERGY FEE
OZ cation Law.of California.Date WATER IfEAD;R W/VENT/ELECTR GRADING FEE
Z 0 Applicant
V) NOTICE TO APPLICANT:IL after making Nis Cenircataof Exemption,yon should WATER SYS'IEMTREATING
f become subject to the Worker s Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT. PAID
I hereby affirm that is a construction lending agency for performance of Date Receiptp
IL (~ the work for which his Permit is i,amd(Sec.3119.Civ.C)
lenders None TOTAL:
Lenders Address TOTAL: "
�s I certify that 1 have read this application and nate that the above information is BUILDING FEE ky
Fa
Z cortdingcometocomply h%erebycityatd mainly of and cram laws trupon the QTY MECHANICAL PERMIT FEE
U Z building comwmiun,and hereby authorim representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purrylus. - PERMIT ISSUANCE.
(We)agree to Save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and cxpenws which may in any way accrue against and City ALTER OR ADD TOYIECH.
PLUMBING FEE
in nICANT Nthegrunting Sthis 1Krmir.
SOURCE
NT UNDERSTANDS AND WILL COMPLY WIT){ALL NON-POINT AIR HANDLING UNIT(N 10.1MM1 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,(X0 CFM) CONSTRUCTION TAX
Signature ofApplicansContmemr Date EXHAUST HOOD OGDUCT) HOUSING MITIGATION FEE
EIA. RDOUS MATERIALS DISCLOSURE.
WillNcuppllcamar future balliinglecupanlnorcor handle hmardoaa material HEATING UNIT(TO 100,1X11)BTI)
m defined by the Cupl:nino Municipal Code,Chapter 9.12,and the Hmida and Safety
Cute.Section 25532001 HEATING UNIT(OVER 100,0M)BTU)
❑Yes []No VENTILATION FAN(SINGLE RP_SID) PAID
Dae Receiptg
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(JHP OR 100.000 BTU)emit humorous air contaminants a,Jetined by the Bay Area .
a Air Quality Management TOTAL:
District? BOILER-COMP(OVER 1 fIf1.000 BTU)
I DYc, F]No
I have readthc hawses,materials reyuiamenv under Chaim,6.95 of the Cull- PIR CONDITIONER ISSUA
fomio Health&Safety Code,Safi..25505.25533 and 25534.1 u con Nat if the NEW RESIDENTIAL MECH. SQ.FT.
buildings s al curmndy have a trnunt.that it is my ibilit notifytheoanant
of IM cons which not be of cam of Otte cy.
115
Ow unto t age 6 ate TOTAL: ISSUE Y:
OFFICE