28527 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,. CITY OF CUPERTINO BUILDING-ELECTRICAL - - PERMITNO,
BUILDING DIVISION - APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 28527
BWLDINGADOR SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME' PH E: CONTRACTOR'S NAME: LIC NO:
CS • V '77M N/C CONTROLM -
ARCHITECT/ENGINEER: LIC O: ADDRESS:
CONTAC. PHONE: O BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG -ELECT P U(, MB •CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ 13 'Tf']O t`
® I hereby affnm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aZ with Section 70g)of Division 3 oOhe Business and Potassium Code,and my Emma,is
DO PERMIT ISSUANCE ,yRE,,SIDENTIAL:
F-Y1 Li fullforce vnd cR 91SFDWL El KITCHEN REMODEL
LicenuCl I 42 �D,Lie.M ���� pppL1ANCE5-RGSIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
E, ARCHITECTS DECLARATION• PANELS [D MULTI-UNIT ❑STRUCTURAL
Z O-a 1 understand my Piens shall bre
e used as public cords MODIFICATION
OZ - UPT02WAMPS -
C [I INTERIOR [I CHIMNEY REPAIR
Licensed Professional a 201-I00IIAMI•S . - IMPROVEMENT
OWNER-BUILDER DECLARATION -
1 hereby amrm that I em exempt from the Cnnvecnr's License Law fur the OVER 1000 AMPS. El BATH RBMODP.VREPAIR 0 DEMOLITION
3 a U following boaon.(Section 703 1.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL 0OTx
LLra which requires a permit to convect,ulter improve,demolish,or repair any structurey.l prior to its iasuvnce,also minutes Neapplicantforums permit n fit anai,aM statement SPECIAL CIRCUIT/MISC.
ak
. that he is licensed pursuant m the provisions of the Contractors License Low(Chapter 9
GOO (cannencing with Section 7001 Division 3 of Ne Business end Professions Coic)or TE MP.MUMS OR FIRE INST. COMMERCIAL:
a y y that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X1 {L Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES
m [I TENANT ❑FOOD SERVICE
p.
not mom than fivehundodol loreyempm.Q Dl,uuwner of the properly,or my employwith wages ostheir mmeri
lempcnson, SWIMMING POOL ELECTRIC IMPROVEMENT
Z t
O will the work,and the structure is not intended croB'ered for sale(Say.7044,liniment ❑OTHER
and Professions Code:The Commences License law does nm apply to on owner of OUTLETS-SWITCHES-FIXTURES
a.. popeny wan builds or improves thereon,and who does such work himself or through
his own employees,provided that such impovem,ms are not intended or offered[uro, NEW RESIDENTIAL ELECTR SQ pT.
sale If.however the building or improvement is sold within mu,marmonropletithe SQ. RAREA $/SQ.FT.
ownerhadder will have the burden of proving that he did not build or improve for put-
' awatifsaleJ., '
❑I,as owner of the property,am exclusively conwming with licensed cnnmrnnrsn, TOTAL:
camWat the project(Sec.]004,Business and Profosiom CdeO The Contrecmrs Li
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FBI,
who convects for such Injects with a emanations)licensed pursuant o the Conunetors
License Law. PERMIT ISSUANCE
E] I am exempt under Sm. ,D& on
P C far this reas
ALTER-GRAIN&VENT-WATER(EA) VA 10
Owner Dat
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE �.
1 hereby affirm under p,mlty of perjury one of the following declamtiom:
. Ihaveand will maialoina CertifictimidCmacm mself-imumfor Worker's Compen. DRAINS-FLOOR.ROOFAREA,
scion,as provided for by Section 3]00of thlade,
the labor Cofor Ne perfnmuntt of Ne STORI TYPE CO STRUC ION
work far which this permit is issued FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation imumnce,as required by Section
37Mofthe Labor Code,for tae performance of the work forwhich this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GRO APN
My Wokers Canpenmuon lnsumnce carierand Policy number art:
Caner.Palicyso, GAS-BA.SYSTP.MOVER 4(EA)
CERTIFICATE OF RXEMP ION FROM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRI,WASTE INTERCEPTOR
or leas) aassistant
(This section beconpleted ifthepm
erit is(arms,hundred dollars P$100) GREASE TRAP
) BUILDING DIVISION FEES
PLANCHECK ME
Ioymy flumperm the pcymounceof the work fur which this permit is issuCompall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any mannerrQ as tri byom to the Workrn'Compete ENL•ROY FE8
,z cation Laws of fff...��alifornie.Data Q S/
WATER HEATER WNENT/ELF.CIR
Applicant GRADING FEE
qrn
NOTICE TOAPPLICANT.IL Cin assmic enificme of Latuart.......od hnulJ WATER SYSTF.M/1'RPA9'ING
1 tF>rr baume subject to it Wnrh r'e Compensation permit
i hal of Ne meed Cade,you man SOILS FF.E
fanhwiN comply with such provision or this permit xball he donned revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIJvHL - SQ.TL PAID W te Recei tp
U I hereby offum Nat there is a construction leading agency for the performance of ® � p -
u" lll----��� Nc work for which this permit is issued(Sec.3097,Co.C.)
Q U Lenders Nan, _
TOTAL:
Leader's Address
I certify
Net I have reed this application and state that he above nomination is y BU Q.
F-t
CA correct.l agree to comply with all city and county aNimncesand slam laws misting to QTY. MECHANICALPERMIT FEE C�r
V building convection,and hembyamhnrixerepresentativeso(this city neater upon the SELSMI li
above-mentioned prupeny for inspection purposes. PERMIT ISSUANCE
(We)agree an save,indemnify,and keep harmless the City of Cupertino against ELECTRIC FE I/Np
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit., PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,000 CPM) MECHANICAL.FEE
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER ILIW CFM) CONSTRUCTION TAX
Sigmnm of Applicant/Canuactor Data EXHAUST HOOD(W/DUCp HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfunm building occupant sore or handle huardous material HEATING UNIT TO 100,000 BTU)
as deMn1 by the Cupertino Municipal Cede.Chapter 9,12,and the Health end Safety
Conic.Sation 25532(a)? HEATING UNIT(OVER 100,000 BTU)
DYes ❑No - PAID
VENTILATION PAN(SINGLE R[SID)
Will theupplicas valuate buildingottupant use equipment ordeviceswhich - Data Reeeiptp
BOILER-COMP QHPOR IW,00al BTU) r
emit hazvdous vie contaminants as JefinW by the Bay Area Ail Quality Management -
DismeW
C]Yes EINa �, BOILER-COMP(OVER 1M.000 BTU)
I have Aad the hvamous materials mn uircmems under Chapter fi.95 of be Coli- AIR CONDITIONER-
I P ISSUANCE DA ^fL
facia Health&Safety Code,Sections 25505.25533 and 75534.B.dcrsnnd that if me NEW RESIDENTIAL MECH. SQ.FT
building does not currently have o tenant,Nat it is my responsihiliry to notify the occupant
of the requirements which must be ntd prior to isstunce M a Certificate of Occupancy.
Owner or audioncd agent Doe T. ISSUED BY:
OFFICE .