28692 (2) ' APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
F CITY OF CUPERTINO I
9 L BUILDING-ELECTRICAL PERMIT NO. 28692^ w w „s
EE BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L l8 {6
BUD.Ia1NG PROJECT IDENTIFICA'T'ION
BUILDINGADDRESS: 1 SANITARY NO. APPLICATION SUBMITTAL DATE
AME:
t L "Jif //--?-95-
0 Nr PHONE: CONTRACTORS NAME: LIC NO:
_ N/C CONTROL#'
ARCHITECT/ENGINEER: LIC NO: ADDRESS: - ❑
C LT: e— PHONE: BUILDING PERMIT INFO
I / \ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
(� ❑ DR ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
�Z with Section]000)of Division 3 ofthe Business and Professions Code,and my license is
00 y PERMIT'ISSUANCE RESIDENTIAL
Lifull force end eff
Liansc Cl Lia ✓�� - - DSFDWL (I KITCHEN REMODEL
y�uLLl Dnm coal. nr APPLIANCES-RESIDENTIAL DADDITION [IPLUMBING RE-PIPE
F.pun AR CHI 1."111 DECLARATION PANELS CMULTFUNIT []STRUCTURAL
Z pv�r, T undemland my plans shall he used its public records MODIFICATION
0ZI'1 X UPT0300 AMPS -20'.(-%31 DINTERIOR El CHIMNEY REPAIR
ern {tLicenxd Professional
XyY6j' OWNER-BUILDER DECLARATION 201.10110 AMNS IMPROVEMENT
�YY]] 1 hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1000 AMPS ❑BATH REMODEIIREPAIR D DEMOLITION
36V following mann.(Section]031.5,Business sal Professions Code:Any city or countySIGNS ELECI'RICAI. DOTHER
which requires a construct,to conset,alteran
,improve,demolish,or repair y strunrt
u
H O
furl....r,also requires the,Plicant for such Permit to fileosigred natcment SPECIAL CIRCUIT/MISC. SPG
that sets licensed puanitothe#mumr'
visionfthe C.draca Licenm Law Ch,dc,9
GCa reu(commencing with Section 7001)mf Division Sof Ne usiness and Professions Crisham TEMP.METER OR POLE INST. COMMERCIAL: -
L LL thm heis exempt therefrom and the hasi birdied ged exemption.Any violmim i of D NEW BLDG/ADDITION D DEMOLITION
4, Section7031.5hysnyvppEcantforuper l athth6vpplicannnacivilpenultyof POWER DEVICES
DTENANT" CFOOD SERVICE
E„ not more than mthe a
dd doily ).
1 IMPROVEMENT C ❑I,aowner of the pe a aril ages as their xnle compcnation. SWIMMING POOL ELECTRIC .
wJldathework, n i. 11 jended. fferedfarale aTIH4rilusiness DOTTER
and Professions a Contractst��{�roman v v i ��gt owner of OUTLETS-SWITCHES-FIXTURES
propmy,employees,
builds or Dues t meQn,i pK,, a 'ita tPisel of or,
his awn em to ea,pro Nat me t ry x a not mien 66r uE, for NEW RESIDENTIAL ELECfR SQ Ef.
xale.ILh.wever,Nebui ing or improvement is sold within one year ofcompletion,The SQ.FT.FLOOR AREA VSQ.FT.
oundcob older will have Ne burden of preening that he did not build or Improve for Pur-
p er of sale.). ('`�s
D 1,as owner of the property,mm exclusively contracting with licensed contractors to TOTAL.: -�G'1.7
construct the prejem(Sec.7044,Business aml Professions Cmk:)'I'he Contractor's Li.
cense Low does not apply to an owner of properly who builds or improves thereon,mN QTY. PLUMBING PERMIT FEE
who conmacts for such projects with a comractods)licensed pursuant to the Connuclosev
License Law. PERMIT ISSUANCE
❑ I vm exempt under Sec. ,B&P C far this reason
Owner DALTER-DRAIN&VENT-WATER(EA) VALUATION
am
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
ereby aRmt under penalty of perjury one of the following decimations:
have and willmainmineCenifcateof Conxntlmsel(-iaumfor Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND, *fORIFS TYPECONSTRUCTION
anon,a provided for by Section 37M of the Inbor Code,for the performance of the ..,
work for which this permit is issued. FIXTURES-PERTRAP
D 1 have and will maintain Workers Compensation Insurance,as"cored by Section -
3T00oftheLaborCok.brtlel formnnce,of the work for which this permit is inxtmd, GAS-EA.SYSTEM.I INC.4 OUTLETS
My Work nm epsafoi nl ncecuricrundl'nlicynumber ere' _ OCC.GNOUP.' AI'N
Carrier: Policy No.:"'""�/fU� GAS-EA.SYSTEM.OVER4MA)
CERTIFICATE OF EXEMPTION FROM E S'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(this xcdo t need not ae completed if the permit is for one hundred dNlav(51HE) BUILDING DIVISION FEES
m lea.) GREASETRAP
PLANCHECK FEE
1 employ
my that is the performance.(Ne work for which this due W is banned,Co l Coolant,not employ any person in any manner axmbecome subject to the Wmrken'Compen- SEWER-SANITARY-STORM EA.200 PE ENERGY FEE
Z stand luwsmf California.Dam
0 Appliewl WATER HEATER WATBN ELECT'R GRADING FEE.
F7NOTICE TO APPLICANT.If.af¢ m r making this Cenificaof Exemption,you should WATER SYSTRAYFRP.ATING
a 4
become subject to the Workers Compensation provisions.f the Labor Code,you must SOILS FEE
{>a rt forthwith comply with such provisions or this permit shall he deemed revoked. WgTER'$ERVICE
Q'
CONSTRUCTION LENDING AGENCY NEW I2ESIDEN'ITIAL PLMB. SQ.FT. PAID
UsZ I hereby affirm that hem is a construction lending agency(of the performance of Dale Receipt#
the work for which this Permit is issued(Sec.NETT,Civ.C.)
Lenders Name TOTAL:
Under.Address TOTAL.:
1 rectify that 1 have tend this application and slam that the shove information is BUILDING FEE
tr VI correct.l agree to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE
V building cnnxlreclion,and hereby euNnriec repmxnativ<+of thix city to enter upon the SEISMIC FEE
above-mentioned property for inspection purlaoses. PERMIT ISSUANCE
(We)agree m save,indemnify end keep harmless Ne City of Cupertin.against ELECTRIC FEE Sl•e74J
lubililies,judgments,c.tit.and expenses which may in myw.,.c,.c agvitisl said City ALTER OR ADD TO MECH.
in consequence mf the granting mf this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) -
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFMI CONSTRUCTION TAX
Signature of AFplicant/Contranor Data EXHAUST HOOD(W/DUCP) HOUSING MITIGATION FEE `
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant store rehandle hamdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(6)? / HEATING UNIT(OVER 100,01(10 BTU)
Dyes pF
VENTILATION PAN(SINGLE ftESID) PAID
Udtc Recetpl p
Will the sit cer nr or future building by the B use equipment ter,Muco which BOILER'-COMP(3HP OR IOQ000 BTU)
emit aa¢vNous air cmmm�dnvnb a Jcfined by the Bay Asa Air Quality'Mumtgcmem TOTAL:
District
❑Yet _ BOILER-COMP(OVER 100,1100 BTU)
Nov NMI
A� douldour 'alsxru' memsunder Chztv6.e.9'o"veCaliAIR CONDITIONERp OF OISLSUANCE DATE
C e.Sec255x5Saleco 255341utt_a y tan if the 11YU
NEWRFSIDF.NTIALMECH. SQ.PT.0y a L nismyrespunsibility to twdfy Neoccupnme mmelmiswenceofeifareupe �-g-'I Jae /�/�l]Q/k,/(JfCent Date TOTAL: ISSUEDBY:
OFFICE