28634 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PF,RMITPLUMBING-MECHANICAL 86
BUILDING,PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMIrTALDATT
Q01 aa gngs
QWNER'SNAME: �� �C PHONE: CONTRA:T R'SNAME: e ,^LIC NO: NIC CONTROL#
AlliL
I L41
ARC ITE '/ENGINEER: LIC NO: ADDRESS: I' ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) SLUG [CT PLUMB ME H
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1herebyoff nThateam Hanselunderprovisions of Chapter9(commencing JOB DESCRIPTION
'
OCy 'N SnniceandeffecDivisionJnf the Business and l'rofessinnsCoc.and my license is RESIDENTIAL:
nfull ene Class and effect. - PEBMI'I'ISSUANCC �'
�UF' 0--
License Class Lic.x ❑$FOWL >TCHEN REMODEL
Lai GL Date Cormolor APPLIANCES-RESIDENTIAL �� ❑ADDITION ❑P UMBING RE-PIPE
1-• wn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O n Z 1 understand my plans shall be used as public exceeds MODIFICATION
O,Z,.,Q UP TD 207 AMPS [I INTERIOR OCHIMNEYREPAIR
1-.'4F'W Licensed Professional 201-1000AMP5 PROVEMPIT
�Y�� OWNER-HUILUERDECLARATION OVERI#x1AMPS THR&MOUE REPAIR C1 DEMOLITION
C C 1 hereby affirm m e L
that I uexempt from the Can neelo,s License farm.
Vk0 W V following reawn.(Section 7031.5,Business and Professions Code:Any city or .only SIGNS ELECTRICAL ❑OTHER
LL7 ;u which requires a permit to construct,alter,improve,demolish,or repair nay stroame
�1�0 tnprior to its issuance,also requires the applicant for.such permit m file a signed stmemem SPECIAL CIRCUGUMISC. 20 r�
fiat y' that k.,licensed..rsssam m the Provisions of the Commie nr's License Low(Chapter 9
WaO� (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR PD INS'. COMMERCIAL•
6 d m C that he is escmpt thereGom and the onto for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y
Section 7031.5 by any applicanlfar is permit subjects the updicmr ,,a civil penally of POWER DEVICES []TENANT ❑FOOD SERVICE
[q-Z. not ort Nan fivshenJre dollars(5500). IMPROVEMENT
s
2= owraof Ne pny,
.peroriny employes with wages as their sole compensation. SWIMMING PO .ECfRIC
CF will ework.and the structure is not intended or offered for.sale(SaA(H4.Business OGTHIiR
L 3 and Professions Code The Contractors License Law doer not apply to an owner of OVILEI'S-SWITCHV F1 74URES
pro,voy who hadds or improves there n,and who does such work himself or through
his own employees;prmided nonsuch improvements are not intended or offered for NEW RESIDENTIAL ' SQ FT.
sale.IL howevee the building or improvement iswld within one year ofcompletion,the SO FL OOR AREA LSQ.FT.
owner-builder will have the burden of proving that be did not build or improve for put-
missile).
ut-ofvie). f
❑
T.as owner of the pmpcny.am exclusively contracting with licensed contractors Is, Fp 7
now,be pr..jece(So,7044.Business and Professions Coe)The Contractors LI- Q
cense law dreg not apply to an owner of property who builds or improves Nerear.and QTY PLUMBING PERMIT FEEL f/ w
whocuntmcts forsuch projects wuhacontractor(s)IiumNm
pursun tothe Cannot 01-/ G�-
19gaa
License I.ew. PERMIT ISSUANCE Its ss
1 am exempt under Sec. .B&P C trains r...an Ffl�4 i
ALTER-DRAIN&VENT-WATER dDs) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby a1Rrt under Penalty of Perjury one of the following declarations:
IM1iveandwillmaintaina Cenihcateof Conwnuaself-in.mmlbr Workers Compn- DRAINS-FI.00R,ROOF,AR EA,COND. STORIES TYPIi CONSTRUCTION
soden,as provided far by Section 37004 the labor Con.,for the perfoormnce of the iou
work far which this permit is passed. FIXTURES-PER TRAP
1 have and will maintain Worker's Compem pion Insurance,as required by Section
3700nfthe LooeCole,for the performance of the week lin which this pe mal,,issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Workers ComPenmtion Insurance miner and Policy number are
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EX17MHION FROM WORKERS' OR FASMNDUSTRLWASTEINTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('bisection need not bxcompleted fihe permit is furore hundred dollars Dlip) GREASE TRAP
or less.) PLANCHECK FEE
I cenifydem inch,pcifororeciefthe work forwhich Nispemtit is issued.Ishill SEWER-SANITARY-STORM EA.20o FT.
not employ any person in any turner so as to become subject to the Worker.'Compen- ENERGY FEE
Z .,,on lawsof California.Dole WATER HEATER W/VENT/HLECTR
Z 0 Applicant _ GRADING FEE
NOTICE TO APPLICANT:If,after making this Ccrdficme of Exemption,you should WATER SYSTENIG BEATING
F' ; become subject to the Workers Compensmion provisions of the Labor Coe.you must SOILS FEE
Wforthwith comply with such provisions or this Permit shall M mresidual. WATER SERVICE
a' CON5'1'RUCTION LENDING AGENCY NEW RESIDIiNTIA1,1'LMB. SQ,PT. PAID
'7 Z Doe Recciplp
I hereby affirm that Nmuth
em is a cotnction lending agency forperformance of,
IJ0 the work for which his permit is issued(Sec.3097.Civ.C.)
OU Lender's Nam. TOTAL:
Lt] Lenders Address BUILDING FEL:.
4Q I ceNly that I have and this app?kation and state that the above information is
sF. to correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z buildingconswction.and herebynuNoriee representatives ofthis city menecrupnn the SEISMICFEE
shove-memtioned property for inspection purposes. ILPERMIT ISSUANCE
(We)agr.e m save,indunmify uad keep harmless the Cil,of Cupertino vgains,, ELECTB rx
imbilida,judgments.cosomal ealxmes which in,many wayocemeagainst said City ALTERORADDTOMECH.
in consequcna of Ne g'andng of this permit. PLUMB]
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLN N-POINT AIR HANDLING UNI 1110 10,0100 CFM)
I SOURCE REG' TI NS MECHANICAL P'�
A IR HANDLING UNIT(OVER 10,000 CFM) CONS'T'RUCT NTA%
Signature of Applicar Conwaor Data I IIAUST GOOD(W/DUCT) HOUSING NSJ.GATI ON FEE
HAZ RUOU MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Cone.Chaprer 9.12,end the Health and Safety
Coe,Section 35532(a)? HEATING UNIT(OVER L00.00)BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PND
Date Res 9
Will the applicant or furore building he Be, equipment or devices which BOILER-COMP(311P OR 100,0(1!1 BTU)
nil M1aeardonn in
s aamnumums as def moil b,by the BA Management Air Quality MnnagcmeTOTAF/
District? BOILER-COMP(OVER 100.000 BTU)
CYea Otho
AIB CONDITION[
eryuiteoan k
(have read thehmardous materials tsuocr Chapter h95 of the Call-- ISSUAN i E
fornix Health&Safety Cade.Sections 25505.25533 and 25534.1 midcrstael Nat if Ne NEW RESIDENTIAL MECIL SQ,FT.
hailJing does not curen0y have a lemon,that it is my res,onsibi lily to ratify the cesup int
of the eyeimterm which most he met prior m is,..of a Certificateof Decrier,
Owner or amhinueda,ent Date ISSUED B .
OFFICE