28773 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL PERMITNO.
BUILDING DIVISION' APPLICATION/PE MIT r PLUMBING-MECHANICAL• 28773
BUILDING PROJECL IDENTIFICATION
tlU1LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
G -�
O 'S NAME: a PHONE: CON'fJ(ACfOR'S : LIC NO:
a tat NIC CONTROLM
ARCHITELTENGINEER: ai IS' 'AI`'GR•PSS: I� i ❑ .
CON'IACU PHONE:'. r BUILDING PERMITINFO
Consultant Foes Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
LICENSED CONTRACION'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing .TOB DESCRIPTION
��2 wird Section 7(00)uf Oivision3ufthe Business and fc in od ardm cote is RESIDENTIAL
❑l0 P/.� PERMIT ISSUANCE. +,
FLL� in full farce and etfea✓ 46 6 ❑SFDWL" ...❑...lIIKRCHCN REMODEL
aV� License CLo LTJ LiaX APPLIANCES-RES IDLM'IAI. - ClADDITION KLUMBING REPIPE
F 2;W Dole.c tire,
ba
rn a �T [I MULTI-UNIT
STRUCTURAL
AHCHITECPS III!, RA O
'ctu z Iordcmm�J myplomsshhll be uredo,public records PANELS MODIFICATION
O�VI„q UPT02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR_
u1 License)Prnfussinal r 201-IWUAMPS .,1 IMPROVEMENT' •,
�Yf,4 " OWNER-BUILDER UECLARA'1'ION OVER 1000 AMPS - ,BATH REMODEVREPAI R ❑DEMOLITION
C 04 6 I herchy affirm tom I am exempt from the Cunhaaors License Law for the
iqqi55 6 U following reason.(Section 703 1.3.Husinesa and Professions Cada Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to construct.alter,improve,demolish,or repair any sauc um
f�"u•ul Pntuar as box...ce,alsorequim,lheaprlicaut hasuch pewm it Elea signedstatement SPECIAL CIRCUITIMISC.
f�} that he is licensed pursuant to the provisions color,Contractors License Law(Chapter 9
(commencing with Steedon 7")of Division 3 ofthe Business and Professions Cale)or. TEMRMErERORPDLE1NST COMMERCIAL ,
a 6 cC that he is exempt therefrom and the basis for the alleged exemption.Any,violation of _ l❑NEW BLDGIADDITION ❑DEMOLITION
NSection 7031.5 by any applicant for o pernausubjects the applicant o a civil penalty of POWER DEVICES OT'HNANT 0FOOD SERVICE
not more than five hundred dollars Mad). - IMPROVEMENT,.
=O
El Los owmmofthe property.or my employees with wages as their solcomencnsition, SWIMMING POOL ELECT RIC ❑OTHER 'l
p., will do the work,and the stricture,is not intended or offered for sale(Sm.7614,Business -
3 m and Professions Crdc:The Contrumors License Law does nal apply to an owner of OUTLETS-SWITCHES-h1X'1'URES
property,who build,or improve,human.and who does such work himself or through I f
his own employees,provided that such inoprove n tas are not intended or offered Tiro NEW RESIDENTIAL ELECT R .,SQ FT
nate lf.however.Nc building nrimpnwen¢ni is sold within ane year ofrnmplelinn,the• . SQ:YT FLOOR AREA $ISQ.FT
owner-builder will have the burden of prlwing that he did not build or improve torpor. .
poise of sale.). t
TOTAL:
-1 Las owner of the property am exclusively contracting with licensed contractors 1. -
construct the project(Sec.704:Business and Professions Code:)The—ou acw/s W- -
censeLawdoesnotapply to as owner of property who ouilds or impowcslocomm.and QTy, PLUMBING PERM IT FEE
whocontmets for such projects with a cotnractimol licenud pursunm to the Contmcum s
License law. - PERMIT ISSUANCE 3 V
[3l um exempt under Sec. .B&P C for this musun
pk
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Do,.
"
WORKERS COM VENSA110N DECLARATION - BACK FLOW PROTECP II
I hemor, from undponablyol perj y of he bit lowing d I ince:
[I
1 have and will common to Celtificale or Consentt Ifinso for Workers Contlen• DRAINS-FLOOR,ROOT..ARE ,C ). - STORIES TYPE CONS IRUCTIOP
mlinn,as provided for by Section 371,1 of the Lulea Code fur Ne perfnrmance of tote
work for which this permit is issued. FIXTURES'-PER TRAP
1 have and will main Win Wmkces Compemahou Insumnce..,required by Section
371X1 mare LaMsr Code for the performarecof the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 UUTLETS OCC"GROUP APN
My Worker's Compensation Insurance cancer and Policy number ate: -
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASF4NDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This soc iun curd not be completed ifthe permit is Porone honored dollars H 1110) GREASETRAP
or less.)a PLANCHECK FEE
I ccnify that in the perform cafthe work far which his .it is issued lshall' SEWER-SANITARY-STORM LA.2W FT.. '>
not employ any Persons n oarsyJlsntyyagryWcal ffi W krs'Co open- 'ENERGY FEB
,� Aaiun laws of Cnlik'my/Dui JG�_L� a7 Y WATER HEATER WNENTIELECB 1, '
O / GRADING FEE
O No licmtt PANT+--ear m.
Noll[ tabj APPUhe WorkANT.If,Com thio i s of of Labor coq you should W F:N SYSTEM?RIiATING
I••'to become subject m the Worker's Cnmpen,mion provisions of tote Tabor Credit,you must - 50145 PEE .
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE -
Z)
UO I hereby aRrm,CONSc ONLLNDINGAGENCY NEW RESIDENTIAL.PLMB: SQ.FT. PAID .. .Dale RmeiptX
Nal thereem is is aa construction lending agency fur the performance of
the work for which this permit is issued(Sec.307,Civ.CJ
Lander',Name TOTAL:
O U Leni AddressTOTAL:
I comfy that 1 have read this application and state that the above information is BUILDING FEE
correcl.I agree locomply with all city and county ordinances and state laws relating to QTy. MECHANICAL PERMIT FEE
U� building construction.and hereby authorize rcprescnwtives clans city m enter upon the SEISMIC FEE
ubov,-carrinneJ propcny far impmtion purposes. � PERMIT ISSUANCE
(We)agnate m save,indemnify and keepy,harndco,the Cr of Catemn,against ELECT RIC FEE:
liibilines.judgmens.costsand expenses whichnmy inunyway cmeegninst,vaid City ALfERORADDTOMECH.
PLUMBING FEE
incnnscquenceofthe granting ofthisnnit. - -
APPLICANT t' -RSTAND WILT.CO P WITH ALL NON-POINT AIR HANDLING UNI'r(TO IRIOUCFM)
MECHANICAL FEE
-
SOURCFsRP ,LATIONS.'
AIR HANDLING UNIT(OVER 10,1000CFM) CONSTRUCTION TAX
Signmare of ApplicanVContmnor Dae EXHAUST HOOD(WIDUCE, - HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ncupant stare or handle hazardous material HEATING UNIT(TO H10.000 BTU)
as defined by the CuKra in,Municipal C dc.Chapter 9.12,and the Health and Solely
Code,Section 255321n)Y_ i HEATING UNIT(OVER 100,000 BTU) -
E3 Yes
- 0NI\I)
VENTILATION FAN(SINGLE REMD)• Dae Rnai IX
Will the ppf t ho hadd g p t "-e coup t l . whJt 113 Cal
1emM1 it rd u: 'r contaminants 1I a: ed by tl e Bay Area Air Quality Mo BOILER-COMI'(3HP OR 00
n r"an n 11(111 BTU) • ... AL:
District? - BOILER-COME(OVER IM.000 BRI)'
❑Ye.c []Nn
- p
EIG
1 have read the bxzardous materials rtquimmems under Chapter 6.95 of are Cali- AIR CONDITIONER BI WIN
fomia Herat&Safety Code.Sadonx 25505.25533 and 25534.l undersho that if IM NEW RESIDENTIAL MCCH. SQ.FT. .CI11 O
F M,1119
buildingmtes nm currently have.tenanr,than,it is my reapansibililym naify the ncupaat
of me requirements which must be met prior to ismanee of a Certificate of Occupancy.
Owner or uuthomed agent DamTOTAL: ISSUEDBY: ' "•�' �A
• OFFICE