28497 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM]f NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAI,
BUILDING PROJECT IDENTIFICATION 28497
BUILDING ADDRESS: SANITARY NO. APPLICATIUNSUBMITEALDA1'1
L ! _,5xotsT
O NERSNAME: PHONE: CONTRACTOR'S NAME, LIC NO:
M
s107AD NIC CONTROL
l�ARCHITEC rENGINEER: LIC NO: ADD ISS:• / Ge ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
SLY ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Ql'Y. ELECTRIC PERMIT PCE
1 hereby i flifm that 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O5C wilt Seedom?")of Division Sof the Bushes.and Professions Code.and my licene is PERMIT ISSUANCE RESIDENTIAL'
00 '
701^
Q infull fume and effct
APPLIANCES- ❑ DWL OKITCHEN
NUV LicenseClass - Lic.p S ❑ADDITION ❑PLUMBING RH.PIPH
WDu1e tfCn RESIDENTIAL
ARHFC'S DFCLARATION El MULTI-UNIT [I STRUCTURAL
Z O y Z l understand my glare shell he used w public records PANEIS 0 'C 1ION
OZ
�O UP TO 200 AMPS ❑INTERIOR IMNI7Y REPAIR
ro Z',F-LL Licensed Pmlessiand 201.1000AMPS IMPROVEMENT
-MZ OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEVRF.PAIR [I DEMOLITION
I hereby rfOrm that I am estard form the Conuacmr's License Law for the
1aX a U following remod(Section 7031.5,Business and Pmfissions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL y which requires a permit it)construct.alter,improve,demolish,or repair any structure
On prior to as irmorearlso respires once applicam former,permit m fileadefermentigned deferment SPECIAL CIRCUIT/MISC.
E } thin he is Iirensed pumu in to be provisions of the Committers License Law(Chapter 9
ad sac N
000 (commencing with Section 7")of Division 3 ofthe Business and Pmfcvsiuns Code)or TEMP.METER OR POLE INST. COMMERCIAL:
to 6 c�• that he is exempt therefrom and the huffs for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y Ssction 7031,5 bynnyapplicant fora permi adjeca the apifcannna civil penalty of MW12R DEVICES ❑TENANT ❑FOOD SERVICE
FZ? not more than five hundred dollars(5500). IMPROVEMENT
6 ❑ Las owner of the pmpeny,or my employees witi wages as their sole romlensabnn, SWIMMING POOL ELECTRIC
`G will do the work.and the nmcmm is not intended sauntered for sale(Site 70W.Business ❑OTHER
L 3 m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or though
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ tT.
eine.Ilhawever,the hulldmilorlmprovemem i,nld wllhitnncycarofcnmplemion.lhc SQ.FT.FLOOR AREA $/SQ.4T.
owroer-bmldcr will have the burden of proving that he bailout build or imprwc for In,
pose d salt.).
❑ 1,as owner of pdto,ore property,am e+ aaively contracting with licensed cmnrncmrs ffiI'AL:
cormorant the Inolec'1(Sea.7094.Boomers and Professions Codec The Comrnemra I,,-
ecuse Law does nal apply in an owner of property win builds or inuumves thereen,and Q1 Y. PLUMBING PERMIT FEE
who contracts for such projects with v conrtacmgs)licensed pursuant n the Contractor's
License Law. - PERMIT ISSUANCE
❑ I am exempt under Sec. .B&P C for this reuvnn
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner UIO
Wm under Penalty
DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under pennhy of pefjury one of the following declarations:
❑on.as pro will for byneio37 Certificate of ConenuoCoode,for for Workersce of the
DRAINS-4100R.ROOE AREA.COND. STORIES TYPIiCONSTRUCTION
nation,as hick this
for mi Saline 3]00 of the tabor Code.far,hc performance of the
work(ave and this pemtit is issued. FlXTURIS-PER TRAP
El 1 have end will rune,for Workds eofb,Compensation works
fid,s as required by Section' - ,.
My arker' Co pWgfonlheperrormanceof and
fman , Nis permit is issued. GAS"EA.SYSTEM-I INCA OUTLETS OCC GROUP APN
My Wodcrs Compensation Nnumhee tamer and Policy num eT art:
Carrier. a'J?2T�—Gyi/'^Pahey Na.:`�r � GAS:EA.SYSTEM-OVER 4BEA)
CF.RTIFICATI?OF4:XEMMON N OR S'1 f GREASEANDUSTRL WASTE INTERCEPTOR
,. COMPENSATION IIi19U 1 l a ' BUILDING DIVISION FEES
(Thisectionneedmu McuirpRhdi2,h`e pe sect foro^ne hundreddollars Oltkp GREASE TRAP
or less.) L I d PLANCHECKFECb
I comity that inmteperfnrmanccof theyin icti mhixpamil issmad,lshull S WERI SANITARY-STORM EA.200 F1'.
nm croncInny per smviarnymrnnersomon Ih !FutheW "Coupc ENERGE ®A
,Z nation laws of Culili�"u.0 I' AFERHEATER WNENT/ELECTR
Q
Applicant l >> gj ADIN
o NOTICH TQ AI'1'LICgNT:II:ober m19 s male of Exmnpmion,you should SVAI SYSi'EMITREATING
F 5. become subject the Workers Compen.smour pre -.urns of the labor Coo you muxl _ "' SOILS pF.F ,
a > forthwith comply with. ci provisions m this Permit shall he deewlid, coked-^`^" WATER SERVICE x
0. c : 2" ging:1w:..,.... . r °Fti
] z CONSI'RUCYION LENDING AGENCY NEW RESIDENTIAL PLACE. SQPT PAID Dam RfcciplN
U O I hereby affirm that them is a construction lending agency for the performance of k
U. (•-' the work for which this permit is issued(Sec.3197.Civ.C.)
C) U Lenders Name TOTAL:
Lenders Address TOTAL:
y 1 cmify that 1 have read this atridemion ministate mm the above information is BUILDING FEE
N correct.I agree to comply with all city and county ordinances and sum laws relating to QTY, MECHANICAL PERMIT FEE SEISMIC FEE
V 2 building construction,and hereby authorize representatives of this city to enter upon the i Jti
above mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree sen cove,indemnify and keep contractsthe City of Cupertino against ELECTRICFEE
Iiabilimies,judgmems.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX
Signamrt of Applicant/Commctor Dam EXHAUST HOOD(W)DUCT) HOUSING MITIGATION FER
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oealsomslrrc or handle hazardous traccol HEATING UNIT(TO 100.000 BTU)
as defined by me CuPcrima Municipal Code.Chapter 9.12,and the Health and lmoly
Code.Stomion 25592(x)7 HEATING UNIT(OVER 100,0100 BTU)
❑Yes ON. VENTILATION FAN I SINGLE RIiSID) PAID
Dame RettiplN
Will the afflicaut or future building occupant use equipment or devices which BOILFR-COMP(3HP OR IW,000 BTU)
emit hazuNou.s air contaminants as defined by the Bay Area Air Quality Management TOTAL,
Disuin! BOILER-COMP(OVER 100.000 BTU)
❑Yes 0 N
I Most fend the M1naarduus maedals requirements under Chapin 6.95 ofare Cali AIR CONDITIONER ISSUANCE DATE
foods Health&Safety Cotte.Sections 2.5!505.25533 and 25534.1 understand that if Jct: NEW RESIDENTIAL MECH. SQ.FT.
building does tut currently have a manor,dot i,is my responsibility to notify the ssccupan, T
of Jin requirements which pars,be Ire priur to jeamoct of a Certificate of Occupancy.
Owner eulhsmiud agent Date TOTAL: ISSUED
r oBY: � Baa
OFFICE