28549 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING•ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 28549
HU1LDING•PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
10 0 - LIC NO: 6 -
OW ER'S NAME: k - P N& CONTRACTOR'S NAME:
NIC CONT0.0LN
fdRCHITBCT/BNCINECR: LIC NO: LV ADDRESS,:
2A
IwwlRs
CONTACT. / PHONE: BUILDING PERMIT INFO
j�,A�wb)-141 —Moo ❑ Consultant Fees Paid by Appllcanl(Initial) BLD ELECT PLUMB MEC
LICENSED ONTRACfOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby from That Imp littmed under provisions of Chapta 9(commencing JOB DESCRIPTION
"Z with Section WIDE) Businesxand Professions Cede,and my license is w PERMIT ISSUANCE -
U� in full farce ande t FOWL ❑KITCHEN REMODEL
�UU Licmise Clas Lie.'. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R4PIPE
��W Dete CTSDmor�
7 v0.i ARCHI'TECT'S DECLARA O ❑MULThUNIT [I STRUCTURAL
~v� lundersand my plans shall he used as public records � PANELS MODIFICATION
OZ�J, UPT0200AMPS El INTERIOR [I CHIMNEY REPAIR
9041 m Licensed Professimal - ]pI-Io011pMP5 IMPROVEMENT
� OWNER-BUILDERm CLARATION . OVER I"AMPS ❑BATH REMODEIIREPAIR ❑DI31OLITION
1 hereby affirm on 1 um exempt from the Contractors Code:Any
Law for she ❑OTHER
igSO00 whichire,micon.(Section 903L9.Bminns eo ProfessionsoAny city or county SIGNS ELECfRICAI. �—
By O ya whil requires a permit to conswe nhcq improve,demolish, file mash any swdure
y.]
prior lieis issuancgrsuant also to the movisio sootheant for such mosconaey ima,Law(ned nammem SPECIAL CIRCIIIT/MISC.
y (home Lscingitpursuasn 7 lM1)of Division 3 oftGuarantorsndproessionsapar9
p 0 (cut he I.(commencing with Scdfront and the
Division oftheegeBusiness xempt Profusions Cale)or TI3MP.MCI ER OR POLE INST.
It. e e' but he is exempt sherefmm and the basis for Ne alleged exemption.Any violation of E)NEW BLDG/ADDITION ❑DEMOLITION
u• Section 7031.5 by anyappliconl forupit,ol jecrstm he.pplicana acivil lwa.Ity,,f POWER DI3VICIS
my enn ❑TENANT ❑FOOD SERVICE
y not more Nen fire hundreJ dollars(YSOU).
IMPROVEMENT
O01,as ownerofthe proinp ter my employees 01 MI'mgcsastha(Say.compensation. SWIMMING POOL ELECTRIC ❑OTHER
mwill do Ne work,nod the he Core is no intended s m as;do lunate(Sec.7014,Business
and property
who
Cnde:The Contractor's License Las;does ora apply to if owner of OUTLETS-SWITCHCS�FI%'fURFS
papery who builds or improves Hereon,and who docs such work himself or through
his own employees,provided that such improvements a2 not intended or offered for NEW RESIDENTIAL ELECTR SQfi,p 1-1
sale,If.however the building of improvement is sold within one year ofcompletion,the SQ.IT FLOOR AREA $/SQ.Ff.
owner builder will have the burden of proving that he did not build or improve for pur-
pose of sole..
h as owner of the property,am exclusively contracting with licensed
contractors m TOTAL;
construct the pored(Sec.7044,Business and Professiom Cock.,1h.Contractor's Li-
censeLawdoesnotapplytoanownerofpropenywhobuildsorimprovesdamon,and QTY, PLUMBING PERMIT FEE
who contracts lir such parcels with a eonteacmr(s)licensed pursuant to The Contractor's
License law. PBRMFF ISSUANCL
❑1 um exempt under Sa. .B&P C for oris mason
Owner Date
ALITR-DRAIN&VENT-WATER(EA) VA -A 1)
WORKER'S
n
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hcmby effnto under penalty of perjury one of the following declarations: Ir
❑IM1nvc undwill muinain aCxnifculenl Cnnsenl m self-insurefnr Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES P RUCTION
soon,as provided far by Swum 37M of the Lebsar Code,for the performance of Inc
work for which this permit is issued. FIXTURES-PER TRAP
cpj�nrco,and will'muintain Wnrke/v Compensation Insurencq as required by Senior CI 1 1 WC i Ln 111VIJ
37W of the Labor Cale,for the performance ofrhe work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worrkpr s Compensation Insurance carier.tnd Policy number are:
Curries Policy No.:yfA;I Os�+-4 GAS-EA.SYSTEM-OVER 4(EA)
CECE TLP"ICATEOOFFEEXXEEMPTIONFROMA KERtOI 5'
COMPENSATION INSURANCE GRF.ASEENDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PCCS
('(hie section need nm be completed ifthe permit is for one hundred dollars(91110) GREASETRAP or less)(This
FEE
Loy any pars.
in the performance of the work for subjectch to thepermitWresued.I shall
Compr. SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner an as to hxomc subject the Workers Cnnlpcm ENERGY FEE
O Z yahoo Laws of Celifomia.Data WATER HEATER WIVENT/ELEC� GRADING TEP.
NOTICE
y NOTICEEIR
TO i 1.the Walker's
Cmr asking this sim.m.of of Lahm Exemption. you
WATER SYSTEMTREATING
Mcome suhjen m the Worker's Comlwnsation provisions of the Lahnr Ede,you most SOUS FEE
WQ forthwith comply with such provisions or this pennilshell be deemed revoked. WATER SERVICE
As CONSTRUCTION LENDING AGENCY NEW RESIDENT'IAL PLMB. SQ. PAID
V Q Ihcreby affum that there isacnnnanion lending agency for me Perfortnerree of Dam Receip,0
(L H me work far which this Permit is issued(Sco.3097,Civ.C.)
0 Lenders Name TOTAL:
Lender's Address 'TOTAL
1 certify for 1 have read this application'auction,thm rhe above infmamion is BUILDING FEE
rr Ln corect.I agree to comply with all city and county ordinances and state laws relmingm QTY. MECHANICALPERMIT FEE
U 4 building construction,and hereby mahonu repmsemmives of tbiscity lemacrt,on the S131SMICFEE
aMwe-nnemioned papery for inspection purposes.
(We)agree to save,indemnify and keep harmless me City of Cupertino against PERMIT ISSUANCEf 0 ELECTRIC FEE
Iiabilitics,judgments,costs unit expenses which may in any way accrue against said City ALTER OR ADD TO MHCH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-I'OINT AIR HANDLING UNIT(TO 10,01M CFM) O
MECHANICAL FEE
SO P.R�P. ,ATION
J\L( yy� AIN HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Sig ire of Applicant/Conrmnor l� lData EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lhoapplieunt or future Wildingoccuprat stureor handle huzardnus anterial H13ATINGUNIT(TO 100.000 BTU)
as defined by me Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Cnde,Section2553200? HEATING UNIT(OVER 100,000 BTU)
❑Yes KNo VHN`rHAT10N PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt M
emit hazardous air conmminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,00)ITT U)
Dimon? TOT
C]Yea XNo BOILER-COMP(OVER 100JM0 BTU)
I have mal me Woreaous materials requirements under Chapter 6.95 of dm Call. AIR CONDITIONER
requi pISSUANCE DATE,
folia gdoHeales&Safety erre Cala Sections 2$5(15,is my and 25534.1 understand that if the NEW RESIDE NTIALMECIL SQ.FT C Q 7
Wilding does nacu currently hnveamnant.maroismymspomiconfito ratify the cecupmn r
of VlRrty-i-men'sk `ich nustM net pnarmissuunce nfa Cerifcma yf9-ncy.
I It
Owner or authonzo agent DataIOTA T ISSUED BY: �+
OFFICE