28799 (2) APPLICANTTO FILL IN INFORMATION WITHIN,RED LINES-USE BALL POINT PEN ONLY - -
CITY OF CUPERTINO BUILDING-ELEL6TRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT t PLUMBING..MECHANICAL. 28799
IIUII,DINGPRO.Il:CTIIIIiNTIFICA'I'ION
BUILDING ADDRESS: SANI'I'ARYNOO APPLICATIONSUBM ITI'ALDNRI
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PHo roR'sN 3DSCONTROLp
GINHfi - LICNO:_�' PHONE: BUILDING PERMITINFO
IJ Consultant Fees Paid by Applicant(Initial)
BLDG IiLECT PLUMB MiiCu
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'fC ELECTRIC PERM['I'O C Z wit65 kl hereby Or..0 mat i am licensed under,niesimis of Chapmr,9(c onmu:ncing Fill? JOB atinn 70X10 or D.M.don 3 nine Busmex,' O DESCRIPTION
Ap0 ) .and 1'rofessinns Cale,and mylianseis
WE+ in full force and R t PIiRMIT ISSUANCE r � RESIDENTIAL-
.—
ESIDENTIAL:
QUU License Class 4, GS Pict 3dsd 1 - ❑SFDWL s ❑KITCHEN REMODEL.
1F...,zW Date 1Comructnr APPLIANCES-ItES1UliN'I'IAL
fn6a ❑ADDITION' LUMPING RE-PIPE
FDw ARCHItECTS DECLARATION
z Oy,� l understand my plans shall be used ns public recmNs PANELS ❑MIJI:I'1-UNIT �IJS'fRUCfURN.
UP T0200AMPS
t�Wy(rOaW y}LWWL Iu11 lwe Ps - (Chapter
e
r
-❑INfiRI
OR -
MODIFICATION N
1�; CHIMNEY REPAIR,
OWNER BUILDER DECLARATION MPROVEMENT
U bill 1 herehY affirm that 1 m euro t from theCatamarca L cense L for the OVER 000 AMPS ❑BAf{REMODC/REPAIR ❑DEMOLTON
hi6 n Petti7031.5.Business J P f ma Cure:A citric
11 repearldquires e permit tc..m eler, p dlisM1' grair n ........
on sty SIGNS CLFCI'tICA. ❑OTHNR
O l igatrmwre
or 10 ice l requires theapplicant f . d t mm SPECIAL CIRCUIT/MISC.'but hesIc n. dpnn theprknoftheCommet
i-
1 Law(Chp¢r9
00 (eO1' 6 0S I ]0(10) fD q ITh B IP f: -:G lu)or TEMV METER OR PULL INST. -0MM -R {AI: or
d y es that h x opt therefromd the b f the pl A Y stamina of r
4X1 tr• Section 70315 by any applicant fan permit subjects lheapplicanno a civil nnh f ❑NHWBLDG/ADDITION ❑DEMOLITION
pe yo POWER DEVICES - ANT ❑FOODSERVICE ,
F z_ nm mart than five hundred dollars($$IXB.
Q I,va owner of the prnpcny,nnny cmployu:sswith wr,cx comer cola canyronnninn, SWIMM ING POOL.ELCC'I'R IC IMPItOVEMI?NT'.
will do me work;and(he.ardcwrcis not intended orolfereJ fir sale(Sec.70H.Business OTIIER-
WW 3 and Professions Code:The Contracmrs License Law doss not apply m an owner of OUTLETS-SWITCHES-IT ORIS -
pmlicrty who builds or improves thereon,and who does such work himself or through
his own employees,provided mel such innprovements arc not intended or effercd for NEW FUSIDEN'HAL BI.HC'TR SQ P. ar
sale.If.however the building oriunpmvemenl is.sold within one year ofcomplelien,the SQ.FT.FCDOW'ARW R I- 'ISSQ,IT
owner-builder will have the buNen of proving that he did nm build nr improve fur pur-
pnse of sale.). .-
1,as owner of the pinparl-n,eselusively a....arraflu,with licensed cmnT@emrs to - TOTAL: )WAR• conslruct[Ile p jeer(Sec.7014,nosiness and i'mfessioissCodegTo,Carlin lnrsLi- � •r � , J9,
cemu law does not apply to an owner of property who builds or improves NercQ'I
en,and Y. PLUMBING PERMIT FEE Cl6
i�.'
who coottacts for such Pr jects wllh n eenwnn11)licensed pursuant to On Contracmrs
"r License Law. I
Uf
"❑lam exempt under Sec. is ea
&PC for the PCRMI'PISSUANCE �,n✓s.r-
Owner. of Data ALTER-DRAIN&.VENT-WATER CA) VAf.UAT10N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
• .,I hereby affirm Under,cnelryofperjuzy one ofthe following declarations:
❑ [have and will maintain a Certificate of Cumentto self-insure for Workers Cnmpen-
DRAINS-FLOOR.RODE.AREA,GOND.
xmion,ae pmviJulfor by Beckon 3700 of the Lnhnr Code,'fmz Ne performhnee of the - STORIES TVPE CONSTRUCTION
work for which lhispenuil is issued, f. •IX-URFS-PER TRAIT
EI I have and will maintain Worker's Compensation Insurance.as required by Section
-
7]fpm(she Later CtWq for the performance at the work for whicIt this pumit is issued. GAS EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP My Wmke' Comperes, a Irisuntn rarrlenmd Policy mµnber yry; I APN
Cartier: // 'c Policy No,NC. Y yam-//� GAS-EA.SYSTEM-OVER4Fell 4
CERTIFICATEO�EMPrION FROM WORKERS' _
COMPENSATION INSURANCE GREASMNDUSTRLWASTE INTERCEPTOR
err less.)
(TM1lsscctinnncwlnia be completed if ale permit ix hannc hwalmd dollar,IS1Oft GNI?ASR]'RI AP d , BUILDING DIVISION FHFIS,
s Icenify tPelinthe-a'arcntrou of 1wobekfir mhicht to due isAia iss ed,Co shall PLANCHGCK PER
nntemploy'my fCalionin a DY manner>o asmbecnme suhjttuolhe Workers'Cnmpen-� SEWER-SANITARY-STORM EA.200 FT.
z cation Luws of Gllifornlu.Data ENERGY FEE
Z� Applicata WA'1IiR HEATER W/VENr/ELECfIt ,
NOTICE TO APPLICANT.If,after making this Cenifcam of Exemption,you should GRADING HE
a ; become subject to the Workers Campensxtion provisions of the Labor Cale, must WATER SYSTEM?REAT'ING
fnnhwiTh cont:l lhxurin Par you SOILS FET?
� Q I Yui provisions tar di,,annul shell he JPemal revoked. - WA'I'TiN SERVICh
az CONSTRUCTION LENDING AGENCY NEWRESIDEMDAL PLMB. SQ PAID
U O l hereby affirm that there is a constructinn lending agency far the perfommnce of Aj Date Receipt N'
�, (~ The work for which this lsrmit is issued(See,3097,Cie.C)
O U lender's Name -
LendersAddress - - TOTAL:
I certify that 1 have mad this application and state that the above information is ITC BUILDING FEE
F-T rA correct.I agree In comply with all ally and comely osnbrunecs and stale lows relating m QTy. MI?CHANICAL PERMIT'
U building construction,and hereby andmiie representatives nNhis city to enter upon the SEISMIC FEE
ebnve-mentioned property for im,Ncho r pu"ua. -
-(We)agree to snvc;indemnily trod keep harmless the City of Cupertino against PERMIT ISSUANCE - ELECTRIC HE
Iiuhilities,judgment,cams and expenses which may in any way accrue against said City ALTER OR AUD'I'O MECH.
in consequence of the granting of this permit. PLUMBING HE
UNDERSTANDS AND WILL COMPLY,WITH ALL NON-POINT q1µHANDLING UNIT fI'O 111,0(X1 CEM)SOURCE REGULATIONS. MI?CIIANICAL PEE .
AIRI{ANDLINO UN IT(OVERIRUX)CFM) GONSTNUCTION TAX
Sngnammo'ApphcanVComractor Dam P.%IIAUST HOOD(W/DUCT);.
HAFARDOUSMATERIAI,SDISCLOSURE IIOl151NG MITIGATION FTI?.., �'
Will theeppliat or future building occupant store err handle h,alloosnmmdal HEATING UNIT G I on.plaI OTU)
as defined by the Cupenino Municipal Code,Chapter 9,12,and the Health and Safety -
Cade,Section 25532(107 HEATING UNIT(OVER 100,000 BTU)
VEN'IILAT10N PAN(SING LE RESID) - PAID
will the applicant(11 future building occupant use equipment or de ic.es which ❑m Rtteipt M
land
dham l .0 c tnmi t axdf ed by the Bay Area Air Quality M (gement BOILER-COMP(7HP OR 100,000 BTU)
D{rict?
01 E]No BOILER=COM P(OVER I WWII BTU) TOI'A L:
1 have moil the ImrzuNous retinal,requirements nm la,Chapmr 6u5 of the Cali- AIR CONDITIONER
fornix Health&Safely CYsle,Sections 25505,25533 and 2553411 understand Thal if the - ' ISSUANCE DATE
building does not currently have a team,Nat it ismy m,,msibilit u,Polity th apart NEW NCSIDENTIALMECH. SQ.F7.
mfthere i cair ov mash bet prio t.is.n ccofa Cenificat f ammo,
uthonzul agent Dat - TOTAL: ,.
ISSUED BY: '
r
OFFICE