28624 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 28624
1 /�/� A
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 8 6 / /I
BUILDING PROJECT IDENTIFICATION L V lit[�'7
ILDINNGGA� )DDRE.SS: SANITARY NO. APPLICATION SUBMITTAL Ds AI
OWN SNAME: - PHONE: ONTRr5C R'S NAME LIC NO,
_e" Z— / O`y N`�R NIC CONTROL#
.ARCHITECETNGINEER: LIC NO ADDRESS ADDRESS: ❑
CONTACII PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
esk
1 hereby#Turf that I nm licensed Bu ander provisions of charter and my
JOB DESCRIPTION
�aZ with SecrceandeffecDivisinn3nfthe Business and Professions CnJu,andm license is
��O y PERMIT ISSUANCE RESIDENTIAL
F ifell force and effect.
tY�F• t ❑SFDWI. ❑KITCHEN REMODEL.
<FUz U Liccnse Clens Lic,a
NQU Dam Cummmor AI'PLIANC[S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑ IUNIT ❑STRUCTURAL
~v=i y I understand It 1 'bull he used as public recoM. PANELS MULTI
ZOy,7j ypanss a MODIFICATION
oz-, UPTO 200 AMPS
f-�FW
Licensed Professional CI INTERIOR ❑CHIMNEY REPAIR
S
20LIIXIIIAMPS IMPROVEMENT j OWNER-BUILDER DECLARA'TIUN
C 6 I hereby affirm m shat 1 aexempt from the Comracwrs License Law for the OVER I000AMY5 ❑BATH REMODEVREPAIR DEMOLITIONPae,3 tL U following reason.(Section 7831.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL. ❑OTHER
41 LL. which ri tires o permit to comeo 6 alter.Improve,demolish,or repair any structure
F u-OQ poor to its issuance,also requires the applicant formch Permit o file o signed statement SPECIAL CIRCUITIMISC.
�s mat he is licensed pmvisi p
y Dursuamwlhe ons of the Contractors License Law(Cha nr9
DOS (commencing with Section 7000)of Divleien 3 of me Business and Professions CWc)or 'TEMP.METER OR POLE INST AMM R IA
C.L e that he is exempt therefrom and me basis for the alleged exemption.Any violation of
x^ Section]831.5 h xn pplicam fora ❑NEW BLDG/ADDITION ❑DEMOLU'ION
W m y y n permit subjects the applicant io a civil penalty of POWER DEVICES
not are than Eve hundred dollars($500). []TENANT ❑FOODSERVICE
~?M I,as owner of me IMPROVEMENT
_� ❑ propeny,or my employee.#mothered
for their Stale compensation, SHIMMING POOL ELECTRIC
Wg will du the wnrk.and Cars, so mreis ma cter,Livens Uredos not
Vile tapply oar Business ❑OTHER
63 and
ertywho b Cod e:The Contractor's Liccnselawdrecnotapply to owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves t sucan.and who does such work himself or through
his awn employees,building that proh improvements are nil intended or offered for NEW RESIDENTIAL ELECTR SQ Ff.
sale.ghowevw,the llhabuildingebanderrwement ismlhewithinione tbuild lir improve for the SQ.FT.FLUOR AREA
posyr-builder will have the banderol that he did ern build or improve for per- SF f..JJ
of sale.).
C]L as owner of are property.an exclusively contracting with licensed contractors to TOTAL:
onstmm the project(tie,.7(M4,Bashes,and Profession Cud His,Convaemr%Li- �s O
Li-
coast,Law does not apply to an owner of pmpany who builds or improves thereon,and QTY. PLUMBING PERMIT FEE Chi Y G 9g5
who contracts for such projects with a rectracmr(S)licensed pursuance the Commemrs f- LU
License Law, PERMIT ISSUANCE ` /~`s i rho
E]I am exempt under Sec. ,B&P C for this Lemon
ALTER-DRAIN&VENT-WATER IFA)
Owner - Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm ander In�nalty of perjury one nl'the following declarations:
❑Ihave and will trwimaine Cenifcaw of Conumto
"'If-insutefor Worker's Compen- DRAINS-FLOOR,ROOK AREA,COND. TYPE CONSTRUCTIOI
Wine.as provided for by Section 3700 of the Labor Code,for the performance of the STORIES
work lin which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as requited by Section
3700 ofine Labor CtNg to,the pentorroccufon work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number an:
Comer: Policy No.: GAS-EA.SYSTEM-OVER 4(PA)
CERTIFICATE OF EXEMPTION FROM W ORKF.RS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
ter le.Ss.l
(This section aced not he oomplcted if the permit is funne hundred dollars IS 11GRIiA$E'1'RAP
X)) BUILDING DIVISION PEES
PLANCHECK FEE
Toy any Nat in Idecarearsoan,
of Ne work far which misp eWorkes Camper- SEWER-SANITARY-;'
not employ any petnm in any mannan#m to become whjea to the Workers'Compen- 51'ORM EA.200 FT. ENERGY FEE
Z Armon Taws of California.Date
Z 0 Applicant
WATER HEATER WNENT/ELECfR GRADING HE
Z) NOTICE.TO APPLICANT:If,after making this Cenllicate of Exemption,you should WATER SYSTEM,TREATING
7 become Subject to me Worker'x Compensation provisions of me Labor Carlo you must SOILS FEE
W foMwim comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
aQ
'Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
O I herehyaffirinh'hi that permit
issuconstruction So.3lendie. agency for the performance of Date Receipt#
[is Hthe work fur which'his panni)is issued(See.309],Civ.C)
Lenders Name
LUkI Lenders Address TOTAL TOTAL:
y I ccnify that 1 have read this application and.gate that the above information is BUILDING FEE
lin correct.l agree w comply with all city and county ordinances and state laws nlatingm QTY. MECHANICAL PERMIT FEE
U Z building contraction,and hereby amhorile representatives of this city to enter upon the I SEISMIC FEE
above-mentioned Profanity for inspection purposes. PERMIT ISSUANCE
(We)to.m rove,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
ixbiliticajudgmmints,eons and expenses which may in any way acme against said City gLTER OR ADD TO MECH.
in consequence of me granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL C MPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE RF )LATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER III,BfIB CFM) CONSTRUCTTONTAX
mgnamre of App]ic=VCon=;or Date EXHAUST HOOD(W/UUCO
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building becupant stare or hand le hemNoas materialHEATING UNIT(TO 100.000 BTU) �a
ax defnW by tn
he Colon-Municipal Cade,Chapter 9.1Z and me Hwlm it Safety
Cale,Section 25532(x)? HEATING UNIT(OVER lauding)BTU)
❑Yah -1 No
VENTILATION FAN(SINGLE RCSID) PAID
Will the applicant or furore building bytheoccupant use equipment or devices which Date Receipt a
emitBair contaminants as darned by the Bay Area Air Quality Management BOILER-COMP(THP OR 100,000 BTU)
District?
❑Yes [IN. BOILER-COMP(OVER 100,000 BTU) 'TOTAL:
I have mad the harardous matenals requirements under Chapter 6.95 of the Cali. AIR CONDITIONER
forma Death&Safety Gude,Sections 25505.M533 ani 25534.1 understand had if the ISSUANCE DATE
buildingdoes two currently have a temmt.that it is my responsibility to testify the occupant NEW RESIDENTIALMECH. SQ.ET.
ofine rgairemenn wMch mast be mm prior to ihraaneeofa Cmdr acts of0aapaney.
Owner or namoar<d agent Date
SSUED BY:
OFFICE