28599 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT N0 28599
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL
IBALDINC PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS ' NAME:eTpq PHONE: CONyR C OR:tiN E: LIC NO: '�' •
�(�`l1JRk.�11 NIC CONTROL#
ARCHITEC TEN EER: - LIC NO: ADDRESS: El2
l)5 4sld
CONTACT: 'PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEF.
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Oc0 with Section 7000)ofDivision 3 orthe Busmessnnd Professions Code,emf my licenseis RESIDENTIAL;
�� in lull force unit eR yy� �/— PERMIT ISSUANCE'
aUZppF License�o=re,12Lic.M 6-103..) Y ❑SFDWL KITCHEN REMODEL
H6W Dam Contractor �(7LG�� a APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPP.
Z ly„py ARCHITHCTS DECLARATION 0 PANELS
❑MULTI-UNIT ❑STRUCTURAL
Gs V2 Z_ 1 understand my plans shall be used as public records M IFICATION
OZ-- UP TO 2101 AMPS
cctM El INTERIOR IMNEY REPAIR
Eg Licensed Pndessiowl 2(11-IfIUl1AMPS IMPROVEMENT
��dd OWNER-BUILDERexemptDF.CLARATION BATHRMODE
ag 6 1 hereby affirm that I am exempt from the Commaors License Lew for the OVER IBRO AMPS ❑BATH REMODEI/REPAI0. ❑DEMOLITION
tl V following recon.(Section 7031.5,Busineu unit Rvfcssions Code Any city ar count# SIGNS ELECTRICAL ❑ THER w a_
fV O E" which require,. samit m enutrvu6 olmr,improve,JemolLsh.or mpuir any nwemm WG�s
lay-. prionoiu issuance,also requires the applicum for such permit to flea signcJ sutemcm SPECIAL CIRCUITIMISC.
artNat he is licensed prousint Contractor'so the provisions ofthe Contractor's License Law(Chapter 9 A &)r ��A
W COQ (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.MI?TF.R OR POLE INST COMMERCIAL:
d ty o C that he is exempt mereliom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
i� a!) tt
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES ❑T17NANT ❑FOOD SERVICE
s,yyyy} not more than five hand it dollar($50(b IMPROVEMENT I,as owner of the pn;ny,mmy employees will,wagca asunir sole compensminn, SWIMMING POOL ELECTRIC
wdl do Ne work,and the nrocmre is not intended moflered forsale(Sec.76/4,Business ❑OTHER
unit Professions Code:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pro,eny who builds or improves thereon,and who does such work himself or through
In.own employees,provided that such impo,ements are not mended or offered for NEW RESIDENTIAL.ELECTR 'SQ FT.
sale.If.however,the building or improvement is sold within one year ofcampleam,the SQ.FT..FLOOR AREA ESQ.FT.
owner-huilder will have nhc burden of proving that he did not build or improve for aspur-
pose l
sats).
[_] 1,as owner of the property,oro exclusively contracting wird licensed metates i. TOTAL
ccove ultLa the project(Sec.o an Business end ity who ras
Code:)The es themon, n
Genu Law does not apply man owner of propcny who huilJs or impmvevherenn,and QTY. PLUMBING PERMIT � •E
who contracts for such projects with a cornmemos)licensed pursuant to the Commamrs
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B k P C for this..an
Owner Date ALTER-DRAIN&VENT-WATER(EA) J VALUATION
WORKER'S COMPENSA'I'[ON DECLARATION BACK FLOW PROTECT..DEVICE Q L`1500001 herchy affum under penalty of perjury one of the following declarations: P
❑ I have and will maintain u Certificate ofConsem to sell'-insure for Worker's Calliper. DRAINS-FLOOR,ROOF,AREA COND,
cation,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work far which this permit is trued. FIXTURES-PER TRAP I
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Labor Cade,fill he prre�yrf�o�rmancleamrngqae of the work for
!,whhiiicc�hq(teh�isk peermittiis is.sued GAS-EA.SYSTEM.I INC.4 OUTLETSM,WOCC.GROUP APN
CamerrL;r CL�IDa^n nAl[Jftlle Polcy No.�_1P3a♦t'pwas-&=a GAS-EA.SYSTEM-OVER4(EA)
S�tJ7. CERTI FICATE OP EXEMPTION FROM WOR K HRS' ' -
COMPPNSATION INSURANCE GREASWINDUSTRL WASTE INTERCEFIDR BUILDING DIVISION FEES
section need not be completed if the permit is for one hundred dollars(SUM)) GREASETRAP
or less) PLANCHECK FEE
Ioys,thminthe pny arnceo the as
kfnrwbije this permit the Wrkesued,I' SEWER-SANITARY-STORM EA.2(X)Pf.
not employ any person in any manncr.m az n,become subject m the Workeri Co.,..Comn- ENERGY PEE
sebum Laws of California.Date GRADING PEE.
O WATER III!ATF.R WNFNT/ELECTR
7 Applicant
G' NOTICE TOAPPLICANT:ILa@rmaking thisvisiosof of Exemption youshould WATER SYS'1'EM/TRIiATING
h � become subject m the Workers Compensation provisions of the Labor Code,you man SOILS PEE
forthwith comply with such pmaisirm,or permit shall he dcemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
(.J O
I hereby affirm that there is a construction lending agency forthe performance of Data Receipt#
V. F the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name TOTAL:
ELanders Address TOTAL:
LL I certify that 1 have read this application and state that the above information is BUILDING FEE Sri
L11 corer.I agree to comply with all city and county oobnrncesand nate lows relating in QTY. MECHANICALPERMIT FEE
U building construction,and hereby anthonee repreumtiaoal ofthis city to enter upon the SEISMIC FEE D
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City M Cupertino against ELECTRIC TEE
ilniacboilnituieqsuenm oefntshe.cgtinng ofthis.upswmhiti,ch may in any way acerae egaimt said City AIJERORADDTO MECH.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT 0701(I.f CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I0,000 CPM) CONSTRUCTIONTAX
Signature of ApplicanVCommctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupant store at handle hauadous material HEATING UNIT(TO IW,(oa BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)7 BEATING UNIT(OVER 100,1100 BTU)
❑Yes 0 N VEN71ADON FAN IS INGLE RESOD) PAID
Will the applicant or future building occupant use equipment or devices which Dam f:0ccl, #
emit hunardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP 0HP OR 100,000 BTU) - -
Dismin'1 TOTAL:
❑Yes ON. BOILER-COMP(OVER 1010,1100 BTU) O(ITI
I have mud the huzmrdous andermis minicamemc under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE A
fomia Health A,Safety Cade,Sections 25505,15533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT CII Y
building does not comently have a moral.that it is my responsibility to notify the occupant wr k x,,-LHIINp
lima , obs eh must .may nolxeuwee nfu CeniOeatc of Occupancy.
Aw IIi�•IJ
Owner or nuthon W ager. Date TOTAL: ISSUED RY:
OFFICE