28826 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM1'TNO. 28826
BUILDING DIVISION APPLICATION/PERMIT PLUNIBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT[
2o3119 S..N rnA2 oo ndt i-g- sisL4 + 28
OW R:SNAM:: PIIONF:: CONTRACTOR NAME: LIC NO:
�' owrr SS 6UDo Avner 5�38yDC NIC CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACc//i PHONE: BUILDING PERMIT INFO
d BC l CleppegritL�Of(/jl�S=60 6/ 0 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
25
LICENSED CON TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby of on,aha 1.m licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z
wiNSection7M))ofDivision3afthe Husitesand Professinw Code.ard nr li n
�� y'tt u PERMIT ISSUANCE
in full force end affect.,
�F FDWL ❑KITCHEN REMODEL�UU License Class Lic.p
F�W D.tc Commmor APPLIANCES—REIDENTIAL' ❑A ITION [:I PLUMBING RE-PIPE
VI Z ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
Of/1 Z I understand my plans shrill be used as public meoNs MODIFICATION
Z p UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F°J Licensed professional 201-1f0nAMP5 IMPROVEMENT
OWNER BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEDREPAIR ❑DEMOLITION
1 hereby affirm that I am exempt Item be Contractors License Lew fnr the
3 L fU. following rcasnn.(Section 7031.5.Business and Prufessinns Cod.:Any city m coumy SIGNS ELECTRICAL []OTHER
W r� which Ieyuims a permil m consumer,alter,improve,demolish•or opsur any swcturt
F-�y prior to its issuance,slur"at..the applicant for such permit to file.signedsmm
racm SPECIAL CIRCUIOMISC.
;!(>. Nat ha h hcamed purs...11.be moliosm of the Contractor's License Law(Chapter 9
sap (commencing with Sem ion 700)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
lY y o tL that he is exempt therefrom and the Casio for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
,4t1 Y• no,ion703L56y hundred
dollforapcmtir subjcets the applicennoucivil penalty of POW ER DEVICES ❑TENANT ❑FOOD SERVICE
Z} not more Nun five hundred dollars y em).
SCO ❑Lsowner k,the property,
remyemee with wages aatheir ula(Scle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
rC� will do thework,and :The Cort moot m'intended icense offend loess not apply to n Business []OTHER
a,3
andlimitationswho b Cash:The Cantmereo,and who
rimsnotapplytolfrowner of OUTLIiTS—SWITCI{LS—FIXTURES
progeny who builds or improves thereon,and whn dues such work himself offeredfthrough
his own employers,building ohm such mens is
dw are urn intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
owne L howor .will have dueng or
burden of prow improvement is sold did n one build
or i provetfor the SQ.PT.FLOOR AREA 5/SQ.FT.
owner-rode.)r will have Ne burden of purling that he did not build or improve for bur- /
pose of sale.,. S /
❑L as t the,ofpro the prcpeny,.m sin,.lelyad cnntraninCodc:)licensed Cmur mmsm i- TOTAL:emearJ
,an.Law d project(Sec.o sm Business and rt,profession,hCsor i The Comrecmrs Li- �j�/ ..,/
cense Lawdceanmapply man with
aofpmpcny wcauseddsrsuartoves thoommContra,and QTY PLUMBING PERMIT FEE ? / /
who convects for such projcera withacomramur(s)licensed purnuam Mahe Commmor's J
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,B&P C for this match
Owner - Data ALTER—DRAIN&VENT—WATER IRA). VALUATION
WORKI3R'SCo MPENSATIONDECI.ARATION BACK FLOW PROTECT.DEVICE
lli /�Qs a%V
Thereby aum under penalty ofperjury one elate declarations:
e following declations: p O O �,
❑
[have and will maintain a Certificate of Consent to xelf-insure fin-Worker's Compen- DRAINS—FLOOR,ROOF,AREA.COND. `STORIES TYPI:CONSTRUCTION
seaman,as provided for by Section 37W of the Larm
Labor Cale,fnr the perfoance of the
work far which Nis permit is issued. FIXTURES—PER TRAP '
I have and will maintain Workers Compensation Insurance,s required by Section ,� A 1
(0 ofthe Labor Code,for Ne Performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.a OUTLETS CC. ROUP APN
My War s mpfJ� tion In a ccarticr end Policy beta
Carricr:Lgla_C-0 'nL -P'ONy NOWORKERS'/O/%r GAS—EA.SYSTEM-OVER O(EA) ��Ur llnJ
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
(Thmsectim need nal be completed if the permit is fur one hundred dollars(5110) BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE �Q
I certify the,in the perfnrtn..ceofthe work fsrwhich this permit is issued,Ison SEWER—SANITARY—STORM RA.200 FF..
nm employ any person in any manner an as to become subject a the Workers'Compem ENERGY HE
Z delis.laws of C.lifamia:Dan WATER HEATER WNENTMLECTR
Applicant GRADING FEE
y NOTICE TO APPLICANT.If,after making this Cenificate of Exemption,you should WATER SYSTEM?REATING
I" ^ become subject to the Workers Compensation provisions of Ne Labor Cede,you must SOILS FEE
WfoMwiNcomply with such provislcsocs-his permit shall be decmedrevuked. WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMD SQ.FL PAID
I hereby affirm Nat there is a convection lending agency for be performance of Data Receipt#
U.� Nc work for which this parrot is issued(Sec.3097,Civ.C.)
OLender's Name TOTAL:
V Lenders Addreas TOTAL.:
aI certify that l have and this application and sate that the above fink rmainn is BUILDING FEE
Iii!) correct.las=to comply with all city and county ordinances and slate laws relating to QTY. MECHANICAL PERMIT FEE
V Z building mostmetion,and hereby authorize represenmtivesofthiscityao enterapon Ne SEISMIC FEE
�—' above-memioned property for impectis.purposes. PF.RMITISSUANCE pry
(We) Fee to save,imietrutify and kcep harmles the City of Cupertino against ELECTRIC PEE l TO 80
liabilities,judgments.costs and expenses which may In any way accrue against said City ALTERORADDTOMECH. PLUMBING FEE
in consequence of the granting of this permit.
510
APPLICA' UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURC 'GUTA'�kNg. MECHANICAL FEE S^
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCrIONTAX
Sitfiaturn,of ApplicunVCnwcaor
HAZARDOUS MATERIALS DISCLOSURE a EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
Will NnitEdicaut or future buildi.goccupmrt smrear handle lumoulms material HEATING UNIT(M 100,010 BTU)
as defined by He Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda Section 25532(a)7 HEATING UNIT(OVER IN).000 BTU)
[I Yes 11 Nor
VENTILATION FAN(SINGLE RESID) PAID
Date Rcccips
Willthe app onto inor fooure building by he
soequipmentAir Qunrdeviceswhich BOILER—COMPOHPOR 10.fg0 BTU) K
mit hazardous air contaminants as defined by Ne Bay Area Air Quality Management TOTA
District?
Dyes No
BOILER—COST(OVER 100.000 BTU)
❑
I have read the hamNoos materials mouiremcno uMcr Chapter 6.95 of the C.H. AIR CONDITIONER
ISSUANCE DATE
Tomie Healthg does&Safety Curie.Sections 25505,25533 e25514.I understand thin if Ne NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a te'rmn4e thit is my responsibility
onsibility to nmify rile occupant
of Ne rcyryrlpr/��y/z�,s w hide nu�st hemm mer pint issuance of.Cenieeme of(]pcHupA.
Ow�i ri✓�wnrizeAtah gent s0Hojr - TOTAL: ISSUED DY:
OFFICE