28818 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO881
N
. 2
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL. L VX V% SSS!
BUILDING PROJECT IDEMFIPICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
010'/01 WaSan arflno Lan -f3/!-' of'aa.
O�ER.Nrll: AlAt. �PH NB:� AwoC y7Ry 6 .an /^/ ��Gel NO NIC CONTROLp"
ARCHITECT/ENGINEER: IC NO: A DRP_/1 S6
0 "w a _!I/Ay
CONTACT'. PHONE: - BUILDING PERMIT INFO
ee C er �rdg8s- 6 06 Consultant Fees Paid by Applicant(Initial) ELECT PLS MECy
BLDy
tic SED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ILMI X
I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�pZ with Section 7000)of Division 3 of the Bminecsand Professions Code,and my license is PERMIT ISSUANCE DENTIAL:
in full force and effect.
a UI(�,.J License Class Lic.I El KITCHEN REMODEL
Tgr.Z LLL DateGmtmchr APPLIANCES-RESIDENTIAL AD ION [I PLUMBING RE-PIPE
INF.=N ARCHITECTS DECLARATION PANELS MULTI-UNIT - ❑STRUCTURAL
ZO p( Z 1 understand my plans shall be used M public records MODIFICATION
:t UPTOYWAMPS El INTERIOR [3 CHIMNEY REPAIR
9�5� Licensed professional 201-IMAMPS IMPROVEMENT
�d� OWNER-BUILDER DECLARATION RATION e+
1tF W Q I hereby affirm Net I am exempt from the Cnmmctor'n License Law for No OVER t"AMPS EI BATH REMODEUREPAIR [qDEh10LI70N
ip5s M O following mason"seam,]031.5,Business and Professions Code,Any city or county SIGNS ELECTRICAL ❑OTHER YY11
W C F' which acquires a pemut to construct,alcor,improve,demolish.m repair any swcmrc
--�3 Prior to its issuance,also requires theapplicantfor such Permitto0eastood statement SPECIAL CIRCUIT/MISC. AMR
.Fa aIx that he is licensed punuanuo the provisions ofthc Contractor's License Law(Chapter 9 l �r
0p (commencing with Section 7004B.f Division 3 of the Business ad Pmfcssions Code)or TEMP.METER OR POLE INST. .
q m C that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW 8 D ,1 DI/ION L Q D LITIpN
iWC Is, Section 103 LS by any applicant for u permit..liects Ne applicant to a civil penalty of POWER DEVICES r, t
m not comm Nan five hundred delta,Pis ff. ❑TENANT ❑FOU NV110E
I-=6 hes owner of Nero norm IMPROVEMENT
❑ t pe cl yoramended es wiNwaaesas (Sen.
014.8 sines
SWIMMING POOL ELECTRIC
f..
will do theWords,node: he Coeisnoti License
Law rco,,not.(Seco an Business ❑OTHER
L 6C and property
who
Cafe:The Cnnvuaur's License Law does not apply to if owner of OUTLETS-SWITCHES-FIXTURES /17
propeny who builds or improves thereon,and who does such work himself or through
his own employese provided that such mens is old w thin not intended or offered far NEW RESIDENTIAL ELELTR SQ FT.
sale.If,hower willhveth burdenp fprovint ithath wild none ild,,i provetion Ne SQ.FT FLOOR AREA / E/SQ.FT.
owner-builder i tder will have the harden of proving that he did no,build or improve for pury
Potentiate.).
sown).
EI h asownerof the pm70am exclusively contracting with licensed nttnmorst. TOTAL:
construe (Se
the project o., xi]040. s
Busins and Pmfssions Cock:)The Contain,.,',LI-
censeTmuctsInot apply manownerofpropcnywhosedporimprovesHereon.and QTY. PLUMBING PERMIT E -3
whoc a l.inys Instructs projects with a contmdmrts7licenud purswm m th<Commnors V
40
License law. PERMIT ISSUANCE
❑Icon exempt under Sec: ,B&1'C for Nis reason
ALTER-DRAIN&VENT-WATER(EA)
Owner pate VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /40. 647. �--�
I hereby affirm under penalty of pedury one of the following declarations:
El l have and will maintain.CenificmaofCounts1.self-inume for Workers Compete DRAINS-FLOOR,ROOF,AREA,COND.
.cation, . STORIES TYPE CONSTRUCTION
as Provided for by Secton 3](p1 of the LuMr Cale,for the performance of the
Work for which this permit is issued. FIXTURES-PER TRAP
r1 have and will maiamia Worker's Compensation Imumnce,ss required by Section
"'If the Lubin,Cale,for the perfonoance mon,work for which this permit is issued. GAS-EA.SYSTEM-I INC.40IITLEI'S OCC.GROUP APN
MY Walker' Jntx.n 9y_L�r oli"polucyn nhcrur: GAS-RA.SYSTEM-OVER 4(LA)
Cards, P
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE.INTERCEPTOR BUILDI G UIV 'I FEES
section need not becomplcted lithe permit is for one hundred dollars SRXB GREASE TRAP rs
or less.) PLANC14ECK FEE aJ
I certify thm in the performance of Ilse work for which this permit is issued,low][
not employ SEWER-SANITARY-STORM EA,200 FT.
p y any person in any mannerso us m become subject to the Workers'Compen- - ENERGY FEE
Z cation Lews of Califomie.Dme '
7O7 O Applicant - WATER HGTER W/VENT/F.LECfR GRADING IEE
r7,y NOTICI7 TO APPLICANT If,after making this Certificate of Exemption,you ahould WA'T'ER SYSTEM/TREATING
a become subject to the Workers Compensation provisions of the Luhor Cale,you must SOILS FEE
foMwuh comply with such provisions or this prmat shall he deeadl revoked. WATER SERVICE
UaQ CONSTRUCTION LENDING AGENCY NEW R17SIDENTIAL PLMSQ.IT. PAID
0 B.(hereby of cathat there isseomehumion lendingagency fordicperammuea.f D e Receiptp
Fthe work for which this permit is issued(Sec.3097,Civ,C.)
0 U Lender's Name TOTAL:
yy UJ Leader'a Address TOTAL: I
L, Iy 1 certify Net I hove mad this application and state that the shove information is BUILDING FEE ! am
correct.1 agree to comply with all city and county ordinances and state laws relating rn QTY. MECHANICAL PERMIT FEE Q0
U buildimgcmitworion,and hze
ereby rmdumrepr,,edmtivesofihixchy interior,uponthe SEISMIC E a /
above mentioned Property far inspection pu,s ass. PERMIT ISSUANCE
(We).,re.N save,indemnify and keep hannlecs the City of Cupertino against ELECTRIC E
liabilities.jidgments,.,,a andempenss which amy in any way accrue agaimt said City ALTER OR ADD TO MECIL
PLUMBINGE / UI��yq
in mnssqurnce of the gaming of chis permit. "
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,8.0 CFM) ' p./1
SOURCE ULA'fIO�'S. MECtIANI AL FEE MOM'
O"
✓J (////.�yl���� �.. 4'..�/ AIR HANDLING UNIT(OVER ID,OIM)CFM) CONSTRU TAX 6 S"
Sieg Ewte of ApplicanUConwctor Date EXHAUST HOOD(WOUCI) HOUSING MITIGA ON FEE
-'HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hmurdous material HEATING UNIT(TO IM,000 BTU)
as defined by the Cupertino Municipal Code,CTapter 9.12,and the Health and Safety
Cotler Section 25532(a)p, HEATING UNIT(OVER 100,000 BTU) ,
❑Yes F7 No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Rn ipt p
emh Indianians air emmminems as defined by the Bay Are.Air Quality Management BOILER-COMP OIIP OR 100,00(IBTU)
District?
71Yes ❑Nin BOILER-COMP(OVER I00,000 BTU)
I have mad the hmordous materialsAIR CONDITIONER IS A -
rcquiremrnss under Chapter 6.95 of On Cmi-
fomis Bea1N&Safety Code,Section.,25505,25533 and 25534.1 understand Lha V the NEW RESIDENTIAL MECH. SQ.ff.
buildingds not currently have a tenant,that it is my respmsibility to notify the occupant
of Ne men¢ h test be ten pdono issu.nce of.Ce to of cu c.
teal --
Garner or suthonzed agate Date TOTAL: ISSUED BY:
OFFICE