28822 (2) ' AIIPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. �.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS:' JO/
- SANITARY NO. APPLICATION SUBMITTAL DATE
0
10373 Vial ar' a -e
OW ER'S NA E: - PHONEC�' A OR'SN E: LICN
On y D 0 NIC CONTROL H-
�ARCHITECTfENGINEER: - LIC NO: A PRESS: (/ ` ❑
CONTACT. PPHH'ONE: W BUILDING PERMIT INFO
Com, still,
6O6I Consultant Fees Paid by Applicant(Initial) BLDQ ELECT PLUMBMECH
LICE ED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE IrQYI IQ' Ir��.•
I hereby amffirthat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
" DO with Section?")of Division 3 of the Business and Professions Code,and my license is \" PERMIT ISSUANCE '
�. in full force and effect. 1,
UV License Class Lic.a DWL O KITCHEN REMODEL
y�k0.1 Date Contractor APPLLANCES-RESIDENTIAL CA (TION C PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
F y N - I understand m plans shall be used as blit records PANELS
zonz YPa s public �+ B MODIFICATION
02'-'n
gUP'102W AMPS
I.4 i-W Licensed Rofessional 1:1 INTERIOR d CHIMNEY REPAIR
`l1 OWNER-BUILDER DECLARATION 201-100DAMPS IMPROV ENT
iiKK L hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1050 AMPS, ❑EATH R ./REPAIR MOLITION
ig5O0.U following meson.(Section 7031.5,Business and Professions Cade:Any city or county g10N5 ELECTRICAL OOTHER 2
W `s" which requires a permit to construct,alter,improve,demolish,or repair any structure MTV y
Ia4�
prior to its issuance,also requires the applicant for such permiun file a signed amtement SPECIAL CIRCUIT/MISC. i-1:11
1i 6� that he is licensed pursuant to the provisions ofthe Control License Law(CM1apter9 - INI)
W 00 (commencing with Section 7000)of Division 3 ofthe Business and Professions Cede)or TEMP.METER OR POLE INST. COMMERCIAL
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
i� ' ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.56y any applicant for u permit subjects the applicant m a civil penalty of POWER DEVICES []TENANT '❑FOOD SERVICE
�,'y'y•� not more than five 1u41-pdrilldol.1 my employees
IMPROVEMENT
R' C Losow work,
and properly,remyemntended or offend
as thei(Se.compensation, SWIMMING POOL ELECTRIC
Cl will dothe wons and the m Cumarcrrhot a Licensor Law
do s a.[apply .ad won,os ❑OTHER
W0. and Professions Code:imp Contractors License Law does not apply s if owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who dries such work himself or through
his own owelcyees,provided that such impms sold within are not Intended m olTered for NBW RESIDENTIAL ELECTR SQ PT. EF
sale.IL howeveg ll hav i the hung i n of movant ithat heid one build
improve
the SQ.FT.FLOOR AREA EISQ.FT
wner-hailder will have the burden of proving thin he did not build or improve fns Pur- /�O
pose of sale.). as
TOTAL:
❑ I,asownen"fine property,am excessively contains with ikonsedarmrmmrsi-
came Ute the lanies not
(Seco an Business and Professions ds ullor
proves theUor', rid
cense Law aces nut apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant to the Contmmors f
License Law. I 'PERMIT ISSUANCE
0 1 am exempt under Sec. H&P C fur this reason
Owner Dare ALTER-DRAIN&VENT-WATER(EA) tJ VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE /,9pel — , VU
I hereby.frit under penalty of perjury one of the following declarations,
❑ I hf C
aveind will maintain a Certificate oonsent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of the Labor Cade,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the perfomranecof the work far which his permit is issued. GAS-EA:SYSTEM.I INC.4 OUTLET OCC.GROUP APE
CMy arrWor. rXlppens}Bs Iu' a carlmer nd Policy nu�1+�prig
TQ/- TE TEM Policy N _ LI 'may GAS-EA.SVSTGM-OVER4(EA)
CERTIFIC OMPE EXEMPTION FROM WORKERS' GREASETNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVLS NFEES^
(Phis sectien need not M1e wmplemdiftM1apetit is foronc hundred dollars IS HIO) GREASE TRAP LO�
or less) - PLANCHECK FEE
(certify thin in the peetimmuctuanymnneeof Nework for which this thopermitWorkers'Compeer-
SEWER-SANITARY-STORM EA.200 PT.
ria employ of person i a any manner so as to become subject m the Workers'Compen- ENERGY FEE
,0 cation Laws of California.Date
7C O Applicata WATER HEATER W/VENT/ELECTR GRADING FEE
G NOTICE TO APPLICANT:If,aflat making his Certificate of Emorptioq you should WAFER SYSTEM?BEATING
abecame subject to the Worker's Compensation pmmsions of the Labor Code, counter SOILS FEE
LTa forthwida comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
4 �
.7. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID t
V ' thereby ilhtlNI.itclsaconstmetiou7,C[coding ageney for the perfotanceof - _ m ReceiptN y
W N Leadeek for which this permit is Issued(gec.3097,Civ.CJ
0 (ti Lenders Name - TOTAL:
Wf<ndels Address TOTAL:
a I certify pmt 1 have read this application and state that the above information is BUILDING FEE - 11,621
rt V) correct.l agree to comply with all city and county ordinances and stare laws relining to QTY, MECHANICAL PERMIT 'FEE y M
V to I
Z building construction,and hereby authorim representatives of this city to enter upon the SEISMIC FEE TMJ
abovo-mcntioned properly for inspection proposes. I
PERMIT ISSUANCE
(We)agme to save.indemnify and keep hatless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way comme against said City ALTER OR ADD TO MECH,
n consequence of the granting of this petit. PLUMBING FEEy�
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010,(NHI CFM)
gOURCER ULATTON MECHANICAL FE ..T-
�
` tlGG "/ AIR HANDLING UNIT(OVER IO,OIXI CFM) CONSTRUCTION % 60 �flsJ
Sig�e ofApplicalre/Conallanclor Data EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIOA ION FEE
Will die applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I00,000 BTU)
as deftnad by Na Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
Code,Section 25532(s)? - HEATING UNIT(OVER I OQ(100 BTU) t
❑Yes 0 N
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Re< t I
q 't hazardous air contaminants as definem by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU?
District? T A D/ U
O Yea, ON. BOILER-COME(OVER 100.000 BTU)
I have read the hazarenus materials requirements under Chapter 6.95 ofthe Cali- AIR CONDITIONER -
- ISSUANCE DATE
fomia Health&Safety Cale,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MUCH. SQ.ET.
build gd nomutntlylls elicenanI,Nor it is my responsib'I'tyto notify the occupant
ad
I rents whit t ase men Poor issuance of a cot�lf Oc �T.
t a Com✓ T
O rorO aur Date - TOTAL: ISSUED BY:
OFFICE