28824 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 28824
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATI NSUB?vl DATE
O s6 ViaS rr /an 919
OW R'S A�MICn e as PH( 610460COM'<t�AaIC 'S NAMF;: ��� �D
V C. NIC CONTR p
ARCHI UOULTNGINEER: lIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
r O /
LICEN UCONTRACrOR'SDECLARATION+ QTY, ELECTRIC PERMIT FEE
C 1 hereby affirm that I vat licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z with Section]000)of Division 3 of the Business and Professions Cale,and my lice me is
I- r infullfarcemadeffect PERMIT ISSUANCE L ❑KITCHEN REMODEL
�UL] Licca.Class Carr APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
ME Dom anuanar
'Dort ARCHITECT'S DECLARATION - ❑MULTI-UNIT [2 STRUCTURAL
I understand my plans shall bo used as blit records PANELS
ZO-a 4)u CHIMNEY
REPAIR oz—, - UNTO 214)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FE W Licarmnl Rofcssmmi 201-IgX)AMPS IMPROVEMENT
X ....11 OWNER-BUILDERexemptDECe Conte ON OVER MOOAMPS ❑BATH REMODE/REPAIR ❑DEMOLITION
PG U. 1 hereby affirm that 1 am exempt from the Contractors License Law for the
"'o 6F followingmmson(Section 7031.5.construct.
Bu sines sand Pe dearmi Cade:Any cityarcounty SIGNS ELECTRICAL ❑OTHER
LL7 n.y which.quires a permit m cnnsweL al¢c improve,demolish,or.pair any swemre In r,_
�y0t� Rod he iiacense purse requis thovisio sofilbe ContremdnLfil icense Low(Cammet) SPECIAL CIRCUIT/MISC, y '
y (comate(commencing
wid Sectio 7 rhe of Division
of rhe Commncesan Professions
Low(s Code)in
W
that
he
engwiNSallon]000)of Divisinn3ofNee,od occOmpl P.Air,as Code)or TEMP.METER OR POLE INST. f -
6 q m a that he is 31.5 b therefrom and far .psis for the alleged exemptium Any viol nal,of ❑NEW BLDG/ADDT�1'ION,�/'1�gD$MOLR VI
iC 4th,
Section
mthan5by any
undredicantrs(S5D mduubjeats the ppplicam macivil pcnahy of POWER DEVICES ❑ j4) �[.j DSERVICE
r more than five ft hunNW tulles(Temp). f
< Lo the w.r of property, employees d,(Sec.tom IMPROVEMENT
xx ❑ prone y y 4) y g compensation. SWIMMING POOL ELECTRIC L1Y�f
FO W it do thewnrk,mode: suucmrctenot sLicenso Lawes no,1 apply
Rosiness ❑OTHER
3 and
property
who
Code:The mes the.r's License Law does not apply to if owner or OUTLETS-SWITCHES-FIXTURES
property who builds or Improves thereon,and who dura such work deed or f Wd for
his own employees,provided that such mentis old w am not fasted or offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.H,howevn,the have
building is at h within one year
or improve
the SQ.PI'.FLOOR AREA 5/SQ.Ff.
owned.]a.)r will hove the burden of proving that he did not build or improve for pur-
poss,of
❑I,trimmer of the property,am exclusively contracting,with licensed o modes i- TOTAL:
construct Lowe pronati apply
704L Business and Professions Cade;)The Contmnon, Li-
whocopwdocsnmapplytourwithaowner ofp.pons who
sedprsuanprovcs Nermn,und QTY. PLUMBING PERMIT FEE 4a
who contracts for each p.jeau with a comnnorts)licensed parsonnt to the Conuactars Cl
License Law. PERMIT ISSUANCE
❑Iamexemp.makt-Sec. ,B&PCfmIblereasnn
ALTER-DRAIN&VENT-WATER IEA)
Dwner Date /9 VALUATION
0 0
WORKER'S COMPf perFI'ION DE Ce folio ing BACK PLOW PROTECT.DEVICE 15"S-1311 I hereby nRrm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certilicam ofConsenl to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
Ounce,is provided for by Section 3000 of the Labor Code,for Ne peRormxnce of the
work for which this permit is issued. FIXTURES-PER TRAP
)r1 haw and will maintain Worker's Compensation benumince,as required by Section
3100 of the labor Code,for o.e permornswe of the work for which this parrot is armed. GAS-EA.SYSTEM.I INC.J OUTLETS OCC.GROUP APN
MY Camerr f Crynpn` ti In'tp cc cTq er and Policy Polcy No: ��1Iq�u7 GAS-EA.SYSTIN-OVER J(EA)
CCRTI FICATE GF EXEMPHON FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRI.WASTE INTERCEPTOR BUIL INC DI ON TEES
(Thiesectinnnmd nut bo romplacd i rhe permit is for one hundred dollars(E 100) GREASETRAP PLANCHECK
m less. O•�O
Toy any then int he anyhammueofthewnsc.rushich Nis permits.'ju ']shall 711
SEWER-SANITARY-STORMEA.2110Ie1'.
not employ any person in any manner so as m become subj¢uo the Workers'Comped- ENERGY
Z smionlnwsof Culifnau.Dute -
�O Applicant WATER HEATER WNENT/ELECTR OR GFEE
NOTICE TO APPLICANT:If,al her makir, his Certificate of Exemption, should
a ^ become subject to the Workers Compensation provisions of the Labor Cade,you must WATER SYSTEM?REATING SOI
{kl G foMwiN comply with such provisions or this permit shall he deemN revoked WATER SERVICE
Q '
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PI'. PAID
UQ I hereby union that there is a construction lending agency for the performance of Date Receipt`+ the work fur which his permit is issued(Sec.309].Civ.C.)
Q (~ Lade',Name TOTAL:
[U[1 [.prices Address 'TOTAL:
I1 I certify that 1 have read this application and suite the the nbovc Infnnnmiop is BUILDIN E QD
to correct.l agree to comply with all city and county ominances and sure laws miming to QTY. MECHANICAL PERMIT FEE O I�
U Z building construction.and hereby milaniac mpoccntutives of this city to enter upon the SEISM IC PEE 1 XII
above-memioned propedy for inspection purpnsa' y
(WO)agree to save,Indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgmems,costs and expenses which may in any way ecce against said City ALTEROR'ADDTOMECH. D-45"
in consequencegreening
of the of this permit. PLUMBINGFEL 73 7
APPLICANT L ERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10.0010 CFM[
SOURCHIZE Tl�� MECHANICAL FLE
SOURCERE TIONS
AIR HANDLING UNIT(OVER 10,10(d)CFM) CONSTRUCTION TAX Lga
Sign m.1'ApplucaphIsCiaturcliur (, e Date EXHAUST HOOD(W/DUCq HOUSING MITIGATION
HAZARDOUS MATERIALS DISCL SURE -
Wiillthe applicant orfuture building occupant smmorhandlehazardous material HEATING UNIT LTO 100,004)BTU)
as defined by the Canadian Municipal Cade,Chaper 9.12,and the Health and Safety
Cade,Section 25532(v)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes JYNo VENTTLATION I'AN(SINGLE RFSID) PAID
Data Recelp M
Will the applicant or future building cecapam use optimum m .00BT
devices which BOILER
District? -COMP(3HP OR 1000 O) LQ^
emit hazadlous air crnuminanu as defined by the Bay Area Air Quality Munagcment T : O /�I O
BOILER-COMP(OVER 100.0.0 BTU)
[3 yes N. t
/a• AIR CONDITIONER
Ihave kedtheh ode.Se mamdW55,2553 and Caspar
tthe Cali- ISSUA
forma Health&Safety Cale.Sections 25505,23533 unJ 2551J.I undersand Na if the NEW RESIDENTAL MECH. SQ.FT.
so III deesr Icurmadyhave a tenant,dent it is my responsibility to notify the occupant
of Ne req. whichhe met prior edific-uoV;v
O rauthorimdt'.1L/ h� to TOTAL ISSUED BY:
OFFICE