28700 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. LOo r 2 8 7 0 0
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: 'SANITARY NO. APPLICATION SUBMI rFAL DXFI
10317 VISTA 1<NOL L 6L-VD S 1,tsiii,C]
OWNERS NAME: PHONE: CON'TRACTOR'S NAME: LIC NO: NIC CONTROLM
W • S-r^ts�Z Z 5-2577
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
0 C NIn•4
CONTACT: PHONE: BUILDING PERMITINF0
❑.Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M1EECCH�
❑ ❑ ❑ yq
LICENSED CONTRACTOR'S DECLARATION Q•fy. ELIiCTRIC PERMIT FEE
1 hereby affirm that I am IicenseJ under.d Padonn of Chapter 9(commencing JOB DESCRIPTION
O a'Z with Section]000)of Division3ofthe Businesx onJ Professions Cade,entire license is PERMIT ISSUANCE
00 y RESIDENTIAL:
n full agree and effect.�UI'" License Clnsx Lic.N - CSFDWL CKITCI1EN REMODEL
II--�� nl Dote Contractor APPLIANCES-RESIDENTIAL ❑ADDITION CPLUMBING RF.-PIPE
Zptzn7, I understand my piatn,hal To codes pubfcrecons PANELS RATION CMDLTI-UNIT El STRUCTURAL
TION
oz-, UP TO 2 W AMPS
El INTERIOR CCHIMNEY REPAIR
Uccrucd Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER I ma
Dt the RATION OVER IIIW AMPS
tX� I hereby affimt that I um exempt front the Conaucmrs License Law Bm the El BATH REMODEI/REPAIR ❑DEMOLITION
3 a F following reason.(Section 7031.5,Business and Pro(essim s Code:Any city ar county SIGNS ELECTRICAL []OTHER
.LL.C which requites a pertain to conoruct.alter,improve,demolish,or mpai y nrucmrc
y0� prior to its issuance,also requires the applicant for such permimo file it vi
g wamem SPECIAL CIRCO I I'/MISC.
vyW�I p. that he is licenpursuant ns en
sed pursuano the previsions;of the Commerce,Licxe �shapar9
yj 4'pp (commencing with Section]0007 of Division the Basin rd fie 'o Mr)nr TEMP.MLTER OR POLE INST. COMMERCIAL:
a thin he is exempt Ihcrefmm and the basis for the a11erM ex a violation of C NEW BLDG/ADDITION C DEMOLITION
EE Section 7031.5 by any applicant for a permit xubjeca the t t civil penalty of POWER DEVICES
F-ZY re then five hundred dollars($500).
❑TENANT [I FOOD SERVICE
C� ,"owner ofthe progeny,army employe we .as Neil ame wto uo, SWIMMING POOL ELECTRIC IMPROVEMENT
ii a work,and the structure is not in n r fire braale(Sea lD44, COTHER
and Professions Code:The Contractor's uw does not apply ouppee f OUTLETS-SWITCHES-FIXTURES
0' property who builds or improves thereon,and wh ocs such work hi If thaw
his awn employees,provided that such improvnn arc not tended hired for NEW RESIDENTIAL ELECT R SQMI
' sale.If,however the building or improvement is sold within�T ar oma etioaJhe SQ.FT.FLOORAREA $ISQ.FT.
owner-builder will have the burden of proving that he did nd'�u I reprove for pur-
pose of rale.). \
❑1,as owner of the property,am exclusively contracting with licenced conductors a TOTAL:
construct the project(Sec.7044.Business and Profusions CWe)The Conmactots Li-
sense Law does not apply toanowner ofproperty who builds or improves dereon,and QTY, PLUMBING PERMIT [ZEE
who enma¢is for such projects with a commmarta)IicenseJ puromm m Ne Contracmr'x
License Law. I PERMIT ISSUANCE
C lame cm t ec. ,B&PC Builds reason
DA Date ALTER-DRAIN&VENT-WATER(EA)
O g yA�AT10N
WOR MPEN. fCLA
ION DRATF BACK FLOW PROTECT,DEVICE
I hereby affirm and ally olperjury,one of the fallowing declarations: C'
❑ I have and will maintain a Certificate ofConsenuo self-insure for Worker's Coupon. DRAINS-FLOOR,ROOF,AREA,COND. STORIES- ONSTRUCTION
ana9 ion, provided for by Section 37M of the Lubar Code,for Nance e performof the •,
work for which this permit is ismd. FIXTURES-PER TRAP //'YU nn',
F have and will maintain Worker's Compensation Insurance,as required by Section
3700ofthe Labor Cde,for Ne pedomancenfthe work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC..GROUP APN
My Warkr's Compensation Insurance carrier and Policy number an:
Carrier: iPolicy No.: GAS-EA.SYSTEM-OVER 4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEtINDUSTRL WASTE INTERCEPTOR
CDtis section ted not h rmtridetd ifthe pemsit is(orane hundred dollars($100) BUILDING DIVISION TEES
nr less.) GREASP.'1'RAP PLANCHECK FEE
I certify and in In,performameaf Ne work for whieh,hia permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
Out employ any person in any mannN
manner m as to become subject to e Worker%Compen- ENERGY FEE
OZ saliva Lawaof Califomis.Dam WATER HEATER W/VL'NTMLF.CfR
Z Applicant GRADING FEE
ti NOTICE TO APPLICANT:IL after naking this Certificate of Exemption,you should WATER SYSTEM)TREATING SOILS FEE become subject to the Worker's Compensation provisions of the Labor Code,you must
W forthwith comply with such provisions or this permit shall he deemed revoker. WATER SERVICE
0. Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PI'. PAID
.I he
rebywhich thi that them Isom,
ixuce(Sce.ti0leading agency for the perfommntt of Ume" Receipt Ji
the work far which this permit iz issued(Sec.309],Ci,C.)
O Landers Nemo I TOTAL:
L) Lender's Address TOTAL:
OWi I certify that 1 have read this application and state that Ne above information is BUILDING FEE
to correct.I agree to comply with all city and county announces and sate laws relating in QTY. MECHANICALPERMIT FEE
U building construction,and hereby authorim representatives of this city it)emu upon the SEISMIC FEE
above-mentioned property for inspection purposes. \ PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgmena,costs and expenses which may in any way accrue against said City g1.TER OR AUD TO MF.CH.
in eminal emce of the gaming of this permit. PLUMBING FEB
APPLICANT UNDF ANDS A 'IL -O Y WITH ALL NON ' NT PIR HANDLING UNIT(TO 10,000 CFM)
S01' C RF. 1 S. /� G MECHANICAL FEE
7/7 AIR HANDLINOUNIT(OVER I(),(MCFM) CONSTRUCIONTAX
gnaare'd pplicanUContn nor Dam EXHAUST HOOD(W/DUCT)
HAZAR rTERIALS .CLOSURE HOUSING MITIGATION FEE
Will the epplicam ur faun uilding occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health gad Safety
Cole,Section 25532hd? HEATING UNIT(OVER 100,000 BTU)
❑Yes r7 No VENTILATION PAN(SINGLE RESID) PAID
Will the applicant m fuare building occupant use cquipmem.,devices which Dote Receipt 0
Ld�snm
nt hnous air Content
its defined by the Play Arca Air Quality Management BOILER-COMP(3UPOR 100,000 BTU)
TOTAL:
a []No BOILER-COMP(OVER 100,000 BTU)
ve reed the hazurdons mmeriala requirements under Chapter fi95 of the Coli- AIRCONDITIONER ISSUANCE DATE
h&Safety Cone,Sections 25505,25533 and 25534.I undersand that if the NEW RESIDENTIAL MECH. SQ.pL
s not cummly have a tenant,Nat it is my responsibility m notify the occupant
rements which must he met prior m issuance of a Certificate of Occupancy.
thanzed agent Date AL. ISSUED BY:
OFFICE