28513 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. I
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. ; . 285 '13
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SHBMI'FI'AL DA'Z'E
jig
1 ']'71 LoiflIT4 ALIC• C 'V,
OWN 'S NAME' }]109 ' r CONTRACTOR'S NAME: LIC NO: -
N/C CONROLM
ARCHITECDENGINEER: LLC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FOCZ with Section]00o)of Division 3 ofthe Business and Professions Code,and my license is - RESIDENTIAL:
OO in full farce and effect. PERMITISSUANCE ���
W SPDWL ❑KITCHEN REMODEL
F-UU License Chea - rame lm APPLIANCES-RESIDENTIAL ADDITION EI PLUMBING RE-PIPE.
F-Q d Date-C C1'S DE
ARCHITECTS DECLARATION PANELS ElMULT4UNIT C1STRIILTURAf.
Z O to Z 1 undern3nd my plans shall be used vs public records MODIFICATION
OZ,�O UPT0201AMPS
[I INTERIOR ❑CHIMNEY REPAIR
F4LW Licensed Professional 201-1000AMPS IMPROVEMENT
a OWNBR-BUILDER DECLARAT [I ❑
3ION OVER 10n AMPS BATH REMODEUREPAIR DEMOLITION
C O w Q I hereby affirm I am exempt from Ne,Cmurcturs License law for the
LL F m But,
reason.(Section]031.5.Business and Professions Cade:Any city ar county SIGNS ELECTRICAL [I OTHER
m which requires a permit to conswm,aher,improve,demolish,or repair any noicmre
.b.��� prior to its issuance,also requires the applicant for such permit to file v signed statement SPECIAL CIRCUIT/MiSC.
f y thin he is licensed pursuant o me provisions ofthe Cormoctora License Law(Chapter 9
IyW (commencinCIOg with Section 90W)of Division 3 ofthe Business and Professions Code)or TEMP METER OR POLE INST.
6 y cy thin he is exempt Therefrom and the basis home alleged exemption.Any violation of 7NEWLDG/ DUITION ❑DEMON
Xmta.
Section 7031.5 by any applicant for a permit subject the applicant to a civil penalty of POWER DEVICES
W^rn T ❑FOODSERVICE
notmomNanfivehundreddollars(5500). SWIMMING POOL ELECTRIC VE NT
�I as xw.,k,wner Rhe property us My i...t i h y lh reds nerd m'Mime,ill do lesionsander mvcmreisnonme d d row does I,, Ppl,Sec to an.. e,4
L 3
and Professions Cede The Co,mervn Unease La .nes n t pply T an awn r of ' OUT LETS-SWITCHES-FIXTURES L s
Property who builds in improvth thereon,and who nts such work himself or red for
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTS SQ FT. ,
sale If,however Be building or improvement is sold within one Year ofcompletion,me (S .FT.FLOOR AR IfS1 .W.
owner-builder will have the burden ofpPoing That he did not builder improve for par- n
p ase f 1. TOTAL:3/,
1 f thepr PcnY am a lu.' sly< nTracrn8 with licensed t tors to u ^ f
nein uh 3 Irt(Sx 9014 B ' d Pn fc de,:Cothe C ere T rs LT lN/A�.
c Ise Law does not apply it) ref property who builds oriniprovesthereon,and QTY PLUMBING PERMIT FEE
who n tfesuchproject, itha comms f)li,cPwd Pursuant auditCmrneme, _
License Law. PERMIT ISSUANCE
❑ I ran exnaso
npt under Sec. ,9&P C for thin ren
O n r ALTER-DRAIN&VENT-WATER 0EA) VALUATION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby.]firm under penalty of perjury it,of the following declaration,: V l�
I have and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND.-
sation,as provided for by Section 3900 of the labra Code,for Ne performance of The - STORIES TYPE CONSTRUCTION
work for which this Permit is issued. FIXTURES-PER'FRAP
0 1 have and will maintain Worker's Cnmpdnsrtion Insurance,as required by Section -
37M fine labor Cei fee the perfomare,afba work for which this permit is issaad. GAS-EA.SYSTEM-I INC.4 OUTLETS IXC.GROUP APN
My Worker's Compensmmu bomarre carrier and Iblw,number are:
Carries ' Policy No.: OAS-EA SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR -
BUILDING DIVISION FliliS
IT section need not lin ttndpWCA iRhe perininte for lac hundreddollars(5100) GREASE'1'RAP
ser Ices, PfANCHECK FEE
I certify that in me perfonnanx ofthe work forwhich this prmi is issued[shall SEW EA.2W FT.
not employ any person in any manner,vn its to become subject wife Worker.Cnmpen- ENERGY FE17
O Z ..tion Laws of California.Date WATER if3ATER WNENWELECTR GRADING FEE
Z Applicant
M NOTICE TO APPLICANT:If,after making this Certificam of Exemption,you should WATER SYSTEIA TREATING -
,� , become subject to the Worker's Compensation provisions of me 111hnr Code,you most SOILS FEE
roPermit Enhwith comply with such provisions or this Peit shall he deemed rev'kW. WATER SERVICE
aQ
CDNhemis aTIONLENDINOACENCYo NEW RESIDENTIAL PLMB. SQ. PAID
.7 Z [)are Recciptp
V I farwhicfrm that issued(Sectionlending agency for Performance of
the work for which this permit is issued(Sec.3097.Civ.C.) -
{A F lender's Name - TOTAL:
U Lender's Address TOTAL:
1 certifthat I BUILDING FEE
have read rats applicaion and eta¢mal the above information is
.F. Tit correct.I agree to comply with all city and county ordinances and%true laws refining to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby aunhinue representatives oflhisclty in emerupot the SEISMIC FEE
aMve-mentioned property,for inspection purposes. PERMIT ISSUANCE3
(We)agree ser savq indemnify and keep harmless me City of Cupertino quemt�Ji F.LECfRIC FEE
liahilities.judgmems.costs and expenses which may in any way accrue against said City ALL ER OR ADDTO MECI{, PLUMBING FEEin asequence of the granting of this permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,010 CFM) - MECHANICAL FEE
SOURCE RGGULATI NS, e.
SAIR HANGLING UNIT(OVER 10,000CFM) CONSTRUCIONTA%
Signature of ApplieanVContruium Data EXHAUSTHOOD ONMUC) HOUSING MI'rIGAT10N FEE
I IAZARDOUS MATERIALS DISCLOSURE'
Will the applicant or future building occupant store or handle hazardous mamrial HEATING UNIT(10 100,00E B'N)
as hefted by the Cupertino Municipal Cade.Chapter 9.12,and me Health and Safety
Code,Sermon 25532m)p HEATING UNIT(OVER 100.000131U)
❑Yes - ❑No PAID I
NT
EPW
VEILATION FAN(SINGLE RESID) Dote Receipt#
Will the applicant or future building occupant use equipment or devices which
01 emit hazardous air camtaminan,as defined by the Nuy Area Air Dimity Management BOILER-COMP(]HP OR 100.000 BI �J'
Dional TDTAL: 3� (,
AUG
❑Yes ❑No
BOILER-COMP(OVER 100.00(i
A IR CONDITIONER
Ih adtheh ab to M05. I. d 1h1 un 695 that Cali- CITY (,Ji' VVII$SUANCE DATEV
Tom a Heald&Safety Cod Sect 25505 is my d 255th.I understood that if the NEW RESIDENTIAL MECH. SQ.FT. If\I
buildingdx.not comedy h: tenant.that l Y c.pu M1IryT i fY the cupaaT
ofm�gq ms subs gM: pit t s. ante nfa Ccnifcalyyl p�c`�' ps, ' ''-'
)wnermvmheriud.libb Date TOTAL' ISSUED BY:
OFFICE