28771 APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-F,LECTRICAL - PERMIT NO.
BUILIJING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28771,
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2/390, Val , /�v�'pc r q-z s-9r
OWBERQ ME �Y`/ Z�i� �I2 7 DONEC 'RACTON'S NAhyy//7 LIC NO: .
ATJ! / 'ACTOR\�1JYV]�,l/— NIC CONTROL.
ARCHITECT/ENGINEER: LIC NO: A KESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
R,ek f3d / n C44 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aff that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OCZ with Searn.70 P fDivlslan Sof rhe tlusiness and Professions Qde,andm license is
)" Y RESIDENTIAL:'
Fpp in full farce and effect. PERMII'ISSUANCIi
y.U f- SFDWh [I KITCHEN REMOUEI.
U Daenu Class Contractor
r�%�
�Ci Date Commnur APPLIANCES—RESIDENTIAL 'OADDITION ISr1.VMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTFUNIT []STRUCTURALF,=,ata PANELS
Zpv)Z I understand my planssba0 be used as public reconLs MODIFICATION
pZ—Ns O` UPTO 200 AMPS El INTERIOR [I CHIMNEY REPAIR
F-4tuo Licensed Professional 201-I000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEVREPAIR [I DEMOLITION
C Q 1 hereby al'11rm that 1 am cxmnpt lam the Cummer.,,license Law for the
k 3 i f following reason.(Section 0031.5.Business and professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
which regmres a permit an construct,mime improve,demolifi,or repair any swctum
I"'LLpQ prior to its issuance,also requires the applicant for such Permit o file a signed comment SPECIAL CIRCUIT/MISC.
>,C
t(abar he is licensed pursuant to the pmvisios of the Contmetca,License Law(Chapter 9,
z�G�O smranwingwim Sectian]o00)of Div'.n Sof the Pusiness aaJ Professions Cedcpn 'fEMPI'O
.METERORLEINST. COMMERCIAL:
4E d e C thin he is exempt Ncrcfrom and me asis to a alleged exemption.Any violation of -❑NEW BLDGIADDITION ❑DEMOLITION
tiSection]031.5 by any applicant a permits jens me applicanno a civil malty of POWER DEVICES
not more than five hundred di n($SW). ❑TENANT ❑FOODSERVICE
fb0 F-16nsownpnl'Iheprop ,ormnsmw
ycc loyues i .....as dwi,ode mpenlion, SWIMMING POOL ECT
LERIC IMPROVEMENT '
Fwill do the work.and machine is not intended roffered for sale(Sec.]044,Business ❑OTHER
W 3 m and Professions G :The Contractors Licere Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
. .property who bimproves thereon,and w does such work himself or through
his awn em yeas provided thm such improve ems are not intended ,,offered for NEW RESIDENTIAL ELECTR. SQ FT.
sale.If, rise,the building.,improvement is s Id withinone year efatmpletian,the SQ.IT.FLOOR AREA $/SQ.rn
own mIde,willhave m barren f prowin,th he JJ co,b IJ or improvefar Par-
e of
ar-eof side.).
1 as o er f the Prop, cly r ,I b with licensed r r .to' TOTAL
comborcume p jest(Seo Vt 4 irx,,and Pi ,,icana,Codo)The C nr t :P'
cense Laosa o wacr fpnyyyycccc, ho huildso improver thereon d Q'I'Y. PLUMBING PERMIT FEE
who t f s 3ttt aha to O licensed passage,to the Contractor's
se Lam
]�I uexert n mder$ PERMIT ISSUANCE
ec. B&PC fortis reason
ALTER—DRAIN.F VENT—WATER(EAI VALUATION,
Vaffimi
Dam
wine, WO KER'SC PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
ereby affimi under. any ofOwHmy one onhe following doclarationsnd will maintain 'enificateofConsenttoxclfinsumliaWorkersColnpea- DRAINS—FLOOR•ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
provided for b ection 3]W of the Labor Code,for the perfomunce of thehich this it is issued. FIXTURES—PER TRAP
and wit aintain Worker',s Compensation Insurance,as required by Section
e Lo Cod,for tbsperfornanceof Ne work for which this permit is issued. GAS—EA.SYSTEM.I.INC.4 OUTLETS OCC.GROUP APN
r' ompsnsatim lostaxi cans,and Policy numer arc:
Policy Nu: GAS—LA.SYSTEM OVER 4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAI ION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This rection need not hecomPletW iflhe psnnil isfnronehundred dollars($IIM)) GREASC TRAP
inless.) - - PLANCIiIiCK FEE
I verify that in the performance ofthe work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any persue in any manner sur us to becmue subjwr m the WmkeirContpen- ENERGY PEE r
ZZ saloon Laws of California.Date WATER BEATER WNENT/HLECTR
0 Applicant - - GRADING IEE
y NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WRIER SYSTENVOTREATING SOILS ITE
F become subject m the Worker's Compensation provisions of Ne Uhis,Cede'
you most
canons comply withxnch provision-s-Chia pimut shall be deemedurecked: WATER SERVICE s
Cbl) ,
U z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
Date Receipt.
I,Q khereby for
thi thanhereissued(waion tending agency for Ne performance of
Ne work fm which this permit is Issued(See.309],Civ.C.)'
OU Lender's Name _ TO"fAh:
Lender's I Anifyt
BUILDING FEE
1 certify that I have rcaJ this applicadon and shim Nm the above information is
Z) comet.l agree to comply with all city and county ordinances and%rule rows relmingto QTY. MECHANICAL PERMIT FEE
.C) Z building construction,and hereby auNori'rcreprerhadec,of ho,ily to enter upmme SEISMIC FEE
above-aetnioned property far inspeednn purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless me City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way secure against said City ALTERORADDTOMECH. - PLUMBING FEE _
in consequence of the granting of this permit. D
APPLICANT UNDERSTANDS AND WILL COMP) C ITU ALL NO'-PO AIR HANDLING UNIT(TO b0ufl CFM) g If'
2� �[ MECHANICAL PRE
S(I %REG AT A`J
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTR
reof Applicaot/Contracm, Dans EXIIAUS'THOOD(W/DUCT) HOUSING MI'HGATIONFE.
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicam or future building uccupamsmreon handle benardous material HEATING UNIT(TO 100.000 BTU) r VT*
nd by the Cupertino Municipal Code,Chapter 9.12,and Ns Health and Safety I'VtVEYi)I /l
i7orn
on 25532(a)I HEATING UNIT(OVER I00,0k)BTU)❑Yes ❑No VENTILATION FAN(SINGLE REMO)' PAID
Will thea licamorfurore buildin t uu t or devices which Date Receipt p
pp dby thea, ea Air cn BOILER—COMP(JHP OR IW.OW BTU)'mit haair canmminants as ddined by the 11ay Area Air Qualiry Manugemenr TOTAL:
)ialnletEl
` BOILER—COMP(OVER 100,000 BTU)
❑Yes ❑No
AIR CONDITIONER
I have mad me hazardous mmmim%mquiremems under Chapter 6g5 of he Cali- ISSUANCE DATE
fi mla Health din Safety Code.Sections 2.1505 25593 and 25534.1 understand thW If Ne NEW RESIDENTIAL MECII. SQ.FT.
building does not currently have tenant,that it -my resInarsibilay to notify the occupant r p/
of de,segmremems which mustbe criet prior t .. fa Certificate ofOccupancy.
Owner or authorized age m Das TOTAL: ISSUED BY:
OFFICE '
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