28455 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO; _^
BUILDING DIVISION APPLICATION/PRRNIIT PLUMBING-MECHANICAL "' . 2
BUILDING PROJFECI' D ENTIF'ICATION
BUII.UINGADDRESS: - - - SANITARY NO, APPLICA'r1ON SUBMITTAL DAT[
1?R'S NA f^
PHO 'TRA )R'S ME: - LIC N0:
ho _ NIC CONTRULp
CH GIN R: LIC NO: ADDRESS:, ❑ -
CONTACT. PHONE: BUILDING PERMIT INFO
L�(.� E] Consuhant Fees Paid by AppliceRt(Initial) BLDG, ELECT - PLUMB MECH
ee
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby effort Nat l tan licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ will,Section 700E of Division 3 of the Business and Professions Gude,and my herowm RESIDENTIAL:
O . . y PERM[f ISSUANCE R
in fiat I fora and ulibc,:
JF.0 Limns Class ' Lic.M ❑SFDWI. [I KITCHEN RCMODEI.
Vf<6 Data - Camrvcmr APPLIANCES-RESIDENTIAL
Z ❑ADDITION ❑PLUMBING RE-PIPE
pi,o
ARCHITECTS DECLARATION C MULTIUNIT C STRUCTURAL
ZO >> Iundcrsmain,y plans shall be used as public records PANELS MODIFICATION,
OZ-`, ' v - - UP TO 200 AMPS -
yr.- Licensed Professional 11 INTERIOR [I CHIMNEY REPAIR
E50YG -aJ 301-1001)AMPS. PROVGMENT
OWNER-BUILDER m Ce C.aniON OVER 10N0AMPS TH REMODEUREPAIR ❑DEMOLITION
LL �a. I hereby (Section 11. exempt from the Convn,Cod License la,w vo 0w
pd 3 ti U following reason.(Section]OJ LS,Business unA Professions Crile:Any city or uonnty SIGNS ELECTRICAL OTHER
wall`O which requires a Pr mi,m Imimnuct,ahcr,improve,demolish,or repair any s,mcwre
prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUTVMISC.
yy. tba,he is licensed pureuammthe provisions of,he Contractors License Law(Chapter 9
T ai (commencing with Section 7000jof Divi.siiin3 of the Bust nese and Professions Gude)or TEMP.M ETER OR POLE.INST. ,COMMERCIAL:
ca that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION C DEMOLITION
t4 Satinn70JLsby unyapp!natatfor a permit subjecis the appliann„o a civil pealry of POWER DEVICES
^so ❑TENANT ❑FOOD SERVICE
11FF...... no,mom than five hundred dcllars(8510). ,IMPROVEMENT
q 6 D l,nsow.rr of the propeny,or my employees with wages aa(hetr so le cnmpensminn, SWIMMING POOL ELECTRIC
ra ,
will do the work,and the scture is not intended or offered for sale(See.71,/4,Business OTHER
3 and Professions Cede:The Contractors License Lew does no,apply to an owner of OUTLETS-SWITCHES-FIXTURES '
property who builds or improves thereon,and who does such work himself or through - A
.his own etnployees,provided that such improvements are not intended or offered for NEW RESIIIENTIAL ELECTR SQ FT. /V
sale,If,however.the building or Improvement is sold within oneyearnfmmpletion,the - �'I/ FLOOR A#EA - 9/RQ.ET.
wrier-huilder will have the burden of proving that he did.,it build or improve for par-
poseafsale.).
❑1,as owner of the properly,am cxclmivcly contracting with licensed convectors m �_ Gj( •�)'. '
c ..trucuhe project(Sea 7044.Iuminegs and Proprietors Ccde:)Thu Controcmr's LI
cense Law does not apply to an owner of pmpeny who builds or improves thereon,add Q'T'Y, PLUMBING PERMIT PEE ice:. Ga t�p
whocontrectsforsuch pmjecu with a contractors)licensed pursuam to the Contmeres
License low. PERMIT ISSUANCE -
C1umexemptunderSec. ,B&PCfim JHsmmnn
Owner Date ALTER-DRAIN&VL'NT-WATER LEA) S .11 s ,t _
VALUATION
I, WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT,DEVICH
I hereby affirm,under Penalty of perjury one of the following declamations:
].I have and will maintain o Ccfffcum of Consent to self-insure for Wtomes Cnmpce. DRAINS-'FLOOR,ROOF,AREA,COND.
sation,as provided for by Section 37M of the Labor Code,for more perfmance of the STs..' TYPE CONSTNUCIION
work for which this Penni,is issued. FIXTURES-E'ER TRAP -
CI have and will romemin Workers Compensation Insurance,a mquimd by Section
37M of the Labor Code,for theformance of work for which this penal,is issuul, GAS-EA.SYSTEM.I I INC.4 GO r1.ETS
Per. OCC,GROUP' APN
My Worker's Compensaion Insurance carrier and Policy nnmher are: _
Cartier. - Policy No.: GAS-EA.SYSTFN-OVER4EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPEiNSXfION INSURANCE GREASPIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION P[?PS
'('Ihissectionneednmbecnmple,ediftheperi,isforonehundreddollaripSI(NE GHEASE'1'HAP
or less,l - - PLANCHECK FEE
I cmifythatinthe perforvna of the work for which this permit is issued,l shall SEWER
not employ any person in an manner so as to hecame subject m the Workers'Com m SANITARY-STORM 1?A.300 FT. ,
Y h pe IiNERGY FEE
O ,� Applianwx of Colilixnia.Date
' WATF,R[]EATER WNF.NT/CLECfH
O
Applicant - GRADING FEE
y NOTICETO APPLICANT If.after Air,this Cenifieme of Exemption,you should WATER SYSTEWTREATING
1^' become subject to the Worker's Compensation provisions of the Labor Cole,you must SOILS FEE
0 (onhwi,h comply with SucM1 provisions ar this permit shullMdeemeA revoked: WATGRSERVICE 11
CONST RUCTION LENDING AGENCY NEWRESIDEWIALPLMB. SQ.FT. PAID
U O Thereby of rrnthathen,is a conswc,ion leadinga,nis,fmma Perfomance of Da,e RaeiptM
W. d-' the work for which this permit is issued(Sea.3097.Civ.C.) Cl Lid -
C)U Lcnder(s Name TOTAL:
1 mho's Address' „ 1
f,,� I certify that I have read this application and state that Ne above inforaion is - BUILDING FEF. Cr e—
.-IN cortect,Iagmcmcomply wim old city andcoumy mishooncn and Stam laws relating to QTY. MECHANICAL PERMIT FEE
.0 buildingeanswcmm�,,mdherehy awhorite representatives of this city to enter upon me SEISMIC PCH ' ' •
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(Lac)al m save,indemnify and keep horless Oe City of Cupertino agates, M.1!M C FF.E
liabidities,judgmenu,costs and expenses which may in any way acme against said City p1:TER OR ADD TO MECH.
in asequence of the granting of this permit. PhUMBING FIJI: '�.
APPLICANT UNDERSTANDS AND WILL C OMPLY WIfT ALL NON-POINT AIR HANDLING UNITOPO I0,M)CFM)
501" ERCGUhAT .5MECHANICAL FRE 2F SP
as
/�//ls r ••// AIR HANDLING UNIT(OVER 10,1X10 CFM) CONS TRULTJUN.TAX
S' numrca pplicnnJCnntructor )m HXHAUS'1'I IOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle htoomus materod HEATING UNIT(TO I W.000 BTU)
as definal by the CuKriino Municipal Cole.Chapter 9.12,and me Health and Safety
Caine,Section 2553200? I EATING UNIT(OVER I l(N),CW BTU)
❑Yes, No - VENTILATION FANS INGLE RESID) PAID ,
Will the applicant or furore building occupant use equipment'or devices which -
Date Receipt I
:mithumaink s air fmairmainm of dcfned by the Bay Area Air Quality Management
BOILER (3HP OR 1f10,fNq RTU). 1
TOTAL:
n Disvic El ' I BOI1 ER-COMP(OVER 100,000 BTU) '
C Yes' � ❑No -
Ihovereadthe hamrdous mmeials requirement under Chapter 6.95 of the C.H.' AIH CONDITIONER ISSUANCE DATE
humin Health&Sam,,Code.Sections 25505,25533 and 25534,I understand that if the t -
mildirsalasnotcurrcml have a whom,Nm i,is m NEW RESIDENTIAL MECH. SQ.FT. .
b Y my pancy.
of Ne requirtn,acts which most be ext priormissuenre ofa Ceruficae nffkculn,cy. ��'�/�/`� y
Owm lo,ma ni,mc a,an Date ISSUED BY'�/g,Js?�.�
OFFICE s