28983 APPLICANTTO FILL IN INFORMATION.WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEiRTINO v BUILDING-ELECTRICAL PERMIT NO. 28983
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BUILDING DIVISION' APPLICATION/PERMIT - - PLUMBING-MECHANICAL /Q Q 8 .(
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PROJECT IDENTIFICATION L V V V
BUILDINGADDRESS: lr SANITARY NO. APPLICATION SUBMITTAL DATE
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Z�' OWNER'S NA PHONE.PHONESd CONTRTOR'S NAME:. LIC NO:
L\: Cu-WS,O N ." I-WO a A, 5,
N/ CONTROLN
ARCHITEUDENGINEER: LIC NO: ADDRESS:
? 2q Wzarielj. . - 'l
a CONTACT: - - PHONE: ' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
11 El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Nat 1 am licensed under provisimi of Chapter 9(commencing JOB DESCRIPTION '
Wcd with Section 7001 ofDlvislon 3 ofthe Business and Professions Coda.md m,Hearst,is RESIDENTIAL:
0 in full force and effec Z PERMIT ISSUANCE
�UV License Cla' Lic.b ��.3 S „ „ ❑SFDWL ]KITCHEN REMODEL
IOU Dace Contras a I n OD APPLIANCES-RESIDENTIAL El ADDITION [3 PLUMBING RE-PIPE
y ARCHITECES DECLARATION- PANELS ❑MULTI-UNIT 0 STRUCTURAL
Z�j rr�'� 1 understand my plans shall be used as public recoids MODIFICATION
O Z� UP TO 200 AMPS
E'
all Licensed Prafcssional ❑INTERIOR [I CHIMNEY REPAIR
¢a OWNER-BUILDER DECLARATION OVER
AM IMPROVEMENT
^+ st I hereby affirm that I am exaction from the Commacu's License Law for the OVER 1000 AMPS El BATH REMODEVREP [I DEMOLITION -
iqg504U following rainum(Section 7031.5.Business end Timms (Any city or county SIGNS ELECTRICAL ❑OTHER'
r+13 4 F which mquims a permit m'conswcl alter,improve emMieo,or tar any mortme
II 0, prior no it issuance,also requires the applicant for. ch,madittofilea.' nedstatement SPECIAL CIRCUIT/MISC.
a3£ What M1e is licrosed p.......he provisions of CMntmcmr'a LicenaeL (Chepter9
00 (commencing with Stanioo]dW)o[Divisioo3 thelocuntexand Professit Code)or TEMP.METER OR POLE INST. COMMERCIAL: -
4 4 m that he is exempt therefrom and the basis fa a alleged exemption.Any vi anion of
El NEW BLDG/ADDITION [I DEMOLITION
W^« Senion]031.5 by any epPlicanc fur.e perm' subjedsthe spplicannoacivil pe Try.(of POWER DEVICES ❑TENANT ❑FOOD SERVICE
.nal more than five hundred dollars($5W
' - IMPROVEMENT
60 O
Its owner ofthe property,.,my e' oyeeswithwagesasthelrsolecompensa n. SWIMMING POOL ELECTRIC
wtildothework,anlfficarnewriva mmndeJ nndferW for sale(SecA044.Basin ]OTHER
m end PoMessious Cale:The Contra is License Lew does not apply to an toward OUTLETS-SWITCHES-FIXTURES
�' .. property who hoilds or improves and who d«s such work himself m through
his own employees,provided t such improvements are not intended or offered for ,NEW RESIDENTIAL ELECTR SQ EL
r sale.ILhoweveg the building improvement is sold within one year Mcompletion,tae SQ.IT.FLOOR AREA, $/SQ.IT..
owner-builder will have toe Nen of proving that he did not build or improve for pan `
From of sale.). t >AVID i
I,as owner of the pr rty,am exclusively contracting with licensed contract gy i TOTAL: I
.or The project( .]04Q Business and Professions Code:)The Conamen.s Li-
whe ta taw d«snot ply m an owner of propatty who bol s itnpmvcs the T. PLUMBING PERMIT NEE 0 41995
ocontmetsfors It projects with a c«lractorio bens araanua the Co o
License Law. PERMIT ISSUANCE y' Y�
❑[am exam under Sea .B&PCfor bis reaso �'�f
OwnDare -fIIINV
ALTER-DRAIN&VENT-WATER TEAT CITY VALUATION
er '
WORKER'SC PEN ECLA TIONI BACK FLOW PROTECT.DEVICE
Thereby rrmunderpma of 'u worth 9'oil wmgdeclamtions:
•�Ihave andwil aintaina Certi onsemr.od-inst�cjer Work&,C pen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,ns provided n by Secti a Lhur Cu f he perfurmanc of the -
workforwhichthisp it is issued. FIXTURES-PER TRAP
❑I have and will mar rain Worker's C p sation Insurance,as required Section
37X)ofthelabor Code, rthepearsomen ofthe work for which this per issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP t APN
My Worker's Compensanio Insurance carrier and Policy number arc: -
Camiee me Policy No.: GAS-EA.SYSTEM-OVER 4(TOO -
CERTIFICA -OFEKEMPTION FROM WORKERS'
CO ENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
t (This.0kanmdwa1xa mpletedifNepermitisforanehund ddellam($ItlO) - BUILDING DIVISION FEES
orlow.)l GREASP."TRAP - PLANCHECK FEE -
Icertifythatintheperforma a.fdo"orkanwhichthisper it is issued,(shall SEWER-SANITARY-STORM EA.2W FT.
not employ person's m mance o as to became subject to Workers'Compm- ENERGY FEE
p'Z vocrn laws elifor . ae _ ' WATER HEATER W/VENT/ELECTR
Applicata GRADING FEE -
NOTICE TO LI AN :IL eftei makit this Certificate/ Exemption,you should WATER SYSTEMAT EATING
abecome subje o the Worker's Compensmio cavieions lF Uc Labor Cale,you must SOILS FEE
{kI forthwith co y with such Provisions or Nis pe Anel a l be deemed revoked. WATER SERVICE' -
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CONSTRUCTION LENDING AGENCY' NLW RESIDENTIAL PLMB. SQ,E, PAID
U O Ihereby affirm that them is a construction lending agency foi the performance of Data Receipt#
the work for which this Permit is issued(Sec.3097,Civ.C.)
O U Under'a Name � TOTAL:
fTJ Lender's Address
L1•r I certify that I have read this application and state that the above information is BUILDING TEE
(4 correct.l agree to comply with all city,and county ordinances and state laws relating at QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives Michas city to enter upon the SEISMIC FEE
shom
ve- entioned property for inspection purposes. •1. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way aceroc against said City ALTER ORADDTO eqMECH. '
in onsuence of the granting of this Permit. PLUMBING FEE
'I APPLIC NT UNDERSTANDS W L COMPLY WITH ALL NON-P INT AIR HANDLING UNIT TO 10,CW CFM) -'
SOUR LATIONS MECHANICAL FEE -
AIR HANDLING UNIT I0,000CFM) CONSTRUCTIONTAX
igrwum Mf Appli bConmwmI" ' I IOf EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
-Will the it. or future building occupant store or handle hazardous material _ HEATING UNIT(TO 100,00)BTU) -
as defined by Ur ri,camo Municipal Code,Chapter 9.12,end the Health and Safety -
Cod a,Station2532(a)9 HEATING UNIT(OVER 100.000 BTU_) -
❑Yes No
e VENTILATION PAN(SINGLE RBSID) PAID Dem Recelptx
AIM Will no applicant or future building Mccnpmt use equipment or devices which BOILER-COME OHP OR IW,000 BTU)
mit Immrdous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District'? BOILER-COME(OVER 100,000 BTU)
(]Yes ❑No -
tA1RCONDITIONER
(have mad the hazardous materials requirements under Chapter 6.95 of the Cali- ISSUANCE DATE '
fomia Health&Safety Code,Stations 25505,25533 and 25534.1 understand that if the' NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a tenant,that it is my responsibility to notify the occupant
MF the requirements which must h tact prior to issuanm of a CSNfiwte of Ocwpancy. .
Owner or authorized agent "Date TOTAL'. - ISSUED BY:
" OFFICE