28868 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. X86
t8^a�a a� ^ /N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. LSVS
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRF4 SANITARY NO. APPLICATION SUBMITTAL{OTT
OW R:ti 111.1. PHONE: O ACf N'S ICy � � v+
6 NIC CON/TR Lk T
LIC NO: ADDRESS: 1:1 e)r U
CONTACT: PxoNe: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT PLUMB MECH
i/� /riwgrX/ ❑ ❑ ❑
LICENSED COM RACTOR'5 DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby arBmr Had I am licensed order pr , a i of Chapter 9¢ammencing - JOB DESCRIPTION
WOO with Section T(XIU)of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL:
Fel- infullforccand' I. PERMIT ISSUANCE
QUU License Clara Lie CSFDWL C KITCHEN REMODEL
F�W Date---1�Contractur APPLIANCES-RESIDENTIAL Ll ADDITION E:1 PLUMBING RE-PIPE
rn ge ARCHITECT'S DECL.ANAi N
FOm PANELS CMULThUNIT CSTRUCI'URAL
Z 0�2 I undersmnd my plans shall he used as public records MODIFICATION
OZ-Cl UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4t:W Licensed Professional 201-10WAMPS IMPROVEMENT
gmf� OWNER-BUILDER DECLARATION
C C 6 I hereby affirm mm I um exempt from the ConvectorOVENIgX1AMP5's License Law for the C BATH REMODEUREPAM C DEMOLITION
1S O L U following mason(Section 7031.5.Business and Professions Code:Any city or county SIGNS F.LF.CI'RICAL []OTHER
W 3 W y which mquirec o permit In conswn,alar,improve,demolish,m repair any strvetum
E'!!:0o7)
=-y; priormits issuance,also requites the applicant rnr sucM1 permiuofleasigneA sta¢mcm SPECIALCIRCUIDMISC.
F amat he is licensed pulsuanl to me provisions of the Contractor's License Law(Chapter 9
OWCcepO (vemm,neing with Section?00))of Division 3ofine Basinars and Professions Cde)nr 'IEM 1'.METER OR POLE INS'1'. COMMERCIAL
5.6 ey� that he is exempt therefrom and the basis far the alleged exemption.Any violation or
Xm4. Section 703156 ❑NEW BLDG/ADDITION OLITION
y any applicant for u permit subjects the applicant m n civil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
FZy nut mot,man five hundred dollars($500)l IMPROVEMENT
C Las ownenofthe pmpcny.or my employees with wages expreer sole cmopereation, SWIMMING POOL ELECTRIC
F-. will do me work,and the structure isnot inatodedoroffeted ke,ale(Sec.]014.Business COFFER
and Professions Gide:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a progeny who builds or improves themon,and who does such work himself nr throughrc -
his own employees,provided that such improvements anot intended or offend far NEW REST ELECTR SQ FT.
aaR.If.however,the building or improvements sold within one ycarofeimpletion,the SQ.FT.FLOOR AREA $/SQ.Fn
owner-builder will have the burden of proving that he did not build or improve for par-
,rose oLsaleJ. x
C Las owner of the property,am exclusively contracting with licensed contractors m TOTAL: -
snawn the projwt(Sec.?1H4,Business vnJ Profession Gdc:)The Conwemr'x Li.
cause Law does not apply loan owner of pmpcny who build;or improves thereon,and QTY. FLU 1 ,PERMIT FEE
who commaas for such projects with a emtmmu
et00%)licensed punano the Commclor'sRia GGl
License law. PERMIT ISSUANCE
1.,it exempt under Sec. ,B&P C far this eason
ALTER-DRAIN&VENT- ATT? )
owner Data VALVIOJ/v��
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE ���(JI
Ihcrthyal maifirm undertaina enaltynf ofConencolllf-insowingdeclurutions: it I v y O/q� r
❑Ihave and will mainminaCeniacale ofConsent Worker's Compete DRAINS-FLOOR,NOOP.AREA,GOND.
cation,s provided lir by Section 3]1X1 of the Lila,Code,for the pa furmm�o,of the STORI -' tit /TY ECONSTRUCTION
work far which this permit is issued. FIXTURES-PER TRAP
C 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700of Ew Labor Cuda fon he isadmamanccofthe work for which this parrot islswcd. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AIN
Workat ,yi�l 'uom
ce cae and Polcy No.: GAS-EA.SYSTEM-OVER 4(EA)
Caner: BB Im5
CERTIFICATE OF EX EM PTI ON FIR OMWORKB t5'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need ma be completed tribe permit is forooe hundred dollars($100) BUILDING DIVISION FEES
or Iasi.) - GREASE TRAP PLANCHECK FEE
I certify that in the any man n r a)the work for which this permit is issued.'Co I shall
a",employLoy any penoniny rtmnner.a:usmbecome subject Workers'Compen- ST:WGR-SANITARY-STORM EA. FT.
,� cation laws of California.aData ENERGY FEE
ZO Applicant WATER HEATER WNEN'DELECTR GRADING FEE
y NOTICE TO APPLICANT.If.after making this Carriacou,of Exemption,you should WATER SYSTEMOREATING
a ; become subject m the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
ha forthwith comply wird such provisions nr this permit shell he deemed rcvnkeB WATER SERVICE
a
.U. z CONSTRUCTION LENDING AGENCY NEW NESIDEN'1'IAL PLMH. SQ.FT. PAID
U0 I herebywhin thi that there ixaco(See. 097,Clending
e.agency for the performance of Date Receiptp
6. Fy the work for which this fail is issued(Seo.3X9),Civ.CJ
�
Lender's Name L) Lenders Addrcsx TOTAL: TOTAL:
y1 certify that I have read this application and state that the above information is BUILDING FEE
W correct l agmen,comply with ah city and c,maly nrditmourS add state laws mmlag to QTY. MECHANICAL PERMIT FEE
L) Z building construction.and hereby authorise repmsentatives ofthis city to enter upon the SEISMICFEE .6
abovbmentioned property for inspection purPoso' PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino in
agast ELECTRIC FEE
Imhilities,,dgnte costsand expenses which may in anywayaccmnaguinst said City ALTER OR ADDTO MECH.
in consequence e egrantingo1" s ermlt. PLUMBING FEE
APPLICANT NE 'TAN S \' WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT To 10,0011 CFM)
SPnatuar
ERE ,1 (IONS MECHANICAL FEE
D� AIR HANDLING UNIT(O'ER 1(,0011 CFM) CONSTRUCTIONTAX
ofApplican on actor Date EXHAUST HOOD(WNUCID
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Wll the applicant lir future building occupant start orhanAlc hazmdoux mamdal HEATING UNIT(TO 100.00las defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Solely
Cale,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
C Yes No
VIIILATION FAN(SINGLE RESID) PAID
Wdl[tic applicant or future building pun equipment or devices which Dae Receipt p
pp gby h occupant peen BOILER-COMP iH
emitict? mai;cnnmminams as defined by the Bay Arca Air Quality Management L POR IIX),00(18TU)
District? TOTAL:
❑Yes ]NaBOILER-COME(OVER 100,000 BTU)
I have mad the hvmdoux materials requirements under Chapter 695 of the Cali- AIR CONDITIONER
fomiu Health of Safety Code,Sections 25505.25533 and 25534.I understand mSSUANCal if the NEW RESIDENTIN,MECH. 5Q.FT.
EDTATE
building does not currently have a tenon,that it is my resp risibility to notify the occupant
of the requirements which must he met prior to issuance of a Ceniucate of Occupancy.
Owner or authnnud agent Use TOTAL ISSUED BY:
OFFICE