28640 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. a.a �a ^ O
BUILDING DIVISION APPLICATION/PERMIT . PLUMBING-MECHANICAL. L r'8{6
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDA-.
101610 *Ael , Nomm rvo ted. f"f&c
OWNER'S NAME: PHONE: ONTRACTOR:S NAME: LIC NO'.
51D) T `-C/N-Sr + �t NIC CONTROLp
KCHITECDENGINEER: LIC NO: ADDRESS: ^"x-t ❑
COONTAC,T.1.rVN V'w �F'' PHO E BUILDING PERMIT INFO
s/1-Mi �1SA4 ❑ Consultant Fees Paid by Applicant(Initial) µ,DQ E.PLUMB MECH
Aro8 � - 2
LICENSEDCONTRACIOR'SDECLARATION QTY. ELECFRICPERMIT FEE
1 hereby of in i mat 1 am licensed under prnvixinn.of chapter 9 Qmomemm, JOB DESCRIPTION
��Z with Section7000lol'Division3ofthe B sinessand Profcasime Cme,andmy headsets RESIDENTIAL:
FSO in full memorial all.,. PERMIT ISSUANCE
�UU License Class cW
Lie, 0SFDL ❑KITCHEN REMODEL
4.
NQ1 DAe Contractor APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTFUNIT P p I ❑STRUCTURAL
Z p y Z 1 understand my plans shall be used as public records A MODIFICATION
OZ-Q l UNTO2W AMPS ❑INTERI CHIMNEY REPAIR
ceased Profeadmial 2UI-IfIW AMPS PR
OWNER BUILDER DECLARATION 1
W Q I hereby affirm that 1 am exempt from the C.ntmaors License Law for the OVER 10(g)AMPS BATHq REM IYB E�AI7��J]ijD MOLITION
3,eUF. following reason.(Section 9031.5,Business and Professions Cmlc:Any city m county SIGNS ELECTRICAL OT�T9' -"
LL g.N which requires a permit to e.mtrua,ahem improve,demolish,or repair any mrac,rc w
prior to its issuance,also require.the applicant for such pemot to file a signed statement
h SPECIAL CIRCUIT/MI
�p.
that he
menccensdpursoanuo mepmvisionsof the Contractors License law(Chapmr9 Jh(1
It. the,he,,.rm,ItSationniond f basis
ortheeged c.sanl ProfessmnsCode)or TEMP.METER OR POL t COMMERCIAL_
It. e the he is exempt therefrom nark the basis for me alleged exemption.Any violmion of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES.,. EW BLDG/ADDITION C3 DEMOLITION
=pnot tame than five hundred dollars($5W). NANT ❑FOOD SERVICE
�1,m owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ' IMPROVEMENT
yFo will du the work,and mestmcmre is not imismdorotlbred for .[a(Set.70M,Business ❑OTHER
u]3 m and Professions Cextc The Contractor's License Law does not apply to an owner o' TLETS-SWITC - /
G� property who build or improves thro mn,and who does such work himself m through
zw
his own employees,provided that such improvements are not intended or offered!for NEW RESIDENTIAL.ELE SQ FI'.
sale.If.however,me building or improvement is sold within one year of completion,the SQ.FT FLOOR AREA ASQ IT.
rn rov
,wobuilder will have the burden of ping the he did not build or improve for par- �� a
p,c e-of sale.).
El 1,as owner of the property,am exclusively conterning with licensed contractors to
construct the project(Sec.7014,Business and Professions CWC:)The Commerce v Lt.
seLaw does not apply to an owner f property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts forsuch projects with a contractors)licensed Pursuant tome Contractor's
Utmsc Law.
❑ I um exempt under Sec. ,B&PCfimthiartason PERMIT ISSUANCE.
Owner TER-DRAIN&VENT-WATER(EA)
Dole VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Thereby arthro under penalty of pej.,one ofine fallowing decmmtions
❑ Mascara will maintain uCenifcme ol'Consem mselGinsurc l'nr Worker's Cumpen- DRAINS-FLOOR.ROOK AREA,CONE). V
mtion as provided fm by Section 37W of the Lahr Cade for me pindereance of the STORIES TYPE CONSTRUCf101
work for which this permit is issued. kA FIXTURES-PER'HE P
❑1 have and will chairman Worker's Compensation Insurance,as required by Section
37M affirm labor Code.for the performance ofine work for which this potash is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Workers C.mpcn.atlon lnmrance carrier and Policy number are: OCC.GROUP APN
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not be m
completed if the pnit is for one hundred dollars(S 100) BUILDING DIVISION FEES
or less) GREASE TRAP PLANCHECK FEF.
Icenify that in the perfnmunce of the work for which this perttdtisissued,l shall SEWER-SANITARY-STORM EA.200IT
not employ any person in any manner so as to become subject m the Workeri Compen- [NENGY FEE
,Z sation Lmwsof Califorma.Dwe
z O ApplicantWATER HEATER W/VE,NT/ELECTR
GRADING FEE
h NOTICE TO APPLICANT:IL attarmaking this Cisionsf of Exemption,you should WATER SYSTENUTREATING
horn ne cid,comp y it Worker's Compensation provisions of the Imedr Coke,you must SOILS FEE
W forthwith comply with such provisions of this permit shall he deemed invoked. WATER SERVICE
0. Q
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID
U 0 l hereby affirm that is o commotion lending agency for the perfmirmlie of Dam Receipt to
Cl. I•-' the work for which this permit is issuoil(Sr,3097.Ci,C.)
C) U Lenders Name
Lenders Address
IOTAL
1 :
comity that 1 have read this application and state that the above information is TOTAL:
F BUILDING FEE
If) burtdingemreemim, ad with all chyand county ordinances iom,ofand state laws rammgto QTY, MECHANICAL PERMIT ^�
U 4
building hereby amtionF nace,nmtives of this city to enter upon me FEE SEISMIC PER
above-men0ond pmlmy for inspection pkenus.
(We)ogme to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE. ELECTRIC FEE
Iiabilities,judgmcros,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
m c.nseque
cc
0'
me graming of this permit PLUMBING FEE
APPLIC'n T t1NDERSTANDS A U WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IB,000 CFM)
SOURCE R:GULAI'IONS, _ MECHANICAL FEE �P
l AIR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX
ignamm of ApplicnVContraeor Got I EXHAUST HOLD(W/DUCT)
AZ S DISCLOSURE HOUSING MITIGATION FEE
Wil app¢am orfuwrt building acupant wore or haodlc harardnus material HEATING UNIT(TO 100,01108TU)
in defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553260? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No
VENTILATION FANS INGLE RESID) PAID
Will the applicant or future building occupant use equipment as devices which Date Receipt a
:mit harried.,nit criminal...is as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP,OR 1(S."BTU)
Dbmien
❑Yes ❑N, BOILER-COMP(OVER 100,000 BTU) 7
I have read the hmad<ms materials requirements under Chapter 6.95 oftlm Cali- AIR CONDITIONER
f,mia Health&Safety Code.Sections 25505.25533 and 25534.1 understand that if theISSUANCE DATE
buildingdeas notcurrently have a tenant.that it ismy reapnnsibility to notify Wetxcupam NEW RBSIDEM'[Al.MECH, SQ.P-n
.rine tegairemenu which must be met prfirm iwaance of a CeniOcam of tJccupmcy.
Owner m authorised agrnt
Data TOTAL:
ISSUED BY.
OFFICE