28935 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. OC1 C
BUILDING PROJECT IDENTIFICATION o J J
BUILDINGADDRESS:
A
6' SANITARY NO. APPLICATIONSUB
M TTAL DA
T
Staff "2^a 4r 0
O AMPPHONE: CON _^'/ �K
RjaRSNME NIC CONTROL as
RC HEC /LNGINIaM: LIC NOADOR� h
7X32
CONTACT: - - PHONE: BUILDING PERMIT INFO
Ion 3I_ i R C4 S-002 Consultant Fees Paid by Applicant(Initial) BLDG PLUMP . MECEI
k rhaS3
LICENSED coNTRACTOR'S DEMARAI'EON QTY ELECTRIC PERMIT FEE
1 hereby.term thnt 1 am licensed under provisions of Chapter 9(robmnencing JOB DESCRIPTION
HCat wies Scefion]OW)of Division 3ofthe Rueiness and ProPosvionsCWe endmylicense is PERMIT ISSUANCE �, RESIDENTIAL
O ' full Porn end effect. l/-J
�FUz�c1 License Las LIf.M - ❑SFDWL ❑KITCHEN REMODEL'
NQ Date Cnnvaaur APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
t„p Ern A CHIIECT'S DELLA I PANE ❑MULTI-UNIT C3 STRUCTURAL
O Z E Z I underm
. nd.,,[.,.bull be used as public record.
MODIFICATION
UP T021p AMPS ❑INTERIOR GCHIMNEY REPAIR
gaCY1 ucenxed Pmfcubonal 201-1000AMP5
�0bill qq OWNER-BUILDERDECLARATIONthe Cmu woo IMPROVEMENT -
dd'' << 1 hereb ffirm that 1 am exempt from the Canvucmr'x License Law for the OVER 1000AMPS ❑BATH REMODEVRF,PAIR
Y a p '' DEMOLITION
[?y5 06 U which ire'un �n. ermiito construct,
Business and improve,
da mtx h,mr re ray city nr county ctme ❑OTHER
W a Wr which re mires u - SIGNS ELECTRICAL
Fqq,E-,Oa ts Permit cr c hes the pt c improve,demolish, file
repair any swment
2 rA.l that heor ists
edPalso regmres the so for CoastWeb permitto
Lawned(Chapter
SPECIAL CIRCUIT/MISC.
Y } es:n he is licensed pursuanuo life previsions of the Commcmrx License law(Chagcr9
W.00 lcl;.encingwith Section]OW)afDivision3ofthe Busin"l rad Pmfessions Codo)ur TEMP METER OR PO LE INST. COMMERCIALd q C that he is exempt derefmm and the basis for the alleged exemption.Any violation of W BLDG/ADDITION C3 DEMOLITION
ti+C] a•
Section 7031.5 by any applicant fore permit subjects the ap,lietat mo civil penahy of POWER DEVICES
Z} not more than five hundred dollars f$50(h. NT ❑FOOD SERVICE
CO ❑ 1,as owner of the property.or my emploYers with wages as their Who asmpenxutlom, SWIMMING POOL ELECTRIC IMPROVEMENT
�C`•. will do Nwis
e work,and the schre not intended oroffercJ for sale(Sce.]OMI,Business ❑OTHER
3 ane Pmfessions Code:The Contracmr's License Law does out apply to an owner of OUTLETS-SWITCHES-FI%TURFS
property who builds or improves thereon.and who does such work himself m through
his own employeesprovided that such improvements ore nut intendedor offered for NEW RESIDENTIAL ELECI'R SQ IT.
sale.If.however.the building or improvement is sold within one yearofcompletion, c SQ.FT.FLOOR AREA $/SQ FT.
owner-builder will have the burden ofprv,mg that he didnotbuild or impmve frr Cur 12s,b `r�
1 f sale^).
R
aw crofthe Cmperty,am exclusively nmtmdin with licensed commcmrnny
ons the pmjen(Sce.7114,Bmenamd P
anmfexsi0ns Cede)'Tbe Conmmoses Li-
cense law does nm apply to as owner of property who builds or improves Ncreon,and QTY, LUMB G PERMIT FEE
who ac¢for such projects with octntmaorts)licensed pursunnuothe Commmors OCT 241995
Licenseence bow.
exemptEUfann under Sec. ,B&P C for this reason PERMITSSU
ALTER-D I WATER HEA) 1 1.
1 I r �VAL......ATIONI�
•WORKER'SCOMPENSATION DECLARATION BACK FLOW O .DF. CE IJPS
'1 hereby affum under Penalty of perjury one of the fallowing declarations
❑I have and will maintain o Cenificam ofComent mself-insure for Workers Camper- DRAINS-FL ,R }AREA,COND.'
tenon,as provided fm by Section 37M of the Labor Code.for the performance of the STOR S TYPE CONSTRUCDON
weak for which this permit is issued. FIRLURES-FER A
❑1 have and will maintain Worker's Compensation Insurance,as required by Seminn
37M of the Labor Cole,for the performance of the work far which this permit is issued. GAS-HA.SYSTEM-I C.4 OUTLETS � OCC,GROUP APN
My Worker's Compensation Inwmnce artier and Policy mmcber are:
Cancer Policy N., GAS-FA.SYSTEM-OVER 4(HIM
CERTIFICATE OF EXPTI
EMON FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUS WASTE INTERCEPTOR
Mix section need not be completed if the permit is fix one hundred dollars f$1011) BUILDIN DIVISION FINS
lesxJ GREASETRA pLANCHE FEE
I certify that in the performance of the for which It in permit is issued,lshall,.. ��
nm em ploy any Cassoniny incantations b,become subjenmthe Workeri Gmbpem SCW DRY-S'IORM Iv1.2tN1 Ff.
,� sution Laws of California.aDam ENERGY E O01
zO Applicant WA • TER WNEWMLECTR GRADE
NOTICE TO APPLICANT.If,after,making this Certificate of Exemption,you should WAT SYSTEMOREATING
abceonr subject to the Workers Compensation Provisions of the labor Cade,you men sol*EV
CU fonhwiN comply with wch provisions onhis patent shall bodumed revoked. WATER SERVICE
aQ
� z CONSTRUCTION LENDING AGENCY NEWRESIDENDALPI,MB. SQ.Fr. P I
V Q Iherchy affirm lhmtheacotte e,...on lording agvmy fnnhe performance of p e ReceiptY
Uy the work for which his permit is issued(Sec.3097,Civ,C.)
Lenders Name TOTAL:
Lenders Address L,
ly 1 ceniry Ihet I hove rwd Nis epplicmion and stem theuhe above informainn is ING E _y
(A rorren.I agree to comply with all city unit county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
21!t 5
V 4 building construction,undhereby audience represenwtivesofthiscity to Won.pon the ICF E ata—
above-mentioned ympcny for inspection pia,cm.
IWe)agree to men.indemnify and keep hornless the City of Cupertino against PERMIT ISSUANCE ELECTRI FEE
Iiabilities,judgmenb,costs and expenses which may in any way weeme against mid City AUFERORADDTOMECIL
incersequenceofthegrantingofthispermit. PLUMBI GHE a`
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT fT0IU,1%p CFM) MECHA CAL FEE
SOURCHG//,1LAT1 S ,^7 //.. y11��,�[p /q/
� /1 VI I `�t� o •f AIR HANDLING UNIT(OVER I0,000 CFM)
—I—n CONSTRU ON TAX
Sbgnawreo ApplicaH/U!Aracmr - wa��— EXHAUST HOOD(W/DUC1)
f1AZARDOUS MATP.R ALS DISCLOSHRI? HOUSING MIT ATION FEE .
Will Ne applicant or fumre building cempem more orhavdle hamrdou.material HEATING UNIT TO 100."BTU)
ss defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety
Code,Section 255320)? HEATING UNIT(OVER 100.100 BTU)
C]Yes FIN.
VENTILATION FAN(SINGE R['SID) PAID
Will nue applicant or future building by the B use equipment I Jevicca which Uma ReceiplN
emit hazardous air eonmmineme ns defined by the Bay Arco Air Quality Management BOILER-COMP(3HP OR 1011.00d BTU) -
Disrict? T L:
Dy. First. BOILER-COMP(OVER 100,000 BTU)
I have bead the herardtus materiels AIR CONDITIONER ISSUA CE DATE
requimme an undo Chapter 695 of the Call.
Reales&Safety Cole,e.terfa 25505,25533 and 25534.I understand,not,. Net if the NEW RESIDENTIAL MECH. SQ.
building does not currcnUy have a tenant,este it is my respmsibility m ramify the occupant
of the requi me Is which nmst bo met prior a i"mour of e Qyt 13 on Occup ,
Owner ora orirNagem ( o'` m
ISSUED BY:
OFFICE