28903 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITIIOFCUPERTINO - .BUILDING-ELECTRICAL PERMIT.NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 9
2Q �Q�
BUILDING PROJECT IDENTIFICATION VQ J v
BUTLJDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER' NAME: - PHONE: - ON TRACTOR'S NAME. LIC O: ton
NIC • - COM'ROL#
\RCHITECT NGINETR:'. - 'LIC NO: ADDER S /� •1 1� Q'.
CONTACT. •PHONE: BUILMNG'PERMIT INFO
• N Q g) ;^LA —I(a g 1 11Consultant Foos Paid by Applicant(Initial) BLDG ELECT PLUMB MECH '
TO o / 1D B i - C:1P o.
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
hereby affirm that 1 licensed under provisions of Chapter 9(commencing JOB DESCRIPTION ., •
�aZ th5 ion]000)of D' Sof the Business and Professions eandurlicensees pERMITISSUANCE
full force and e t (, Q y - RESIDENTIAL,
T[AL:
U License Class Lic.# " 5 " ❑SFDWL„ [I KITCHEN REMODEL
HsT Dmc Conlrucmr APPLIANCES-RESIDENTIAL ' O' ADDITION ❑PLUMBING RF-PIPE
ARCHITECT'S DECLARATION PANELS EIMULTTUNIT' ❑STRUCTURAL
1 understand my plans shall be used as public records MODIFICATION
O Z'�-1 UPTO2WAMPS, '
F W Licensed Professional' - - _ ❑INTERIOR [I CHIMNEY REPAIR '
aj - OWNER-BUILDER DECLARATION OVER IWO AM IMPROVEMENT
1 hereby i ffinorth it I am exempt Laroche Contractors License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
a L F following reason.(Section 7031S,Business and Professions Code:Any city or county - `❑OTHER
SIGNS ELECTRICAL
V.� which req ' Permit tase t h improve.demolish,' P y structure
F„O poo t t issuance,als rey lh ppficaulf suchpe tt fl u,od tntemeat SPECIAL CIRCUIT/MISC.
7+
'hat he is licenshipmoruato the provisionsaftheContrichoes License La (Cbpter9
�C morrmenemgwlth Section 70007 of Divislon3 offlue Business nd Professions Code)or. TEMP,METER OR POLE INST. COMMERCIAL:I,'
d fy M e' that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLERNADDITION ❑DEMOLITION `
LitCl Wy
Section 7031.5 by any applicant for a permit subjects the applicanyo u civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
yz not more Nun five It it it dollars($500).' IMPROVEMENT
FF6 �1.as owner of the propemy,or my,employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
rya O will do the wrrk,and Ne structure is not intendedmeffered Initiate Else.7044,Business ❑OTHER
Yl and Professions C-Aa:The Coutracor's License Law does nm apply do an owner of OUTLETS-SWITCHES-FIXTURES ' e"
6'3^ property,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements,are not intended or offered for NEW RESIDENTIAL ELECTR SQ EL
sale.If,however the building or improvement is sold within one year of completion,the - SQ.FI'.FLOOR AREA $/SQ.FT.
owner-builder will have the thereat of proving that he did not build or improve for pur- "
poseofsale).
1,as owner of the pmperly,am exclusively contracting with licensed contractors m - TOTAL:
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's Li-
cerise Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a conaaevn(s)licensed pursuant to the Contractors
License Law. 1kRMIT ISSUANCE
❑l am exempt under Sec.. ,B&PCfmthN ween
Owner
_ AL ER-DRAIN&VENT-WATER(E.A) VALUATION
Dnte '
WORKER'S COMPENSATION DECLARATIO BAC FLOW PROTECT.DEVICE
hereby affirm under penalty of parjmy one of Ne full,, ' deche atio..: -
❑I have and will maintain eCvrtficatcofCmormI meclf-in for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES" TYPE CONSTRUCTION
station.as provided for by Section 37M of the Labor C ,for the perform.nce of the
work for which this permit is issued. FIKTU ES-PER TRAP
F1 have and will maintain Worker's Compens a lasuonce,as required by Section
3700o1fthd Lahr Code,for theperfonnunce thewurkforwhichthispennil M...W, GAS- .SYSTEM-IINCAOUTLETS OCC.GROUP - APN
My Worker's Crmpensatumbsurancee. rand Poiicynumbo'cae: p5-F. SYSTEM-OVER Cartier: Policy No: „
'CERTIFICATE OF EX PTION FROM WORRE S' -
COMpENS rIONINSURANCEINDUSTRL WASTE INTERCEPTOR'
(This section neednotbecompl edifthepermitisfr, holiunS BUILDING DIWSION FEES
or less) AR EASE TRAP ptANCHECK FEE
cenifythat in lhepMormanc dthewmk rvvhi si. L her
lo an SEWER-SANITARY-STORM EA.200 FT.
immid
p y y person in any manner o as m bac a ec to th rker,Compen- ENERGY FEE ,
7.. sation Laws of California Date
zO Applicant WATER HEATER WNENT/ELECTR GRADING FEE -
h NOTICE TO APPLICANT If,after' king this Ce if ate of Exemption,you ould WATER SYSTEM/rREATING
a [h became subjem to the Worker's Cotn• nation prnvis sof the Labor Code, must - SOILS FEE'
wry forthwith comply with such provisions this permit shall be deemed revo WATER SERVICE '-
0...Q
z CONSTRUCTIO LENDINGAGENCY " NEW RESIDENTIAL PLMB. SQ,FT. PAID
Itereb affirm that rets o Date Q Receipt
y a e ' s ai n lending egeahy fo a performance of ppTt P ,
`LJ� the work for which this permit is issued(S 3099,Cie C)
Lender's Name - 'TOTAL: !
WLender's Address - TOTAL: f
0. I cenifythat I have read this application and cram that the above information is �9UILDING FEE
LI context.I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V 4 building conswction,and hereby authorize representatives of this city to enter uponthe SEISMIC'PEFs-r
above-mentioned properly for inspection purposes. _ ] r pERMITISSUANCE I ELECTRICFEE U
(We)agree m save,indemnify and keep harmless the City of Cupertino against
lieldities,judgments,costs and a tenses which may in anyway accme againstseid City ALTER OR ADD TO MECH. - ,
in consequence of the graining this permit. PLUMBING FEE ^
APPLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)SOURCE REGULATIONS. / MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX" -
SignamreofApplicantsCommcror I I Date EXHAUST H006(WIDUCT) HOUSING MITIGATION FEE '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532m)1. HEATING UNIT FOVER 100,000 BTU) 01
❑Yes ❑No '
^• VENTILATION FAN(SINGLE RFSID) •PAID
Date Receipt#
Willthe applicant or future building occupant use equipment or devices which BOILERCOMP(3HP OR 100,000 BTU7
emit hazardous air contumacious as definedA.by the Bay AAir Quality Manage -
ment
Di _ TOTAL:
sbict^, BOILER'-COMP(OVER 108000 BTU)
❑Yes El No '.
i .I have read Ne hazaerous materials requirements under Chhpeor 6.95 of the Cali- AIR CONDITIONER - o ISSUANCE DATE
from.Health&Safety Code,Scrar,25505,25533 and 25534.1 undereeand that if Ne NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a[count,that it is my responsibility m notify the uor....t �
of the requirements which most bemet prior to issuance of.Certificate of Occupancy, e '
Owner or tamarind u ent Date '
g ISSUED BY: '
} OFFICE
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Joe
W. FRIESEN CONSTRUCTION CO.
SHEET N0. OF
• 1212 Oakland Road #144
SAN JOSE, CA 95112 CALCULATED BY DATE
(408) 448.6304
C.S.L. 521907 CHECKED BY DATE
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