28655 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL
2 8 6 5
BUILDING PROJECT IDENTIFICATION V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'
la,,_. !� +)-G--RIC
O tli:� CtMkAy HONE: CONTRACTOR'S NAME: LIC NO: NIC ^ COM(RO^^�Lp
'NCIN :R: GLIC NU: �j ADDRESS: ❑ / ��
CONTACT: PHONE: _ BUILDING PERMIT INFO
/1/k }'7 f 7J;7--7R0
7^R)t ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MUCH
�f/LLr , I (� ❑ ❑ ❑
LICENSED CONTRACTOR DECLARATION QTY. ELECTRIC PERMIT FEE
e s z 1 ion? affirm that I am f he Bu under cut
ofs Calmer 9(rommencmg JOB DESCRIPTION
OO with SaarceandleffecDivision 3dthc Business and Professions Codc.and my license is PERMIT ISSUANCE RF ID NTIA
F in full ftree.rM effect.
<—U License Class Lica DSFDWL CJ KITCHEN REMODEL
sFaa Datc Contncmr APPLIANCES-RESIDENTIAL DADDITION D PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ElMULTI-UNIT []STRUCTURAL
Z p n Z I understand my plans shall he used as public records MODIFICATION
OZ-0 - UP'10200 AMPS ❑INTERIOR DCHIMNEY REPAIR
r4E"w Licensed Professional 201-IgM)ANIPS IMPROVEMENT
be
Q �,
OWNER-BUILDER DECLARATION OVER II1LYIAMPS D BATH REMODEUREPAIR 0DEMOLITION
1C'C) 6 I hereby.(firm on 1 1. exempt Froin the Cunvns Co e:Any c taw Far
2O a U following mann.(Satin.703 nowt,Businessw.and Professions Cale Any city our countym, SIGNS ELECTRICAL []OTHER
which rcyuires a permit m rnmtrn.alter.improve.dcmolisq or repair any awmurt
W�J prior to its issuance,also requires men, licaut for such mrtnit h,file a signed pFp--y 4 Ip 1 tiaw(Chastatement SPECIAL CIRCUITIMISC.
thal he i y (commesccensed gwith Srsama tion7 he provisions ian 3 ohe fthe dmaorsnd Prone Law(Chapter
(commencing with Scnion]OWpJDivisirn3of the Bmincss and PrtfnsionsCode)or TEMP METER OR POLE INST. COMMERCIAL:
6 n C that he is exempt Therefrom and the basis four the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
•„y Section 7031.5 by any applicant fora Permit subjects dre.,licanuoacivil penally of POWER DEVICES
F Z y not more Than five hundred dollars 145(I0). DTGNANT [IFOOD SGRVICF,
,5p ❑ 1,as owner oftne property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
C o will dothewtrk,ond the structure is not intended m offered for sale(SeeWeN.Businiss DDTHER
6 3 m and Professions Code:The Contractor.,License law does not apply man owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves them r.and who does such work himself or through
his own employees,provided that.such impmvemen¢ore not interned or offered for NEW RESIDENTIAL ELECTR - SQ Fn
sale.If,however,the building our impmvemcnt is sold within one year ofeumpleden,the SQ.IT FLOORAREA LSQ.FT.
,builder will have the burden of proving that he did not build or improve for pur-
puseofsale.).
1,as owner of the prepeny,am exclusively contracting with licensed contractors to TOTAL:
msauct she project(Sec.7044,Business and Professions Code:)The Confiscates Li.
tense law does not apply in an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such protects with a comractor(s)licensed pursuant R,the Cnntracmfs
License Law. PERMIT ISSUANCE
[:II am exempt under Ser, Il&P C for this reason
ALTER'-DRAIN&VENT-WATER(EA)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
�x�a Jesse
1 hereby affirm under penalty of pe Jury one of the following declantionc (no
❑ I have and will maintain a Certlfcateof Consen to sell'-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCrlO
cation,as provided for by Section 3701)of the labor Cade,or the performance of the
work far which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as requirW by Section
3700.1`11be LabafCode,for the peif.....ceafthe work for whichthis permir is iswW. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC CROUP pPY
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE'INDUSTRI.WASTE INTERCEPTOR
phis section used not be caro jetted Hire BUILDING DIVISION FLES
p permit iz ftranehundmlddlan(5100) GREASE TRAP
or less.) PLANCHECK FEE
Toy my Natinthe anymannrof shesock for whichthis perJlisissued,Comer- SEWER-SANITARY-STORM EA.2tM1 FT.
not employ any person in any manner so a m become subject at the Workers Ctmp<n- ENERGY FEE
zAz pplito nws of Cal if Dam WATER HGTER WN z Applicant
W
nt GRADING FEE
0) NOTICE DO APPLICANT:If,after making his Cenificam of Exemption,you should WATER SYSTEMOREATING
a ; become subject to the Worker's Compensation provisions of the Labor Cod,you must SOILS FEF,
forthwith comply with such pm,i.ommar this perms,shall be deemed revoked. WATER SERVICE
4
az CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ,FT. PAID
U 0 l hereby affirm that hem is a construction lending agency for the p,riarmncc of Dam Reccipta
Lt. Pthe work for which this permit is issued(Ser.3097,Civ.C.)
Lendees Name
WLenders Address TOTAL: TOTAL:
F4 1 certify that 1 have mad this application and slate that she above information is BUILDING 1 '
rn Correct.)agree to comply with all city and county ordinances am state laws relating to QTY. MECHANICAL PERMIT FEE
U a building ecomrunin o.and hereby authorise repreaenmtivesofthi6 cifyw enter upon he SEISMIC FE
abuse-mentioned property for inspection pdo,cov. PERMIT ISSUANCE 1❑ II��''
(We)agree to save.indemnify and keep hsrtnless the City of Cupertino against ! P (EftuE�
liabililies,judgmcros,oras and expenses which may in any way acme against said City ALTER OR ADD TO MF.CH. 0 UIQ
in asequence of are granting of this perad,
PLUMBING PEE
UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO IB,tgp CFM7
4,APPLICANT
DEREATIONS. C IC
AIR HANDLING UNIT FOVER 10.000 CFM) If lei NSTRUCTION TAX
us, Date EXHAUST HOOD(W/DUCT)
HALIRDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
pplicant our future building occupant store or handle hmardou.s material I MATING UNIT LTO I Lo f1IX1 B'T'U) BDG. INSPE
is defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety t
Cade,Sation 25532(.)! HEiA'rING UNIT(OVER 100,000 BTU) `'TTM
❑Yes Glom
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt a
unix hamr lous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP OHP OR 18100 BTU)
Dislriel? TO'T'AL:
❑Yes Fl No BOILER-COMP(OVER Rill."BTU)
I have read the haimduus materials"a mooems under Chapter 6.95 of the Cali- AIR CONDITIONER
fomiu Health&Safety Cale,Sections 25505.25533 and 255J4.1 understand that if the ISSUANCE DATFt„�\
buildingdoes aricuncatlyhmea tenant.that hism 'hili. mnotif thcoecudat NEW RESIDENTIAL MECH. SQ.FT. I\f`/'1/fs,_,I
of Nc rt ulrcmen¢which moa be met y mnpans y y p-
4 prior to issuance ofa Cenificam ofOaupaney
Ownermsutnomed.gem Dam TOTAL: ISSUED BY: IOr/
OFFICE