28466 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECTRICAL PERMO'NO. 28466^4 ^6
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL L VX LI•I LVA
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ill M1, 7
OWN R' N�l1Fy:,/ uy / PHQNt NTR OR'S NAM E: WCNO:
/.`-v /l/ CE G NIC CONTROLX
ARCH]'IECI'RiNGIN,,R: LIC NO: ADDRESS. ❑
L JZ.k/ Los oM 6vtt
CONTACT. PHONE: X03 ❑ Consultant Fees Paid by Applicant(Initial) B❑ BU ELECT
PLUMB
L MB
NPO Mf
Im 1:1 51
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm mat I am licensed vada provisions of chapter 9(«mmaenemg JOB DESCRIPTION
O d'Z with Section 7000)of Division 3 ofrhe Business and Professions Code,and my license is
RESIDENTIAL
mop . PERMIT ISSUANCE
CWF- m full force and effect. �i/�D!.J/ 0 SFDWL ❑KITCHEN REMODEL
aUZU License Clasj C1^ —Lice Y / APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F-6W arena /Hi
Content...ECL
HDh �u� ACPS DECLARATION PANELS ❑MULTLUNIT C1 STRUCTURAL
Z Opt Z I understand my plans shall he used as public records MODIFICATION
GPTO 2(U AMPS
OZ—� ❑INTERIOR [I CHIMNEY REPAIR
F,al,�W Licensed Professional 2014000AMPS IMPROVEMENT
�xOWNER-BUILDER DECLARATION OVERlots)AMPS ❑BATHREMODEUREPAIR ❑DEMOWTION
y WC 6 1 hereby affirm mat I am exempt from the Connector's License Low for Ne
X O a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Y7 3Is. which requires a permit to eonswn,abet,improve,demolish,or apnir any swnure 7
o prior to its lssnance,also regmios the applicant fufsuch pemtino like a signed,amemem SPECIAL CIRCUIT/M ISC.
to
that he is licenvolpumoant toduprovisionsofthe Conuactors License Law(Chapmr9
a6f (commencing with Section 7000)of Division 3 ofthe Business and Professions Coale)or TEMP.METERORPOLEINST. COMMERCIAL:
6 a o yO the he is exempt NeaWm and the basis for the alleged exemption.Any violation of [INEW BLDG/ADDITION [IDEMOLITION
XM Section 7031.5 by ony applicant ern pe man subject,the aptilicmumo civil penalty of POWER DEVICES ❑TF,NANT ❑FWD SERVICE
W not more than live hundred dollars(S500f
=� IMPROVEMENT1,as owner of me property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
F- will do the work.and thestructure is not intended or uttered for.wle(Sec.7044,Business ❑OTHER
¢WIand Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
IS.3.. property who builds or improves thenen,and who dues such work h e,,a]I or through
his own employees,provided that such imprevements are,not intended or clfeml for NEW RES]DENI'JAL ELECT SQ FI'.
ode.If,however.the building or Improvement is sold wiminane an,ofcmnplau.n,the SQ.Ff.FLOOR AREA SISQ.fT.
tar-builder will have the burden of moving that he did not build or improve for puts
pose of laky fix
-11,as owner of the pmpeny,am exclusively contracting with licensed contractors to TA W h
consumer the project(Sec.70.4E Rosiness and Professions Code:)The Contractor's Li- / R
cense law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT PEE
who sontents for such pmjects with a ctmuactons)licensed pursuantto the Cmnuaaors Jt/
License law. /!r
❑l am exempt under Sec. .B&PC for this f
PERMIT ISSUANCE 4/reawn f/ O
Owner Data
ALTER-DRAIN&VENT-WATHR(EA) (rUr`2 VA�� ION
t"
WORKFIVS COM1117NIATION DECLARATION BACK FLOW PROTECT.DEVICE
I hcrtby a(f,m under penalty of perjury one of the following declarations:
�Olhmve anA will maintain aCenificam of Consenuoself-insure far Worker's Compen' DRAINS-FLOOR,ROOF AREA, N STORIES TYPE CONSTRUCTION
serum.as provided for by Section 3701 of the Labpr_CNC;for do pcRor maim of the .t
work for which dais permit is issued. i4 FIXTURES 'RjrRAPI
1 have and will maintain Worker's Comper(Gtion"nwmwc,as required by mlam 1 - a 1
37M of me Labor Code,Bn the performance of the veffor�hlfi.cermit. issued. GAS-EA.SYST Md INC.4 OUTLETS OCC,GROUP APN
My Works,,Cmm,ra,muni Insurance lienenuid"'obey nu bdf anti
Cartier: Pdky GAS-EACSY -OVER4(EA)
CERTIFICATE OF EXEMPT[ON FROM WVRKERS' �l Wq k'E INjIiRCLPTOR
COMPENSATION INSURANCE �. BUILDING DIVISION 17LM
(This scanou need net ba cmmplocal,I ten merit is Imran handed dulhm(E I( f)
or less.) a,,, rip 1 ) PLANCHLCK FEET
I certify that in the perfmnnanecafthewo 'fmrw hthia mdMdt isislu • SEWF,R-SANITARY-STORM EA.2011 FT.
nw employ any pawn in ony mm�ner w as ran M dime wt u+the Workers'Cmmpen- ENERGY PEE
z sninnlawsnf C0lifomia.Dnm .WATER FIFATER W/VEMT.LECTR
z0 Applicant +� "+=+Ka+ - ' GRADING FEE
NOTICE TO APPLICANT:If.ager making mix CedilRdle o(P,xcmption,you should WATER SYSTEMPIREATING
SOILS FEE
become want to the Wmtker's Com iaraci ied provisions of the Labor Cede,you mot
a > forthwith comply with such provisions or this permit shall be dimmed revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID mData Rs ci
U 0 I hereby off ram that ere is a construction lending agency for the Performance of
8s Pthe work for which this permit is issued(Sm.3097.Co.C.)
O U Lender's None TA
Lenders Address
s� y I mtrify the I hos read this application and stem the the above information is BUILDING FE
FN correct l agree to comply with all city and county ordinances and state laws refacing to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hershyauthnris representatives ofthis city tocnterupunmeSEISMIC E
nbov>memimail property far Inspection an,,..,. PERMIT ISSUANCE
(We)agree to rom
rove.indemnify and keep Ia tlass the City of Cupertino against EI.ECTR .F
liabikitien,judgmets,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH.
inconsequence of the granting of this permit. PLUMtlING F:E
APPLIC NTUNDERSTANDS AND W COMP WITH ALL NON-POOdNT AIR HANDLING UMT(T010JIWCFMk a— MECHANICAL PEE
" n
AIR
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRIICTIONTX
Sisipadureof AppkicanVConinicter Door EXHAUST HOOD UVMUCD HOUSING MITIGA'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havvdmus material HEATING UNIT(TO IW,(XA BTU)
\ as Joined by the Cupertino Municipal Code.Chapter 9.12,and me Ilealth and Safety
Cade,Section 25532(0)1 HEATING UNIT(OVER 100.000 BTU)
❑Yes 0 N VENTILATION FAN(SINGLE R"SID) PAID
�I Doc Race t X
Will the applicant or foam building occupant use equipment err devices which EOILER-cUMP(3HP OR I W,(Xq BTU)
emir Incautious air contaminants a defined by the Bay Arca Air Quality Management T IAL:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes []No
I have revl the Incom ons materialsAIR CONDITIONER
tcquimments under Chapter h95 of dm Cali- ISSUANCE DAT
home Health As Safety Code,Sections 25505,M533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ,pT.
of mengdoes nwcmrently hmotba met hemi is era res of aConficato notifytheoccupanty
ofine requirtmer c which must a t tact prise to issuance of a Ccnifimte of y the
Owner oravthoriaed agent Data J ISSUED BY:
OFFICE