28901 APPLICANT TOFILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY " "
CITY OF CUPERTINO .;BUILDING-ELECTRICAL. PERMIT NO. w O
BUILDING DIVISION APPLICATIONTERMIT PCMBING-MECHANICAL `(JJ
BUILDING PROJECT IDENTIFICATION
INGADDRESX, - - SANITARYNO. APPLICATION SUBMITTAL DATE
BL AVC
O
ERS NAMG'. w� D PHONE: Gv CONTRACTOR'S NAME: a 'LIC NO: -7
K G�T17r��) n•N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO. - ADDRESS: - ❑ Y
CONTACT L plioNe. - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB 'MECH
;!!r,, ❑ O ❑
LICENSED CONTRACTORS DECLARAi'ION - QTY. ELECTRIC PERMIT FEE
a I hereby affirm that I am licensed under provisions of Cha ter 9 commend
❑0y p (commencing JOB DESCRIPTION
�Wrwith Senion7000)of Division Sof the easiness and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL
U UtE1f[orce and affevt. .
License Class Lic.# -- ❑ WL L1 KITCHEN REMODEL
APPLIANCES-RESIDENTIAL
Dam bonvnctor (TION - ❑PLUMBING RE-PIPE
E,py
ARCHITECT DECLARATION - - - MULTI-UNIT ❑STRUCTURAL
> Imnderstandm 1 PANELS'
O Z F Y plans shall be used as public records MODIFICATION
UPTO200AMPS C]INTERIOR - ❑CHIMNEY REPAIR
LsensedProfessional 201-IOOIIAMPS IMPROVEMENT
aV aj OWNER-BUILDER DECLARATION
yy 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER I"AMPS [IBATH REMODEUREPAIR [IDEMOLITION
De 3 0.U following reason.(Section 7031.5,Business and Professions Code:Any city m countySIGNS ELECTRICAL ❑OTHER
{{sill 0.0y¢ which requires a permit to constmct,alter,improve,demolish,or repair any structure
Nprior to its issuance,also requires the applicant for such permit fit File a signed statement SPECIAL CIRCUIT/MISO"
} that he is licensed pursuant m Ne provisions of the Connector's License Law(Chapter 9
00 (commencing with Section7f100)ofDivision3ofthe Business end Professions Code)or TEMP.METER OR POLE INST. AMM R CIA
0. c the he is exempt therefrom and the basis for the alleged exemption.Any violation of
� Section 7031.56 ❑NEWBLDG/ADDITION ❑DEMOLITION'
y any applicant E00nnit subjects the applicant to penalty of POWERDEVICES I' ❑TENANT ❑FOODSERVICE
E„ m not
re
I've
hundred dollars(S50n). - - IMPROVEMENT t
I,as owner of the property,or my employees with wages as their.sole compensation, SWIMMING POOL FLECfRIC '
oil ework,and the tincture is not iniended ormBered for sale(Sec.7044,Business - E]OTHER
W3 and Pro .,ons Code:The Contrcctor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES p
property who bmilds or improves thereon,and who does such work himself or through
his we employe,,provided that such impmvemems are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
sale.If,however,the building or improvement is sold within one year ofcompletion,he SQ.FT.FLOOR AREA $/SQ.PE.
towner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑1,as owner of be property,am exclusively contracting with licensed corona...m TOTAL:
construct the pmject(Sec.7044,Business and Professions Code:)The Convector's Li_
cause Law does not apply to an owner of property who builds or improves thereon,and QTV PLUMBING PERMIT FEE
who contracts for such pointers with s cantmemr(s)licensed pmrsuanGo the Contractor's
Licenu Law, PERMIT ISSUANCE
❑Iam,emptunder .See. ,B&PC forhis real -
ALTER-DRAIN&VENT-WATER O AJ
Ow Dal VALUATION
WORKER COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE OA/1
�. 1 hereby affirm u d p nallY of penury one of the toll w ng d ns:
El.I have and will maintain aCniOca,of Comentmself roan fir Biker's in. DRAINS-FLOOR,ROOF,AREA,COND.' STORIES - TYPE CONSTRUCTION
same,as provided for by Section 37M m the Labor Code,for the rformance of ,
work for which this parnir is issued. FIXTURES-PER TRAP "
❑1 have and will maintain Worker's Compensation Insurance, s regoimit by Section
3700 ofthe LaborCode,forte performanceofthe work for, ch phis permit is is sued. GAS-EA,.SYSTEM-I INC.4 OUTLETS ' OCC.GROUP APN
` My Workers Compensation Insurance artier and Policy nu stare: 1.
Cartier. Policy No.: GAS-EA.SYSTEM-OVER4(EA) n
CERTIFICATE OF EXEMPTION FR WORKERS'
'COMPENSATION INS ANCE REASFIINDUSTRL WASTE INTERCEPTOR
BUILDI ION FEES
s s (TAis Becton need not he completed lithe rmit is foron ars l0(Ih GREASETRAP
or lass) \ PLANCHECK FEE
I certify that in the performance aft work for which th tis4smed SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manna so s m become subject rs'[men- ENERGY FEE
sation L....f Califmmia.Data
O Applicant WATER HEATER WNENT/ELECUt ° GRADIN E
y NOTICE TO APPLICANT:If,after ma ing this 'fie of Eeertip' n,You she. WATER SYSTEM,TREATING
abecome subject m the Workers Compares ion prsw f the Labor Code,you st - SOILS FEW U
W forthwith cmmPly with such promsums or t\3097,
a deemed ive ked. WATER SERVICE "
'z CONSTRUCTION ENCY �1_ NEW RESIDENTIAL PLMB. SQ.ET. PAID
U Q Ihareby af0rm that there is0000stmagency for the perfo arecof Dote RacaiptN
the work for which this permit is issued(S .)
Q Lenders Name TOTAL:
V Lenders Address_ - TOTAL:
4 1 certify that 1 have read this application and state that t information is BUILDING F
y7 correct.l agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V,A building convection,and hereby amhosize representatives ofthis city to enter upon the SEISMIC FE
'abovdmentioned Property for inspection purposes.
(We)agree to save,indemharmless the and keep harthe CityPERMIT ISSUANCE of Cupertino against ELECTRIC -
inconses,judgmentse coming expereas
peualt. may in any way accrue against said City ALTER OR ADD TO MECH.
consequence Nthe granting of this D WILL
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOU .E REGULATIONS. MECHANICAL FEE ,
` AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
liliftiffura of Applicant/Commc r Dem EXHAUST HOOD(W)DUCT)
HAZAR US MATERIALS DISCLOSURE - HOUSING MITIGATION FEE
Will theapplicum an future building occupantstere or handle hazardous material HEATING UNIT LED 100,000 BTU) r
as defined by the Caliendo Municipal Code,Chapter 9.12,and the Health and Safety -
Code.Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) ,.
❑Yes F1 No - PAID
VENTILATION FAN(SINGLE RESID) Dem ReceiptN
Will the applicant or furore building occupant use equipment of devices which BOILER-COMP(3HP OR DOE."BTU)
Lit e111 ws air conmminamx as defined by the Bay Area Air Quality Management
Disirict7 TQTAL:
" .❑Yes � 's ❑Nn _ . BOILF,R-COME(OVER 100,IXq BTU) GGT
1 have read the hezadnus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER /+ ISSUpp N((��q pATE
forms Health&Safety Code,Sections 25505,25533 and 25534,I understand that if the CITY Ur V tat L r17 rl Yt r
NOV RESIDENTIAL MECH. SQ.ET.
building does not currently have a tenant,that o is my responsibility ca enotify the occupant
of the requirements which must be met poor to issuance of Certificate of Occupancy. - -
Owmemauthortud1.agtut - Dote TOTAL: ISSUED'13Y:
OFFICE .