28633 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 28633
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O,AA
E ' NAME: PHONE: Z COM CTOR'S NAME: LIC NO:
NIC CONTROL#
AR LITE GINMR: LIC NO: A RESS:
G - ❑
bC a12�J
CONTACT: \ PHONE- �f�l q G I<^j BUILDING PERMIT INFO
tibc-i0.`n II `M isc'1� �_Loy Q El Consultant Fees Pald by Applicant(Initial) BLDG ELECT PLUMB MECH
^l J�fi 1El . ED F-1LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
QWz I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{{s�00 with Seminn]IXNB of Division3nf Ne Business end Professions Code,endm I'
F W- into foree and effect. Y semen PERMIT ISSUANCE
RESIDENTIAL
IyF ❑ADWL ED KITCHEN RF-PIPE�UZp License Class Contractor
APPLIANCES-RESIDENTIAL C]ADDITION [I PLUMBING RE-PIPE
Q G Duce Contractor
Dm As shall'he no DECLARATION ❑MULTI-UNIT E]STRUCTURAL
PANELS
l understand my plena shall be used as public tecoNs MODIFICATION
pz UPT0200AMPS C1 INTERIOR ❑CHIMNEY REPAIR
%11 Licensed Professinnul 201-10X0AMPS IMPROVEMENT
CY' atIOWNER-BUILDER.exeDECLARATION OVER IOW AMPS ❑BATH REMODEUREPAIR OLITION
1 hereby affirm I pt from she Contractors License law for the ❑OTHER
3aU followingrces. ars(Section co3LR Businesssalmpr Professions Code:Any city orcounty SIGNS ELECTRICAL
❑� which mluirca n permit re cams the autmpplicant
improve,demolish,or repair any swnum
� tpoor hat he itsissuanclsoe. reclaims the thovisiocant for such
naries icerfile signed statement SPECIALCIRCUIT/MISC.
} that he is licensed punuam to the provision of she Contractors License law(Cheprcr9
GAO (commencing with Section]gp)of Division3ofthe Business and Profcssiom Code)or TEMP.METER OR POLE INST COMMERCIAL:
6 X n y the he is cxemps Iherefmm end Ne basis for the alleged exemption.Any violtam.of ❑NEW BLDG/ADDITION ❑DEMOLITION
4 Section 7031.5 by any applicant far a permit subjects the applicant a civil penalty of POWER DEVICES
W^rn []TENANT ❑FOOD SERVICE
oat more then Eve hundred dollars y employers
_< Lmowner of Ota n,arm IMPROVEMENT
❑ prosee my withwagas asthei(Sm.compensation,Business SWIMMING POOL
G will do the work'and the anmurc is not intended OroRered for sale(Sm.7044,Business OTHER
S and Professions Code:The Convector's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
" property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR S FT.
sale.IL however,the building e,m_prw.-ent...said wiinnoneyearofmanpletion,the SQ.FT.FLOOR AREA SI$Q.FT.
owner-build ih ve'rttii b fp'vin,that he did not buildnrimproveforpoooaof sale.En sfW1.I
oeft' y,canMing with IicenuJ ronwcmm mTOT L:e0nsvua w uames�d Professions Code:)The Cmmmcrora I.i.eensmCowowner of property who builds or improves thereon.and QTY. PLUMBING PERMIwho ro.. with a cairrecu Hs)licensed pursuant la the Contractor's
License la PERMIT ISSUANCE
❑ I ora exempt under Sec. .B&P C for this rcown
Owner Our ALTER-GRAIN&VENT-WATER IEA) - VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
1 handy affirm under penalty oe of Con one.(no following dedoer's Ca
❑em.as and will forty S ooth370of Consent to ulFinsurefor Worker'sCamper.
of the
DRAINS-FLOOR,RODE AREA,COND. STORIES TYPE CONSTRUCTION
rasion,as hichd o for ra Section 3700 of Ne labor Code,for Ne performance of the _
work for which this permit is iuud. FIXTURES-PER TRAP
❑I have and will rade,for he performance
er or Compensation Insurance,m inquired by Section
my orkers omiuma,for rhsuranc canner and Policy
(number ans- permit is issuN. GAS-EA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Workers Compemation Insurance wrier and Policy number arc:
Cartier. Policy No.: GAS-G.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not hecomplesed ifine pemm is forone hundrtd doll.($100)
BUILDING DIVISIO FS
m less.) GREASE TRAP PLANCHECK FEE
lay any that in the any manner
of thcworkfm which this the W iaisweompershall SEWER-SANITARY-STORM FA.200 ET.
nm employ any person in any manner an as m become subject t0 the Wnrkem'Cnmpen- ENERGY FEE
,Z nation Ltiamof Culifornin Dam
�O Applicant - - WATER HEATER W/VENT/ELECTR GRADING FEE
q V) NOTICE TO APPLICANT.If,after making this Certificate,of Exemption,you should WATER SYSTEMUREATING -
!Yi became subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS HE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FL PAID
L)Q l for which thi that NemiseconsSm.309ending agency for the perfomsenee of De¢ Reccipp
L-t the work for which this pcnnit is issued(Sm.J09).Civ.C.)
0 U Lenders Name TOTAL:
Lenders Address TOTAL:
0. I unify that I have ithJ this application and site Nat dreand
above connotation odishirg is BUILDING ME
N buildingTonstr to comply with all city and county
ntativsofthis statelawsrelatinghe QTY. MECHANICAL PERMIT FEE
V{� building conxwmi0n.and hcrtbyeurM1odze reprtunrativn of this city to inter upon the SEISMIC FEE
above-mentioned propcny for inspersion purposes.
(We)agree to save,indemnify and keep harmless no Ciry of Cupertino a,ainst PERMIT ISSUANCE ELECTRIC FEE
Iiabilities.judgmcros,costs and expenses which may in any way accrue against mid City ALTERORADDTOMECH.
in mmequsmo,of the granting of this permits. PLUMBING FEE
APPLICANT UNDERSTANDS AN W .L COMP Y WITH ALL NON-POINT AIR HANDLING UNIT(TO 110,010 CFM)
SOURCE ULATI 5, e MECHAMCAL FEE
AIR HANDLING UNIT(OVER ID000 CFM) CONSTRUCTION TAX
Signan Islut A atl ntrctate Mi IAUST HOOD ONMUCT)
HAZARDO A IALS DISCLOSURE HOUSING MITIGATION HE
Will the npplictat or far mildiat occupant store m handle hisoodnun material HEATING UNIT(TO 100,00)BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(u)? HEATING UNIT(OVER 100,000 BTU)
El Yes No VENTILATION FAN(SINGLE RESIDE PAID p�
GAIN / R6 Receipt#
Will the air comm or future building by the rat use equipment or Marta which BOILER-COMP QHP OR 100,0(10 BTU) SEP A
emit hazardous air rontnminems as defined by the Bay Area Air Quality Management TOTAL:
Dealer Yes []No BOILER-COMP(OVER 100.000 BTU)
❑
V'
I have rem the hvaNwx m¢ti
tals mluiremAIR CONDITIONER ents under Chapter 6.95 of the Cali- F L ISSUANCE DATE
forma Health&Safety Cade,,Sectionx M505,25533 and 25534.1 understand!this if the VN(;
NEW RESIDENTIAL MECH. SQ.FT H��nff
building Jots noncurrentlywhich have a, metathat it ismyrceof aCerti to notify use mention
of Ne rtquircrnrnu which most be met prior to issuance of a Cenif etc of Occupancy.
Owner or authorized agent Date I I TOTAL I ISSUED Y.
OFFICE