28939 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL. 28939
A f]
BUILDING PROJHI 9
IDENTIFICATION O .7
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
.2-o410 111A 4A LAA40S "
O NFt MEN LIE� �— O CONyiACI'OI�(-S�AM'A /� 2 �3 /
��SS CC 7 N/C CONTROL p
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Adak &E
LIC NO: AR,�g`//J� o 0 /*G() ❑
CONTACT. PHONE: UBUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
1 herch affirm that I am licensed under QTY. ELECTRIC PERMIT FEF.
y u provisions of Chupmr 9lmmmcnuins JOB DESCRIPTION
OmX with Senion]IXp)af Dn isi n3 of the Businessand essione�q�Ie, yT none is
a, an
L/' PERMIT ISSUANCE RESIDENTIAL:
in full force and effort /�O l o
QVZ(�j License ss Lic.p ❑ADPL O KITCHEN REMODEL
Convenor APPLIANCGS1e,RESIDENTIAL ❑ADDITION El PLUMBING R&PIPE
p.O vii ARCHITECTS DF.CLA PANELS ❑MULTI.UNIT ❑STRUCTURAL
Z O y Z 1 understand my plans shall ba used as public records MODIFICATION
OZ-O UP TO 201)AMPS C1 INTERIOR El CHIMNEY REPAIR
�,'4,FqFq. Licensed flofcssionel 201-1000AMPS IMPROVEMENT
04 2a that I a OWNER-BUILDER fr DECe Coulo ON OVER IWAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
W W 6 I hereby.(five that 1 1. exempt from the Cssion, re License Law for the
°.3 aF followingrdasua(Section 7o)comma,sitexs end Professions Ca de:Any city slcounty SIGNS ELECTRICAL ❑❑OTHER _e
tL which mrluirck o Pcnnit re te.0alma improve,such r o pt t o repair any ned statement
a
��0 prim minecense pursuant
to the thrvu,iocant for Contrarmiuoicensfile.e aw(Charom SPECIALCIRCUIT/MISC.
!!(y Nmheislicenwit Pursuant mth).fDiviomn3.f the
License Low(Choe).
app (cat he is xempt tSectiomn and the
the ageBusd exempt on.fAny vi Cale)m TEMP.MEI'f:R OR POLE(NST, COMMERCIAL
d q^C Nm he is exempt thcrefmm and the husix fits ubj alleged exemption.Any violation of O NEW BLDG/ADDITION ❑DEMOLITION
i� LL
Section LS by any applicamfor u permit subjects the applicant macivil penalty nl' POWER DEVICES
rn ❑TENANT ❑FOOD SERVICE
)„ nm mom than foe hundred Jollunp y employees
, - IMPROVEMENT
r
60 (] Las owner nl the propcny,or my empinyces with wages as their sole compensation. SWIMMING POOL ELECTRIC
will dothework,and the he Cirahisnots Livens Lawdofor sol e(Sec.]044.Business ❑OTHI3R
and arty who
Cole:The Convent's License Law dos mm apply to if owner of OUTLEfS-SWITCHCS-FIXTURPS
6 3 property who builds or improves thereon,end who etc a work deed to offered fah
his own employees,building that such mentis old w thin nm intended ur offered fur NEW RESIUENTIAL131.CCI'k IT
sale.ILhoweveethe
ve the burden
provinissoldwithinone tbuild year(if the SQ.FT.FLOORAREA $ISQ.FP.
wner-bailder will have the burden of Proving that he Aid not build or improve I'nr bur- `s,��
pose of sole.). -APR
❑I,as owner of the property,am exclusively eommcdng with licensed contractors m TOTAL: 11Cy(t
construct the project(Sec.]61A,Nosiness and Pmfcssinns Codeq BTe Commcmrx Li.
aco,a Law doex nm.,yu,an ownerof prolady who huilds or Lmpntvekmareoaand QTY. PLUMBING PERMIT FEE CITY OF curEH TINO
who convects formch pmjecrs with a cnnwnnds)licensed pursuant m the Conwcmrs
License Law' PERMIT ISSUANCE
❑I am exempt under Sec. ,R&P C for this reason
Owner are
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of Perjury one of the following declarations:
L] I haveandw ill mainminu CralOam ofConxent m 16f.i.surc for Worktr'a Compem DRAINS-FLOOR,BOOR AREA,COND.
cation,as provided for h Section 3700 of the Labor Code,for the STORIES TYPE CONSTRUCTION
y Performance of the
work for which this permit is issued. PIX'TUNES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,ss rcquircd by Section
My of the labor Code,for the perfannanchnflhework for which this pcnnit is issued. GAS-EA.SYSTEM-]INC.4OUTLETS (KC.GROUP APN
MyWork Cptnpegsepn �n a 'eraniyNo
Cartier. la C!'/ Policy No �� ?� GAS-IIA.SYSTEM OVER 4IEA)
CERTIFICATECOMPENSATION
NPRO. O K N '
COMPm SATION INSURANCE GIiEASPIINUUSTNI,WASTE INTERCEPTOR
(This section need not he rompkmJ if the permit is forone hundrcddallas(SI W) BUILDING DIVISION FP.T:S
or less.) GREASE TRAP PLANCHECK FEE
I cerify that in the performance oft he work I which this pewit is issued.)shall SHWER-SANITARY-STORM EA.200 IT.
not employ any pnson in any manner so as to become subject to The Workers'Compem ENERGY FEE
Z kation Laws of California.Data
O O Applicant WATER HEATER W/VENT/ELECTR GRADING FEE
NOTICE TO APPLICAN9:If,after making this Certificate of Exemption,you should
1` ecoe subject the Workers Compensation provisions of the Labor Code,you must WATER SYSI'E.M/TREATING
-' become m SOILS FEE'
Wforthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
Uz Cthe is.a. NLENOINGAGENCY NEW RESIDENTIAL PLMB. $Q.fT. PAID
VQ work
rwhaffirm That Pemits issed(Secti0lending agency fonhh PerBnwnnccof Data Receipt
0f" thewr's Na which this Pewitisissued(Sec.7097.Civ.C.) '
Q Lenders Name T L:
L) Lender's Address TOTAL:
yI certify Thu 1 have reed this apPlicmion and cram That the aMve information is BUILDING FEE
13 0cored.lagree m comply asphall city it county ordinances and star,laws relating to QTY, MECHANICALPERMIT FEE
1 Z Inildingconswaim.andhereby amhmirereprowatioNes of thiscity mm
enr upon the SEISMIC F1313
ahavcmemioned propcny far inspection parpoms.
(We)agree to save,indemnify and keep harmless the City of Cupertino ngninet PL•RMIT ISSUANCE ELECTRIC F N
liabilities,judgments,costs and expenses which may in any way theme aspirin said City AVMRORADDTOMECH.
in consequence of the granting of this pewit. PLUMBING
WE-
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON.POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL HE
AIR HANDLING UNIT(OVER 10,000 CFM) GDN$TRGGTIDN'TAX
Signature of ApplicanUContrucmr Date EXHAUST HOOD CMDUCT) HOUSING MITIGATI HE
HAZARDOUS MATERIALS DISCLOSURE
Will tire applicant or furore building ocupamtsmre or handle haamdoasmtstid HEATING UNIT GO I00.000 BTU)
as defin a by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Code,$mtinn 25532(u)1 HEAPING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Data ReceiprY
Will the applicant errfumrh building by the
one equipment Qm ildeviceswhich BOILER-COMP(3HP OR 100,000 BTU)
emit District?
us air conmmimnls as JefneJ by The Buy Arca Air Quality Management TOTAL:
Dist ct?
❑Yes [2 No BOILER-COMP(OVER 100,000 BTU)
I have real the hmmdoux mmnialb r`uircmcmx under Chapter 6.95 or the Cali- AIR CONDITIONER ISSUANCE DATE
(omit He a(ety Code,Sections 2550,25511 534.I understand that if the NEW RESIUGNTIAI.MECH. SQ.F1'. "
huildi remly have a tcnam k itis ym mnsibility to notify the occupant
of s h' to' c ofa Cervi a of up
Own or authoia eat ale TOTAL:
SUED By.
OFFICE