28792 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO. 2
28792^7 9
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L VX JU L
BIIII.DIN(,PRO]IiCT 11)EWIF'ICATION
BUILDINGADDR S: - SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
�f -� 3
OWNS• R45 NAME: PHONE: C A AM. J 0.
W w SEC CONTROL If
ARCHHUCT/ENGINEER: LIC NO: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
,K z�-79330 ❑ Consultant Fees Paid by Applicaut(1 tial) BLDG ELECT PLUMII MF.CH
1:1 El El
LICENSED CONTRACTORS DECLANA'1'ION QTY ELECTRIC PERMIT FEE
1 hereby aferm mal I an licensed under provisions of Chapter 9 fcommenrinll SOB DESCRIPTION
�cz with Section]0W)of Divisio oflho Business and Pnficeo.ns Code,and nay license is RESIDENTIAL
Iy0 ' full force and B PERMIT ISSUANCE RESIDENTIAL,
4 U by Lice
ns C s.a 6 CSS Lica 7 ❑SFDWL C KITCHEN REMODEL
+ W Dme Conlructnr APPLIANCI!S-RESIDENTIAL ❑ADDITION F1 PLUMBING RE-PIPE
ARCHITECTS DECLARATION. - PANELS
p.nw CMHLTI UNIT CSODIFICTIO
Z 0 n 7j ..I understand my plans shall be axed as aurone reatrds MODIFICATION
O z-. :UP'IT)200 AMPS
F 41"'tOil Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
'� 201 If100 AMPS IMPROVEMENT
OWNER-BUILDERman the RATION OVER 10110 AMPS
yy��Iy 6 I hemby affirm hat I em exempt from the Convaclor's License Law for the El BATH REMOUf:UREPAIR ❑DEMOLITION
pd a 4 U following reason.(Section 703 1.5.Business and Protections Cattle:Any city or county SIGNS ELECTRICAL C OTHER
whirl,requme,a period 1.cOnxlNt't,aloft,Improve,demolish,I,,ar un,day fi1NCW fC
fp"'�y prionoi.issuance,also rtquires the applicant pvr such parolee file a,igned stnemrnt SPECIAL CIRCUIT/MISC.
Es,qqz,, Y that he is hem, dpmatem to the provision.or the Commences license Law(Chapter9
n+ 00 (commencing with Salion]OOB)ef Divivion Sof the Business and Professions Code)or TEMRIARTHROR POLHINSTV COMMERCIAL
a X ea eC that he is exempt IM1cafrom and me basis for the alleged exemption.Any violation of C NEW BLDG/ADDITI N C DEMOLITION
F4• Section]031.5 by any applicant for u arrant subacts me applicant to u civil penally nl POWER DEVICES ❑TENANT CFOOU SERVICE
z Pry not mart dis.five hundred della.1$500).
€^Q C 1.0 owner of the pmaeny or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will Jo the work,odd thf amcture is nm inrended proffered for vale(Sm 7044.Business ❑OTHER
0.3 add Professions Care:The Conlmctors License Law docs not apply 1.an owner of OUTLETS-SWI I CHM-FIXTURES
property who builds or Improves thereon,and who does such work hiinsclf or through
his awn employ.,.provided that such improvements orf nal intended or offered far NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however the building or improvement is sold within one year offomphaion,lite SQ.FT.FLOOR AREA $/SQ.Pr.
owner-builder will have the burden ofproving that he did not huildor improve forpur,
pose ofsole.k
C 1,os ownerof the proli not exclusively trimmed,with licensed ambort a to TOTAL:
construct the project(Sec.7044,Business and Professions Crile:)The Comracar's Li.
cense Law does nm apply m an ownerof property who builds or improves meson.end QTY, PLUMBING PERMIT FEE
who conwetsfarsuchpaxjcda with avmmmor(,)hernial purvuant 1. he Contractor's
License Law. PERMIT ISSUANCE - 6
C lames crop)under Sm. ,B&P C for this mason /
Owner Dale
AL'T'ER-DRAIN&VENT-WR'I'ER(LA) - VALUATION
'
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm ander penalty of perjury one M the TO lowing declarations:
CIA have and will maintain a Certificate-fConxnl to sel Nation,for Worker's Co.,.. DRAINS-FLUOR,ROOF AREA,GOND, STORIES TYPE CONSTRUCTION
stains,ax provided for by Section 9]00 of the Inbar Coda,for performance of rhe
work for which this permit is issued. FIXTURES-PER TRAP
ave and will maintain Workers Compensation Insurance,as requirW by Section
37110 ofine Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEm-1 INC.4 OUTLETS OCC.GROUP APN
My Worker Cam sa'm Incur ce c rtie and Pnliey nyytmr)yy
Carrico Policy N..:N`js Ti7�1f4s ,GAS-EA.SYSTEM-OVER 4(PAT
EROTICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(This aselinn need not The completed if the permit k forme hundred dollar,1$1!x0 BUILDING DIVISION FEES
less) GREASE TRAP PLANCHECK FEF.
I certify that in the performance nfine work for which this pemlil is issued,l shall
sol employ enyp in an mann, vats to bmome sub act ratite Workers'Cam ml- SEWER-SANITARY-S'fORM BA.211.14,
Y j P ENERGY FET? `
,0 ration Laws of cell JA� r�
Z O Applicant � a I WATER HEATER WNF.NT/ELECfR -V tiGRADING FEE
iq NOTICC AP (CANT:If,otter making this Cenificam of Exemption,you should WATER SYSTEM/TREATING
I"! become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
ITW] fonhwilh comply with such provisions or this permit shall be deemed mooted, WATER SERVIC17
0
� z CONSTRUCTIONLENDINGAGF.NCY NEW RESIDENTIAL PLMB. SQ.EL PAID
U 0 I hereby affirm mal there is o construction lending agency forme performance of Da Recabin#
the work for which This ismmil is issued(Sec.3097,Civ.C.)
Q Isndcr's Name TOTAL:
0 Landers Address TOTAL:
y I certify Ihm 1 have read this application and state that the above information is BUILDING FEE
nF.a rn correct.l agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICALPFRMI.1' FEE
U z building construction,and hereby authorize representatives ofmis city to enter upon the SEISMIC THE
above-mentioned properly for inspection pulpascs. •
(We).9.To.,a.indemnify and keep h:umless the City of Cupertino against PI;RMIT ISSUANCE ELECTRIC FEE
liabilities,judgments.toms and expenses which may in any way accme against said City AT-TERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT fon IO.000 CFM)
SOURCE.REGUI,ATIONS. MECHANICAL HE
AIR HANDLING UNITtOVER It),"CPM) CONSTRUCTIONTAX
Signature of Appllcan/Conhactor Data EXIIAUST,HOOD, WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle limitations material HEATING UNIT GO I W."BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safely •
Curie,Section M532fa)? HEATING UNIT!OVER 100,00i BTU)
❑Yes 0N VENTILATION PAN(SINGLE REST D) PAT[)
Data Receipt k
Will me air mate or famre building occupant use equipment or devices which BOILER-COMP(3HP OR I(p,OW B'rU)
emit hazardous air contuminans as defined by the Bay Area Air Qu:Jily Management 'TOTAL:
District?
' ❑Yes Nr' BOILER-COMP(OVER IW.Uq BTU)
1 have mad the hazmdeus materials AIR CONDITIONER
rtg2,5533 tx under Chapter of Cali- ISSUANCE DATE:
fomie IleullllnaSate ty Code,Becaions 25505,255A3 tm115534 gillIunJe1 f tit 1ha1 if 'a NEW RESIDENTIAL SUCH. SQ,IT.
building ,k,nal arre must
nett
rmr fti yresponsibililym notif me rete am
ofthe Ieman,, ah must) net prior to issu vee o(a QrtiEc eo capon -r Q T
roatthorizedagcnl - Dm TOTAL: ISSUEDBY: `-'�• _
OFFICE