28760 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO i I BUILDING.ELECTRICAL PERMIT ND
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28760
BUILDING PROJECT IDENTIFICATION
�UILDINGADDRESS: ' + / s / r SANITARY NO APPLICATION SUBMIMI'TTAL DATE
,5 az OWNER 'h(E� �� 1 PHONE. CONTRACTOR'S NAM If NO.
CC11 N/C CONTROLp
ARCHITECULLNGINEIiR: I ,LIC NO', AUURES ( . 1, 1-1
-
to /90 w��t _
CONTACT. PHONE: BUILDING PERMIT INFO
L 4 n J n'. �I7/�L/-a �❑ Consultant Faults Paid by Applicant(Initiap BLDG1 ELECT - PLUMS MECH "
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE,
9" I hereby affirm that 1 am licensed under provi+ions of Chapter 9(Commencing I ' ' JOB DESCRIPTION
OZ with Section'!O(10)nfl)vmsionJof the Business and Pmfo>inns Code.an my bcensen RESIDENTIAL
O in full forc,ye and_e�f���fect. r�j� ��.,� ` PERMIT ISSUANCE
License / A Coo �'-���'/"'�� ❑SFDWL ❑PLUMBING REMODEL
Date Comer ftA r�_K AI'PLIANCIiS-RESIUIiN'TIAI. - _ DADLTI-UN ❑PLUMBING RGPIPIi
RCHITECPS UECLAR ION ❑MULTI-0NIT STRUCTURAL
PANELS
Z O y Z l undersand my plans shell M used es public records MODIFICATION
OZ^� ... - UPT0200AMP EINTERIQR ❑CHIMNhY REPAIR
r4F' Lmensed Professional '
' 201.1(IW AMPS IMPROVEMENT
OWNER-B.trap, frDECLARATION
y Q I hereby affirm the 1 em exempt.rum the Convenor's,Aa, law for*' OVER IOW AMPS - ❑BATH RE D P 1 :]DEMOLITION
following rca+nn.(Sao it 703 l 5,Bnamew,nW Prnlcaenn+Cixlc.AnY My or countY SIGNS ELECq'ItICA1. - -I ❑OTHER `1
F�Ny
which meectum1 permit als,re conswet,slier.improve,Jemolmh.or repair any structure
pppQ poor quires the applicant for such permit In fdleaamgned statemere SPECIAL CIRCUTUM ISC.
W ad Ohm he ms lreensed pursuant to the provtsmnnoOhe Camrannrs License Law(Chapter9
lenmmencrng wuM1gectiun]fl(IIIInI Ulvntnn3uliM1e DUxinenend l'mle+,anm Cnde)nl I'EMR1,111'1'IiRORPOLE1NSl' 2y COMMERCIAL:
6 c Nat he is emmn therefrom end the basis lot the alleged exempnon Any vacatmn of
Section 90]15 by any applicant for a porno objects the epplmannn a civil Penalty of POWER DEVICES El NEW BLDG/ADDITION ❑DEAfOSERVI
Zy
not a than rive haralmddmllers($500) - ❑TENANT " OFOOD SERVICE
H6 QI,as owner of the pmpeny,nrnry mnpinyct.with congasitsthem so le ron,ovirlar. SWIMMINI POOL ELECTRIC `t ) IMPROVEMENT
C will do the work,and the+wnum is not intended oroffered forsale(Sec]Oiy ldumness ❑OTHER
a 3$ and Profosions Cade:no Contmcmrs License Lew des na apply man owner of OUTLETS-SWITCHES-FIXTURES '
property who builds or improves thereon,and who does such work himself or Nroug.,
his own employees,provided that such improvements are not amended or oflered for NEW RESIDHN'I[A].IiLECTR SQ IT d
sale If,however.the building or improvement s sold within one year ofcomplevon,N_ SOIFTr)FLOORAREA $ISQ PT.
tor-builder will have the burden of proving that he did not build or improve for pur- '
pre of salene ,
s as owes o act property.amavel. it cantmain,with licensed ntramcmrs i- SEP 20 '9' .
construct the pm3ea(SIN]014,Business onJ Pmfeoi0ns Code)'Thc Contractor's Li-
cart Law does not apply ro am ownerof,.,,ny who builds or [boom., ad IQTY. PLUMBING PERMIT FEE,
who cmnlmew Inr such prim+with a contractors)Been+ed pummnn to the Contractors
Lovense l.aw ' PERMIT ISSUANCE' �IIY Ur t;�rtH PING
❑1 am exempt under Sec. ,Il&P C for this reason
Own^` D,I'., - ALTER-DRAIN&V17W-WATER(EA) j rVALUATION `
WORKER'S COMPENSATION DECLARATION i BACK FLOW PROTECT.DEVICE
I hcmbY i ffird under p r a ly of p,.,one of the following declarations
[have soil will maintain Cenificem of Cnnsem mcelf-inaurc for WOrker'ICompen- DRAINS-FLOOR,ROOF,AREA.COND STORIES TVPF.CONSTRUCTION
satmn,as provided In,by Se d i 37W of tire labor Code;for he penonarn,r of th.. '
work for which this penunu,,ned q FIXTURES-PER TRAP
❑1 have and will mammin Workers Cmia,matmn Insurance,ea occurred by Sreuo -
' 37W of the labor Code,for the performance ofthe work for which this penno isdssued I GAS-EA SYSTEM-1 INC 40IfFLETS OCC.GROUP APN
My Worker's a n'u0n lnsyf;5ilce ca Icr and Polrey number nr'
Carer- ;r �l'01 NO.: [GAS-EA SYSTEM.OVER41EA) � s
CERTIP COMPENSAIIONIINSURANEORKf: S' - 't
GR EAFJI
SNDUSTRL WASTE INTERCEPTOR „
(Toxsechon need no,McumpleteJ ll ilia Penns is lmone hundred dollors($IWI ) BUILUINO DIVISION FF.F.S
or less.) , GREASE TRAP,
[certify that an the pertmucaceo fthe work for which this peon isnsucd.[shall IPLANGHEGK FEE e
O Applicant ��� �— / p I WATER BEATER W/VAT1 STORM CA 200 IT.
not employ any person many manners,as ui become taboo n the Worker,'Cum en- ENERGY FEE ,
,Z Indian Law+of Cut. rem Bane WATER HEATER WNI?NT/ELGC'lA
GRADING
y NOTICE TO A�CANf If,after m.ilmg this Cenrflxete of Exemption,you should
tiecomesublect to the Workers Cminpens,,tion pon....un+of the l,ahor Code,you mil [SOILS FEE'
I^ fanhwnh comply with such pxm,,mns or his permit+hall he deemed revoked. Wp'1'Ek SERVICE
D
I] z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ TT PAID
fJ ,lherehyafOrmthul Nerenn cma,uricuon lend,,,,agency lnnhc perinrmdnee of I I Date Race,,#
the work for whmh Nis pmnn n issued(Sec.300],6v.CI '
I--I Lenders Nam- TOTAL:
O W [.endcra Add-, TOTAL: .
I rarity that 1 have toad this uPplicmimn and,,tam that the shove mfonnatme Is t BUILDING THE
h correct I agree mcomply hereby ndbooz conmyordinmeoand die laws upongto IQTY. MECHANICAL PERMIT FEE
V budding construction, ,herai,ornmr,mr,presenmtives oflhis city to ether upon N- [SEISMIC FEii
uhnve-mce)agree toptny fodemnity anpkeepho' PERMIT ISSUANCE •�City(Wm)agree to cost,ande expenses and keep hay an anyw way of again&,s against ELh:C"TRIG PI?F1 'j
in embe,aim.mehe our e,npensowhmh maymanyway stirs vgmmd veld City AUTERORADDTOMECH. _ [PLUMBING PEE
in cnnxqucnce of the,moon,of this pcnnn.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(TO Ehag)CFM)
' SOURCE REGULATIONS MECHANICAL TEE
/"f .^ / 1 AIR HANDLING UNIT(OVER 10,OW CFM) IrONSTRUCRON TAX
Signammor thcdnPCondcon`a.•✓ Umc EXHAUST 1400D(W/DUCT) -� HOUSING MI'I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hzndk hazardam materal I HIiATING UNIT(TO 100,000 BTU) �.
asdefincd by the Capetian Maine,.]Code,Chapter 9.12,and the Heal@ and Safety --
Code,Scuuo25532(u)'! m IIEA'I'INC ItNi'T(OVER loo,non it U)
[]Yes F Nn
VENTILATION FAN(SINGLE RIiSID) MAID
Data Recedptp
•Will the applicant orfumre budding occupant axe equipment or do...a,wh¢h
ern hazardous air comummanw as defined by me Puy Area Air Quality Management BOILER-GONE(7f{P OR 100,1100 BTU[ ,
Iu:ICL
Drcm[R
❑Yes Olin BOILER-COMP(OVER 100,0(10 BTU) _
.. -
I have rend the hawdmis materials regmremens under Chapter li 95 of the Call. AiIt CONUI"I'IONER , „ ISSUANCE DATE
fume Health&Safety Cale,Secuams 25505,25533 and 25534 1 understand than if the I NEW RESIDENTIAL MECH SQ FT
budding does not curmly have a temmm,Nat n ds my m,ni ibduy m notify the occupant /
of the requinmecox whmhnmet Rnmtpnml m..xmamente Ccmliene of Gec,pmcY
Owner oremhonzeJ agent Data I TO TAE. [ISSUED BY:
OFFICE