28740 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUIIAHNG-ELECTRICAL PERMIT NO /� /� pp
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING'-MECHANCCnI. I �q /'� L X 7 4 0
I BUILDING PROJECT IDENTIFICATION V R
BUILDING ADDRESS.
4 Q/ _ a I SANITARY NO APPLICATION ON_SUB�Mc T-T
AAL DATE
12--+q0 A ALC4C p E Ro wD .I
5 P CONTRACW'S NAME LIC NO. /h
1419AY LJF.9S� ZS'S'J'O16 DwAi� NlCC CONII201,N�
RCHITECEIEN INEER
LIC NO ADDRESS. '
CONTACT:• PHONE BUILDING PERMIT INFO
1 hereby t fli IC mei 1 am Lien eJ TO r I QTY F'FCFT y PP ❑ .8 PLUMB 0
LICENSED CONTRACTORS DECLARATION r ELECTRIC PERMIT Bt(Initial) FEE HIAG � 1 ❑ ❑
due, of Cla, naolnmalsditg PERMIT DESCRIPTION ,
BOZO wab Secuon70(shmf DUmsml3 ofthe BUSmn.end Promssm.Code,ardmy Laneis y pF.RMI'T ISSUANCE r �f O` RESIDENTIAL
n full force and effect / V
W�
F-UV Cl CI... Lm
SFDWL O KITCHEN REMODEL
' L¢eec ° v
H4L Date Cnnhucu„ APPLIANCES-RESIDENTIAL .'' DADDITIGN 0 PL,Hh1BING kE-PII'1?
to ARCHEIT.CTS DECLARATION Cl MULTI-UNIT C1 STRUCTURAL
Zpv2'4 Iundentund my plans shall be.,ad.,public meedI, - PANELS e0 MODIFICATION
O'Z 4 uUP T04118 AMPS zu
rce ]n
Licensed Professmnel ') ❑INTERIOR - y. ❑CHIMNEY REPAIR
OWNER- 12BI-1000AMIS, IMPROVEMENT
OWNER-BUILDER DECLARATION ❑BATH REMODEL/REPAIR 0 DEMOLITION
M1,reby u(Bim ti I um script front the Contractor',Liarme Lew for the LDYEH IWB AhIPS
3aU following reason.ISeaum]011 S.Business end Profn,ions Cale:Any city of county, DOTHER
(� SIGNS 131.F.C1'RICAI.
LL O whmh requires a perm.m construe,nlicq improve,demolish,or rcpan any awmure
.7 prior to itr rsuanecn rcyuues the uppbcanlfor such pennitmfleasigned,teteinem SPI!CIAL CIRCUITIMI5C
rye,p. That he itlieenseJ p.rsuaat In the provision,of the Convector's license Law(Chapter9
GOO (commencing with Section]000)of Division 3 of the Business and Professions Code)or TEhIR METER OR POLE INST. COMMERCIAL:
ayx e' that he in exempt mammon end the bast,India alleged e,entptioa Any vmlation of D NEW BLDG/ADDITION D DEMOLITION
W�
Section 70315 by any applmani for a permit subjects the applicant to a civil penalty of POWER DF:VICFS DTI?NANT El FOOD SERVICE"
not mare than five hooded dollars($500) as
F36 O . SWIMMINGPOOLELECTRIC I IMPROVEMENT
OTHER
w 111 Jo the work,and the,a etude Is not s Lmerd m offered for aide ISm 1844,Business
-i and property who Cade The Contmaars.add w Law Jces not apply himself tin owner of OUTLETS-SN'ITCHIS-FI%'1'UkES .
his ov y who budJS or Improves thereon,and xho day m a work deed or or through a
his awn nnPlayccs,pmvWrJ that a¢h improvements ere sit ImmadeA or offered for NEW RESIDENTIAL liLLC1'R SQ FT.
sale If,however,the bidding or impnirement is sold wiihmone y,u.frmunpleuon,the •SQ IT:FLOOR AREA VSQ.PT.
owner-builder%ill have the burden of proving that he did not build or mallow,for Par-- O
pose rf snled w
01,as owner of the pmpeny,am exclusively contracting with Ilcansed comment..to ., 3 TOTAL:�77 0 Vy
c imam t the project(Sec.]f W,Business and Pmfessmns Cale.)The Commemrs Li- I �`—I T O 0 19
cause Law doe,not applym an owner mopany xhe build,onmprove'thanam.and QTY PLUMBING PERMIT PEE I f/ �C
uM1Ornmmctsfors chpmtcctswtthaco mostr(s)I 'need P.nuunttolba Contamon" _ �Y
License law. I PERMIT ISSUANCE. CITY Lit:fur
D lam extra star s,[. ,B&P C Cardin,m.,.n Ea r1N0
\ w I dla'ER-DRAIN&VENT-WR'I'ER(TAI VALUATION
Dam
r� WORE'.R'S COMPENSATION DECLARATION I BACK FLOW PROTECT DEVICE
1 rehy affirms der penalty of pe,ory one of the following declarmam: ` 1
'Ili cant wJl mmmaanv Certificate of Consent to,elf-insure Bn WOder,Cnmpen- DRAINS-I1,00R,RDOP,AREA.0 STORIES TYPIi CONSTRUCTION
a s provide)for by Section 3700 of the Labor Cale,for the Performance of the
work for which this permd is mr,aed. FIXTURES-PER TRAP �• �, �I
❑1 have and will maewin Wader's Compemaoon In...care,a,rtquirtJ by Section �s•r
3700 of ilia labr Code.Coolie performance of th<wnrA for which this PVnnn is mued sl GAS-EA SYSTEM-1 INC.4 OUT]INS `11 ` I OCC.GROUP APN
Carrier. sCotnpenInsurance n lnsunce canie' lcy N
aam Cy number a
GAS-F,A.SYSTEM-OVER 4(EA) I. -
CERTIFICATE OF HXEMP'11ON FROM WORKERS
COMPENSATION INSURANCE " GRFASF/INDUSTRL WASTE INTERCEPTOR '� -,�•
,- (Dus section road not he cnnphocal lfthe proton is Corona handfed dollars($11)111 t ,� BUILDING DIVISION Il?GS
mEoa) GI21?ASETRAP i vS_I PLANCHECK FEE
I cemfyihet in the performance ofthe work for which thispcwn nissuW.I,hali SEWIiH-SANITARY-STORM EA.2W FT.
not employ any Person In any manners m m become,ubjet9 to4he WnrAers'Compen- ENEIRGY FEE
'0Z sauor Law,of California.Date WATER HEATER W/VENT/ELECTR.r
O Appheant GRADING FEE
rz NOTICE TO APPLICANT.If,attar making this Certificate of Exemption,you shout) r rWATER SYSTEAVfREA'fING
. become au bjeci u;the W'orker's Compensation provaaonv of the Labor Cale,you must SOILS PEE
f� Q forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE s -
Z CONS'fRIJC'I']ON LIiNU1NOAG1iNCV' N EW RES1DENTIA1,PIAM. SQ IT. IPAID f
G0 (hereby effmuhvt there is u<onswcuon lenJing vgency far the Performance of —I Dam Receipt is "
W the work for which this permit is issued(Sec.300,Co,C)
Q U Lender,Nun. TOTAL
,• TOTAL:
`
Lenders Addrer TOTAL
6r 1 comfy thin I have read this application and sivfe out the above mfurmauon I. t BUILDING FEE
4A correct,I ague m comply with all city and county ordinances and state laws mEt w I Q'PY. MECHANICAL PERMIT FEE
L) G building construction,and hereby a.ihome represenmllves ofthaa city locaterupon the (SEISMIC FEE
abovemmmtimmal property for inspection purpmes PERMIT ISSUANCE
(We)agree to save,indemnify and keep barmlear the Gry nr CUpeninu againal _ ELECTRIC FINE 45 . d
habtboes,Judgmenis,cosiv and expemes which may in unywayaccme again,(SmA Cny ALTER OR ADD TO MECH. `��`
cons,mate of the gran ung of,h,s panto. (PLUMBING FEE
APPLIC !T UNDERSTANDS AND WI.L COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'ITO 10.000 CFM( I MECHANICAL FEE,
SOURAI I EGULATION /
/O LAIR HANDLING UNIT(OVER IB,(glll CFM) _ CONS'I'RUCT'IONTAX
Smgnu vof Applican Cnnuaeum Date EXIIAUSTUOOD(W/DUCD 'r (HOUSING MITIGATION FF,E
.AZARDOUS MATERIALS DISCLOSURE?
Will the appbcanl ur(murt hwlding nccuPam,mre orhantlle hazardous mvmriel HEALING UNIT(T0100,000 BTU)
ea defmcd by the Cupertino Munmlpnl Code.Chapter 9.12,and the Health and Safety _
Cade,Secmn 25532(a)!. - HI?ATING UNIT fOV1',R Mitsui B'TUI
r
0 1'es El No VENTILATION FAN(SINGLE RES ID) IPAID
Dam RecelPt k
Will the applicant or future building occupant use ea Air Quality at devices xh¢h
coal hazaNO.s air contaminants as defined by the Bey Area Air Quallry Management I BOILER-COMP(JHP OR IfN1,000 BTU(
Drstn[Il I
OT
' ❑Yes F1 No BOILER-COMP(OVER IW,IpO BTU) h
AIR GDNDIT IONGR
have re d fet haze douv mammals 5,1553 em tin pier F JS of he Cah. SSUA
,inmtx Hnilth&S;tlery Cale,Sections25505,255)3' )25514,1 understand that,I the NEW RESIDENTIAL MECH SQ El',
bomldmgdoes not currently have a tenant,that his my respansmay is notify me occupant I r
oI the requirements whmh must be amet pnono la..me of a CeemOcate of Oe apaacy.
Ownc,m undimmed agent Dale TOTAL( Ig$GIiD BY.
OFFICE