28456 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL I PURMITN
BUIL romING-MECHANICA 028456
DING DIVISION APPLICATIONAPERMIT PLUMBING
I BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ' SANITARY NO. APPLICATION SUBMITTAL DATE a�C
'OWpI!]t$N��1 I ,.�f `PHl)Nfi t y�❑)tM]�gfll�t�/A.(�'O`RB'S N(l+h��`-{�,��/ � . fI/Jq 91S)��� N/C COMIROLp .
ARC'P�—R��E�'1ILlT/ENGINEL•R �Illrv` L/ICTNO Yll(dash N+1�(,l 71AL( ,`Z �1�y4MV_`O`��'ds ❑
'CONTACT. PHONE: ' Q S 0 I BUILDING_PERMIT INFO
r t t S❑ C"annuitant Fees Paid by Applicant(Initial) I - ,IiLIiC' PfJAI�B' ' MECH
• y
LICENSED I CONTRACTOR'S DECLARATION ` QTy ELECTRIC PERMIT FEE EJ
1 nerccy affirm that 1 am lmensea anger prov'inads of ennpmr 9 trammenri 1t( _ _ I JOB DESCRIPTION
OCZ with Secuon]000)af Divi+iun 3 of the BUamexe and l fesum"Cody d my lmen
ADO 4 1 `l/ PF;RAIIT ISSUANCE I RESIDENTIALi,
F aj in fan force and cluster
QUU LteensUC,p _ — OSFDWL KITCHEN REMODEL es,F-�W Dam Comrvcm - �_. APPLIANCES-RESIDENTIAL 11 ADDITION 0PLUMBING RE-PIPE
F.OH _ ARCHITECTS DECI,A PANELS - EIMULTI-UNIT El STRUCTURAI.
Z O I understand my plum Shull he mail a,pnh0c recoNs MODIFICATION
OZ n IPJU 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
1.44 'q Licesswil profesmonul 201_IMAMPS f MPROVEMENT -
F •.t OWNER-BUILDER DECLARATION OVER 100(IAMPS
' I hereby affirm that I am exempt from the Commmor'a Licen+c Law for the I TH REMODE JREPAIR 0 DEMOLITION
X3 S U Iollowing reamn (Secuan]03 L5.Business enA Profm<ions Code:Any city or county SIGNS ELECTRICAL OTHER
YJ 4, which requires a penult to conawcL aluer,improve,demolish,or repair any structure
n
�y proewsteeuanre,akorc, see the applicant La+uch m u
peuo Bleavgnedsmermse SPEC1ALCIRCHIDMISC
} thin M1COlmen.e.l punuun(ni the provolone nl the Cnmracmr'e 1,¢emn Low lCM1apmr9
a0a Iavmmencingwllh Seninn]OnE)ofD.vmlm 3of the Rare,,and Prolesmm Code)ar I EMI`.ME)ER OR POLE DIST COMMERCIAL' ,
0. Qo LL
but he is exempt therefrom and the bei+tor the alleged emanNu n.Any vmlmmn of 0 NEW BLDG/ADDITION 0 DEMOLITION
�y Seetion]0315 by any uWherin for a prism,sub)eots the applicant to a civil penalty of POWER DEVICES ,_ OTENANT ' OFOODSERVICE
no more than Eve hundred dollars(5500) ,.
=O ❑1,as owner o(the pmpeny,or my employees with wages as thensole cnmpensauon, SWIMMING POOL ELECTRIC . IMPROVEMENT
F will do the work,and thestrucmre¢,intended orofered frsmle(See.]IH4,Business OOTHER
3 and Professions Cale The Comnce,ox License Law due+na apply m an owner of ` (DUTLETS-SWITCHIiS-FIXTURES, l ,
prupery who builds or intpmeex thereon,and who does such wok hmsech or throng,. _ c
his own employee.,provided shat o,h Inipo,cmcna are not attended m offered]or NEW RESIDENTIAL ELECTS SO FL. '
,ale.IL M1owevee1behudding nnmpmvememowW within one year nl commletion,th. SQ IB',FLOOR AREA - $/SQ.FT.'
owner-builder will face in;burden of ponying that he did not build or improve far our-
poseafsaleJ. -
❑L as owner ofthe property,am exclusively contracting with licensed commctois to I I -
construct the perfect(Sec.]DW,Business and professions Code)The Contractor's cone Lt- -
ceeLawdoesnotapplytoanownerofprimarywhobuildsorimprove,marean,anA IQTY. PLUM BINGP I FEE
who contorts for such projects wish a commissariat licensed pursuanuo the Contracmea -
Licenmexe ' ' PERMIT ISSUANCE ,
0 lam exempt under See ,R&PCfor this reason
Owner ' Da __ ALTER-0 RAIN iNT-WATER(EA) �VALUATION�
WORKER'S COMPENSATION DECLARATION'S BACK ROH-CL DEVICE I {//��LyLy(
I hereby s ffimt under Penalty of penury one of the following declarations:
son.ave and will lnaimem aCendcem of Conanuo.df-insure for Wider:.Compen- )RAINS-FLOOR,ROOF AREA,CON, - 1
c PrnvlJed for by Sermon 37W of the Labor Cade,for the performance of th_ STORIES TYPE CONSTRUCTION
irk for which this permn is issued t PIX'1'URES-PIik TRAP �Y '
I have and will Inmatnut Worker's Cmnlacoai0on Insurance,m raloard by,Section + I 1 �--� a v
3]OU of the Labor Code,for the performance is]the work for whsh this pern:ius issued I GAS-EA.SYSI'Bit-I ENV 40UTLETS OCC.GROUP' MIN
CY�odeys Colnpenealinn lnncec el'NICY Ncy number are GAS-EA Sl'S N(GI
CERTIFICATE OFPTION(ROM WORKERS' /3 --I
COMPENSATION INSURANCE G EAS I.W S E 1 R
BUILDING DIVISION R.I.
IThs section need notMcompleted lftM1e permit is(Drone hundrcddalla 81 ) RAP ��
or less.) r PLANCHECK FEE'
Icerttfy that mthe perloimarn oOhc w�r_kfm whin thI um ,IS all P
.
not employ any person In any manner ivhs In 14"i:Rii s e i Lai den' ice en- S W -5AN1'1'AR -510RM F.A. 1 PI' - pNP.RGY FEE. d� B
Z nation Laws of Cre,fomlm Da,e,' _ 1 _v
O s WA ER HEATER W/VENT/EL TIR ..
Z O Applicant .; I GRADE
y NOTICE TO APPLICANT,d,+aa n bong tins s-cruncate of Exemption.You should WAT SYSTEMi'LRR G
I-•I become subject to the Workers Compensation provisions of the LaMr Cola,Sou must S FEE 1�
forthwith comply with such pernsmns or this permit shall be deemed revoked I WATER RVICV ' y yy-v �a l4l+
IY G p � ��
Z) Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMI3 SQ Ff PAIU
U O I hereby affirm that,bere is a rumuuctmn lending agency for(he pomimionce of - 'Dam Rr"Iplp
the work for which thi+ rrmmn issued(Sec.309],Co,C)
OU Lender's Non- ./� TOTAL.
W Lender's Add.,- '�'T'I� 4 /
LLLf------ttt G I certify that I have rend this application and state that the aMve mfnmmuon i, - 1 BUILDING FEE 5/ �+
W) ennect.l agree to comply with all city and county mimmeca and smm law.re to IQTY MECHANICAL PERMIT FEE r
L1 � budding construction,and hereby aushomm represenmtiveso(this city toenter pout ISEISMICFEB �O
above-mentioned property tar Inspection purpose,. 1117RMIT ISSUANCE
a ,We)agree I +nvc.Indormfy and keep hanale++•the pipe ELECTRIC FEE
Imbil'nms,)udgment+,coal and enpemcas%Michauy in any sing , d I�r// ALTERORADD'IOMECH. PLUMBING FEE
coneCA a afihegSTANDf,hrs peimlt cu ai !
APPLICANT 'NDIiNSTANDS AND H LL ) P I AIR HANDLING UNIT TO I0,000 CEM)
SOUR EREGU MECHANICAL FEE TIONS.
AIR HANDLING UNIT(OVER 10,000 CFAU -ONSTRUCION TAX
SlltmmmE�plmanVCTtrllcmr Date EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE. .
-• Will the applicant or future buddingocupaui an drhnndle lmeiWous mal,,i (I ILIA LING UNIT(10100,000 BTU) -
I its defined by the Cupemnn Municipal Code,Chapter 9.12,and the Health and Safe,, '
Code.Section 255321x)1 �� HEATING UNIT(OVER I fgy000 BTU)
D Yes [3Nn IyENTILATION FAN(SINGLE RFSID) (PAID
Will then (main ar future builder N i equipment Date Receipt g
pp g..Not use e m teem or deices wh¢h t
emit Loss...air mmatnmor s as defused by the Bay Area Air Quality hl.magerm., I •I BOILER-COMP QHP OR 100.000 BTU) .'
District'! j t TOTAL:
Dyes Fl No
BOILER-COMPIOVF:R 100,000 BTU( v \. `'
AIR CONDITIONER /
` 1 hale rend the hmallous inmennln requtremciiw under Chapter h 9'5 of the Gell- i I ISSUANCE DATE
forma Health&Safety Code,Sections 25505,23533 and 25534 1 understand that if the NEW RESIDENTIAL MECH SQ,FT.
budding does no currently have a moral,that it is my respansibihty m nmtfy the ircuPant
of the requirements which must be met prior to hominess of a Ceerficme of(kcuWncy i
Owner or aumonmJ agent Dam TOTAL .I ISSUEDBY'
OFFICE