28579 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT,PEN ONLY
'I.CITY OF CUPERTINO BUILDING-ELF.CTRICAI. . PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMTf .PLUMBING-MECHANICAL - 9
BUILDING PROJECT IDENTIFICATION 8 8
BUILDINGADDRESS. - • SANITARY NO. APPLICATION SUBMITTAL DATF
I
O NE @M:: PH `��^ �ITRA 'E: • - JLIC Y NO. NIC' z ,CONTROL#
ARCHITECT/ENGINEER: LIC gDDRLS. ❑ - '
.
CONTACT: PHONE: _ ); y BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG SLOT PLU7 MECH
3W r—
IJCFNSED CONTRAcq ORSDECLARATIDN QTY. ELECTRIC PERMIT FEE
',I hereby affirm that I licensed under p Ins of Chapter 9(commencing ]OB DESCRIPTION
',O„ZZ with Sea n]000)uf Di J UM1e Ousme.senJ Prf 'snns CodeanAmyllcese is
full force and - RESIDENTIAL:
L [
PERMIT ISSUANCE
ouZ��2 License Class
�� L(a# _ - ❑SFDWL '❑KITCHEN REMODEL
yQy Date ConvacmF APPLIANCGS-RESIbENT1Al. []ADDITION El PLUMBING RIiPIPB
Haan ARCHIIf T'S DECLA ❑
ION PANELS MULTI-UNIT , ❑STRUCTURAL
IIS Z O 0 q I understand my plans hall be used a,public records .. MODIFICATION
OZ G UPT02WAMPS ❑INTERIOR El CHIMNEY REPAIR
914 sw Licensed Professional - 201.10MAMPS IMPROVEMENT "
fq� a + Oat Ia BUILDER DECLARATION OVER IOWAMPS ❑BATH REMODELREPAIR El DEMOLITION
ps R 1 hereby affirm th t 1 pt f theContractor,
' e - t
{ii�S5O L U folio g (Sect 7031.5,B ❑P fe : cunt SIGNS ELF,CTRICAL. ❑OTHER00 ao,ni
ss+ Oywhich req ' apemtt t t h', p dml', t durapr art s Iso equ a the ppltf hp alt t neat SPECIAL CIRCUI VMISC. /// `thath 1 dpur uv toth p e fth C ntr t Ch pmr9(cord cps ng wuh5 di ]000) CD .I n3 of the tlusmesOode)or P,MP.METER OR POLE INST. COMMERCIAL,
y o p• Otal he i. exempt theref and the basis for the alleged erupt A y violation of -- ❑NEW BLDG/ADDITION ❑DEMOLITION
iYFl1^ZZ-J I+yy,
Section]031.5 by any applicant for a permit subjects applicant m a civil penalty of BR DRVICES
2 nor nue.Pa live hundred d e llars ❑TENANT El FOOD SERVICE
6 ❑I, a fth pope ty y mploy with wages as their sole compensation, SWI ING POOL ELECTRIC -, .IMPROVEMENT
yz o0
will do thew k doe h mreisanti ea fl' d r rsale(Seo]04Q Has El OTHER'
and P f Code:no C t e L ense I w d _ of apply to an uwd o O E tS-SWITCHES-FIXTURES ,
property h bard,o thereon,and h I h work himself or th
h¢own employee "a vidod Pat such tmp v nems not amended m offered Io NEW RESIDENTIAL 9LECTR SQ FT.
sale.IC, gtbebullding nrimprovenounige ddwit ne yevrd lgion.the - .SQ.PT.FLOOR ARCA $/SQ.FT.
r uilder will have the burden of proving t t e nu ud p ve(or .pur. s
po
more
sale.). f the r en " TOTAL: a
❑ p op y,um exoluery ly m g th t comracty Ira
nst th Praia,
(5 c ]M4 Bus nes Calf)Th C nnayyy161v Lt - Q P 2 >
seL d t pplry w er ( ro s,w b ' o t p e 1pcOnn.and QI'Y PLUMAINGPERMIT - FEE QC 1 1995
who 1 f h p l t t O urs e u P vncrors
IJcen L rf ec n v g� PERMIT ISSUANCE �t
❑lam esem tunder3 �•/ ,B ITY Uf LYUPEHII )
ALTER-DRAIN&VENT-WATER EA) f-
Owner - me _ �WUATION
ORKLR'S COMPENSA',mi DECL ATION BACK FLOW PROTECT.DEVICE �0 .` ('
I rtal of iunderpenaltyofafC1Yone of following declarations: - 6
❑Ibvveundwill im,Sccfir 37T0of Gmsenu ode,sum for Worker's Compen- DRAIN9-NLOOk,ROOF,AREA,CAND.
&anion,es provided 0 by Sedien 3]dB of the I r Code,for the performance of the STORIES TYPE CONSTRUCTION
work far which this p it is issued. FIXTURES-PER TRAP -
❑I have and will mini min Wmkefs Co. I.emn Insurance,as required by Section -
3]00oftheLaborCnde, each performs a ofthe work for whichthis Permit is issued. - GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GkOUP APN '
Co er:Worker, as n rr and Policy gtynC/D /d�Y3 GAS-EA.SYST'EM-OVER 4(EA)
Carrier: Policy Nn:/V -�_
CERT E EXEMPTION FROM WORKERS'
CO PENSATION INSURANCE GREASWINDUSTRL WASTE INTERCEPTOR _
(Thlsoution needam becnmplcted illhepetrait is forms,Imadreddoner6($100) " ;, _ 'BUE.UING"DIVISI NFEPS ' s
or lass. CREASE TRAP, PLANCHECK FEE
I nify tha[in the perfomrancwfthe knot which Chip - t' ucq L�hall SP.WEk-SANITARY-STOkM LA:21N1 FT.
not employ yp�pe^r�y�;;n�,y,y/•/'�m�anner heW k Compen ENERGY PBL
0OAlthcam „IeY�YI` /wWA'TERHEATERWNENT/LLECTR - r-elk-
7 pP 1 GRADING FEE
q� NOTICE APPLI ANT If asftc�rmakidg this Cert f ate oflixemption,you should WATER SYSTENYTREATING -
F+
becionde subject to the Worker's Cnmpensan on p c tans of the Line,Code,yan most SOILS FLE
forthwith comply with such prnvisionsor this permit shall be deemed revoked. WATER SERVICE
z CON$TRUCTIONLENDINGAGENCY - NEW RESIDENTIAL PLMB., SQ.FT. PAID
U O I herehy nf0rm that there is a construction lending agency for the performance of Date _Wei,
W. P the work for which this permit is issaed(Sec 3097,Civ.C.
O U Lenders Nome s' TOTAL:
Leadeet Address TOTAL:
WLIa
I certify that I have road this application and stare that the above information is BUILDING FEE
ti
ZZ) correct.1 agree to comply with all city and county ordinances and state laws reiningm QTY. MECHANICAL'PERMJT; FEE
L) bnlldingennAmdioryend herby amtioppose.rm
representatives SEISMIC PED
inspection +
(We)agree'msuve,indemnify and keep harmless the Ciry of'Cupertinwagainst PERMIT ISSUANCE ELECTRIC FEE
liabilities.judgments,costs and expenses which may In any way accmeagainst said City ALTER OR ADD TO MECH. '
inconsequence of the granting ofthis permit PLUMBING FE
APPLICANT U DERSTANDS AN r MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
' SOURCER ” ION MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,0110 CPM) CONSTRUCTION TAX -
Signature App'am/Commcmr I InadEXHAUST HOOD(W/DUCT) HOUSING MI'TIGATfON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applivint or future building eventual storo or handle homonosmmerial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety - -
Code,Section 25532(a)F F s HEATINGIINIT(OVER 100,000 BTU)
❑Yes 7 N
I VENTILATION EAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or nts futurebuilding by the B use equipment m devices which BOILER-COMP 3HP OR 100,000 BTU
moat hazardous'air contaminants as defined by the Bay Arca Air Quality Management ( ) ':''jt
•L
BOILER 100.(100 BTU) • 'TOTAL:
- No' ., a
and the hamrdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ,ISSUANC
&Safety Code,Sections 25505,25533 end 25534:1 understand der if the NEW it MECH. SQ.FT. "
buildingnot currently havevtcnant Not it is toy recponeibiliry to notify the occupant '
ments which must be met prior to Issuance ofv Certineate of Occupancy.harizedagent Date TOTAL: ISSUED BY
OFFICE