28920 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-.6 SE BALLPOINT PEN ONLY .
CITY OF CUPERTINO " BUILDING-ELECTRICAL PERMIT NO I
BUILDING DIVISION - APPLICATION/PERMIT. `PLUMBING-MECHANICAL'
« - 'Ms. BUILDING PROSECT IDENTIFICATION / • - 2 O
BUILDINGADDRESS: i _S 4., SANITARY NO. APPLICATION SUBMITTAL DATE
OW ER'SNAME - PHO E: JaNTRACTOR S NAME�: 5 yp�C O k•r -
s e �` 9 N/C ONTROL# n.
R GINE x:. .� LIC �
1�YRE55: - ��
CONTACT- ' PHONE: - III ILDING PERMIT INF
r Y. O Consultant Fees,Paid by Appliwnt(Initial) BLD ELECT , PLUMB eCx
PID
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
.I hereby affirm that d de v f Chapin 9(commencing 70B DESCRIPTION-
,QCZ thS t ]000) fD s,on3of Ne Bus, .anJ Professo Cade,aadm be se - - - -
CO w,, PERMIT ISSUANCE RESIDENTIAL,
U Ua fon f oe and affect .
Licon Cas; Lic.# - ❑SFDWL ` -❑KITCHEN REMODEL
F�W Dme 'Cont tr APPLIANCES-RESIDENTIAL ❑ADDITION a El PLUMBING RE-PIPE
FOy ///�p,•���q°^�v A HITECTS DECLAR TION • PANELS
❑MULTI-UNIT' "' ❑STRUCTURAL
Z 0 7a pl a shall e W p blot reeoids - �.. -MODIFICATION
OZ- 'd�eST�e�IjJ JI�� UPT021lfIAMPS -
{r1r ❑INTERIOR El CHIMNEY REPAIR
IQ VAW1!,' al 2011000AMPS
'OWNBR BUILDLR DECLARATION ! - IMPROVEMENT' ,
LqPd LLCCCW14 Lhereby aif,.that 1 ma acred,1 from the Contractors License Law for the OVER 1000 AMPS - ❑BATH REMODELIREPAIR 0 DEMOLITION '
W'36F follow, g e nn (Section.IOJIS B me and Prof s Code A y 'ry co county
SIGNS ELECTRICAL ❑OTHER
41 h,h req re a permit 10 construct, It p d n h.h m rep y st ucture
proctor't.issuance.uance 1 q theapplicant[ such permit fl 'g ed t temant wSPECIAL CIRCUIT/MISC
r that he is licensed pt to the provisions ofthe Contractors License'L (Chapter9
AC (commencing withSection 7000)idD 0 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INS T. 'COMMERCIAL,
d cthat h exempt them mad theb f the exemption.Any 1 van of - -
^,al Section 7031.5 6penalty- - - El DEMOLITION
t
y any applicant i f permit subjects the applicant I of POWER DEVICES EINEW BLDG/ADDITION s
Z p. t more than five hundred dollen($500). - ANT " ❑FOOD SERVICE
SdQ ❑I,as owner offie pr pertY'or my employees with wages as th i le cmrpaasamz;' SWIMMING POOL ELECTRIC. IM OVEMENT 11 It
will do the work and fire structurenot intended orofferedf I (See.7044Business BOTHER
aa and Profeas,ons Cede:The Cot tt License Law d es not apply to an owner of V
QWTLETS�-SWITCHES-FIXTURES s Z '
properly who builds otimproves thereon,and who does such work himself or through -I _ tt,,..
his own employees provided that such improvements are not intended or offered for. NEW RESIDENTIAL ELECTR SQ FT.a 4— 4 0 A:
sale If.however,the baldg or amprovempat is sold within one yearrocompiclam,the _ ,SQ I'ry[I,pOR/AnREA $/SQ.PT
mvmprb.ild.,,will have the burden I porid,that he did t build p far par
s „ Ts
p e Lale) s
❑I.res owner of the I p rty am exclusively contracting with licensed nw ton to ' A v« 7 (�
constructh project(Sec ]044 Business d Professions Cole)The Contractor's L, 'F ,, "99
cense Law does not apply to an owner aTroperty who builds or improvestherm d QTY PLUMEI RMIT FEE' LU
who contracts for such projects with a contractor(s)licensed pursuantt the Coutn) �l'rl�,License Law, PERMIT ISSUANCE
I om exempt under Seo ,Il&P C for this reason -
f ALTER-DRAIN&VENT-
Owner Dote t A7 VALUATION
WORKER S COMPENSATION DECLARATION BACK FLOW PROTECT DE
1 h by f under penalty of perjury one of the following deductions: RDE ARE 1❑ Lha eandwill maintain a Certificate of Consent is self,usu for Wrkers Coupon- DRAINS-FLOOR. 2
STORIES TYPE CONSTRUCTION
sntion as Provided for by Section 37M of the Labor Code,for the performance of the _
work for which this permit is issued.',. _ I FIXTURES-PER TRAP
„ ❑ I have and will maintain W k rs Compensation Insurance,as,required by Section
37M of the Labor Code,for the performance fth work for which this Permit is issued. GAS EA.SYSTEM-I INC.4011T� S i2
My Wnr er m I f ace cart 1 Policy OCC.GROUP APN-
MYWr Policy No.: GAS EA.SYSTBM-OVBR4(BA) t;-
1 TIFICATE FBXEMPTION FROM WORKERS' s •�
COMPENSATION INSURANCE GREASFIfNWSTRL WASTE INTGkCEPTO
PLAN BU OI IVISION .P <
„S
(ib,e wcnon oeetl nm heu,mpleted lfthe peal!is fornne hundred dollars($I(Ilq -
of les'.) OkBASE TRAP.�.f+
NChIECK PE
- '
I acibily to,mthe Itaftsommone.fthe walkfar whishthis permit is enIshan
note ply an,person na yin so est b me whutt3eh Weaken'
Camper- SEWER-SANITARY-STORM EA.200 n " ENERGYFEE
O ,0, niticar Law.,of Ciffificirmir DataWATER HEATER WNENT/ELECTR
.� O APPI cam - - y _ GRADINOFF
H y NOTICE TO APPLICANT If, fter making this Certificate of Exemption,you should WATER SYSTEM/TREATING c
(~ ? become subject to the Worker s Compensation provisions at the Lnbor Code,you must SOILS FEE
sem' forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q .
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Q Iherebyarfirmthat there is a construction lending agency,for the performance of _ Da¢ . Receipt#_
OU the weak fee which this perm;, Isved(See.3097,Civ.C)- .. _
Lenders Name // - TOTAI,
W Lenders Address TOTAL:
CL, 1 certify that I have rad this application and state that the bo inf ration is - BUILDING PEE ii.
nFi h correct I agree to complywith all city and county ord,oaners and some.laws mining ro QTY. MECHANICAL PERMIT FEE
U77- building cimswuon,and hereby ethoriva repbientntms of phia city to enter upon the - SEISMIC FEE ' 1
above-mentioned lnopetty for inspection puryoses. 11 PERMIT ISSUANCEWL
(We)agree m sava,indemnify and keep harmless the CRy of Cupertino against ELECTRIC FEE
liabilities,)udgments costs and expenses which may in any rembe agent said City ALTER OR ADUTO MECH. '
inconsequence office grant ng of this per t - _ ». PLUMBING FEE .
APPLICANT UNDERSTANDS AND•WILL COMPLY WITHALL NON-MINT AIR HANDLING UNIT(TO Iff"CFM) '
5 E REOU/LeAT/I^/O'NS ' - jl�� (' MECHANICAL PEE '' ��r
xrU- lO�ZR I a S AIR HANDLING UNIT LOVER IO,W CFM) CONSTRUCTION TA
5 fApp santlC ntt((un6_q„ -I Darr EXHAUST HOOD(W/DUCT) HOUSING MITIGATI NFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT.(TO 100,000 BTU)
A defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Coca Section 25532(a)+, HEATING,UNIT(OVER 100,000 BTU) - -
Eyes E_moi ,. PAID
VENTILATION FAN(SINGLE RESID) Date Rmdpt ft'
Will the applicant or{sore building aocepant use equip nt or devices which
mit hazardous air contaminants as defined by the Bay Area A r Quality Management BOILER-COMP IMP OR 100,000 BTU)
District? r, ' I. - , TOTAL:
s 0Ya --1 <$; BOILER-COMP(OVER 100LOOI BTU)
Iha ad the htoodimm,smaaterials req t.uad,,Ch pt R95 of[[,a Cali- AIR CONDITIONER, ' ISSUANCE DATE
union Health&Safely Code Sections 25505 25533 and.25534 I d rstend that it the NEW RESIDENTIAL MECH. SQ FT. M
build' drestatimbendyh atenanp that t,. spsslbday to ury heat ant _
Low
990-�
requ re en wh ch all t or of a Card"'hi,
authonzedagem ��'�����4//a Da - . ISSUED BY: -
r. OFFICE .
r