28879 • APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull,DING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT- PLUMBING MECHANICAL 28879-
BUILDING PROJECIADENTIFICATION
BUILDING ADDRi S: �A��A�� �� - ; SANITARY NO. APPLICATION SUBMITTAL BAD
OWNER'S NAAMMEE: 1 .pHON@ CONT [ 'S NAME: - LIC NO: lo •� ��
L \ L �; } `' a NIC CONTROL#
ARCHITECTIENGINEER: LIC NO: ADDRESS: - ❑ '
i co
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG PLUMB 21Ec}I
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FF,F: ❑ /tYVI
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�ceZ with Section 7")ofoivision 3 none Business and Professions Coda and my licensees RESIDENTIAL:
I 0 0 PERMIT'ISSUANCE
W I- In full farce and effect/ 2 i_I_�j!]'1D ❑SFDWL ❑KITCHEN REMODEL.
HUr, License Floss `- Leap JlLkY_L TJ 1 H7W "or APPLIANCES-RES'IDENI Al. ❑ADDITION ❑PLUMBING RE-PIPIT
4 ANClIIIIiCI"91lECLARATION ❑MULTI-UNIT ❑S'fRUCfURAL
b n K PANIi1.5" -
ZO!�ZJ IunJecland.,,.plans shall he used as public records - "S MODIFICATION
OZ .. UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
r4twil Licensed Professional - 201-100AMPS IMPROVEMENT
gkdx,4OWNER-BUILDER DECLARATION OVER Iqp AMPS ❑BATH RE L/RCPAIR ❑DEMOLITION
C WQ I hereby,official that 1 am exempt f the Contractor's L c Law f the,
°xx• a following mason.(Sect 7033.5,Business d Professions Cade.Any city or c tySIGNS ELECTRICAL
13OTHER
W 3 LL�j which requires a mount to construct,alter,'improve,demolish, pa ny strocutre 1
�fejG
priorm itsmeals requires m pplk t nonsuchPermitt file a signpidstatement. SPECIAL CIRCUIT/MISC. t"
F. } that 6c is I' en.ed pursuant to the provisions otthe Contractor L 1 ICh pter9 COMMERCIAL'
�C
(commencing with Section 7001)1 ffu ,ion 3 oflhe Business II ofess'ons Cial or I EMR MCI'ER OR POLH I NS'f. � _
6 y o Ivy
hot he is exempt Iherefmm unJ Thu he,is for the alleged cxempuon.Any violation of ❑NEW BLDG/ADDITION ❑ P,MOLITION
aXl IL Section 7031.5 by any applicant for a pem
rmit hjects Iheuppllcvnl loo civil penalty of POWER DEVICES h El TENANT ❑FOOD SERVICE
y r t ramp than five hundred dollars(S50).
E Q 01,as owner ufthe propene or my employers with wages as their stop compensation, SWIMMING POOL ELECTRIC 'IMPROVEMENT
F� will do the work and the suucmm is not intended proffered for sale(See,7044.Business - []OTHER
3 and Pmfevoclut Cede:The Contracmr's-License Law does not apply loan owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,Provided that such improvements ore no,intended or offered for NEW RESIDENTIAL ELECTS SQ ET.
sale.If,however,the building pr improvement is sold within one year afcompletin SQ.FT.FLOOR AREA USQ.FT.
er-builder will have the burden of proving that he did no,build or improv rput
grse ofsala.) -
❑ 1,as owner of the property,mal exclusively contracting with licca ontmetors to b T
construct the project(Sec.7044,nosiness and Professions Code:)rill license
Li-
cense
i-c nse Law does.not apply to an mwnerofpropery who builds or i roecsthereogand QT•Y. PLUMBING PERMIT FEE �•�
who contracts for such projects within commevor(s)liernsedp and o the Compact.?, -
LicenseLuw. PI3 11'T ISS NCE r.
❑I am exempt under Sec. a&P C Ikmbis roawn
Owner _ Dae -D AI &VENT-WATER(EA) LUAI'ION
WORKERS COMI'f• .ATION DECLARATION A Il WPR CT.DEVICE
I hereby affrmuJ Penalty Perjury fth fell nw it 1. ions. O, sC01511IVv
•F1 Ih d will t Count re fC Dieu self n ref) rkers Cooper- •t DRAIN. FLOOR,ROOF ARE ONI -` -
saho' p d d f by S t 081 fthe I h C d for the voce f Y+"`( �S ORIES TYPE CONSTRUCTION
work for which this p I 1 FIX'I' tf.5 PCR TRAP V
❑ 1 have and will mumv'm We,us G:coni,m pn human let nr��/}•��" ,
3700oDhelnhorCnde:forIDep rfonnunceofnewOrk far whl 1l si,noil5e,.+auy . GA -EA.BYS'THM-I INC.4011'U.I3T5 OCC.GROUP APN
My Worker's Compensation Into once artier and Policy n vV '
Currier Policy No G S-I TA.SYSTEM OVER 4(EA).
•
CERTIFICATE :EXE ONF 0 RKE ,REASFIINI3USTRL H'ASTF.INTERCEPTOR COMP SAITQN A OR, L BUILDING DIVISION FEW
[Ibisseetionneednotbeo-s lett if l� eRactimhu pllare(S100) GREASETRAP or less.) PLANCHECK FEE
I certify that in purfnrmeoc mitheworkfor this permit is issued.I shall SEWER-SANITARY-
nntemlo nn STORM IiA.2IX1 lT.
p y y person in any mm�nen as t co ;su ' Mthe Warker.0 CunneenENERGYENf?RGY FEE
z' ,prion Laws of Word D Y '
OQ Applicant" ,; „ WATER IIfiA'I'lik WIVENT/F,hECTIt 'I; GRADING FEE
I'7 Z NOTICE TOA APPLICANT.IL Miter saki g this Cori iff Excnmtion,you mould Wq'I ITN SYSTEMITREATING
a7 become smourn m the Worker's Cnnspemm m provisions of the Labor Code,you must SOILS FEE
forthwith mately with such provisions or thsparmi,h.116edaaudrevoked. WA'I ER SI'.RVICE
.�`7. 2 CONSTRUCTIONL DING AGENCY NEW RESIDENTIAL PLMB. SQ.F.. PAID
U O Iherebyaffinnlhmth mkileunstmcu nlendingagencyfonhep bdRan of Date k°carp
IDI F the work far which this meatier is ismW(See.3 7.Civ.C.)
O U Linares Name - ..
OTA .
Lcnder'v Address -
Hd 1 certify than have read This application e d stop,lhat the ohne info anion is• BUILDING FEE -
Z! correct.I agree to comply with all city and county rdinances and state law: elalngte 'QTY, MECHANICAL PERMIT' FEE
U 4 milJingeordincliom,and hereby vuthorize'npose Iadvesoflhiscoynic cl'uponthe SEISMIC FEE
uhuvc-(WtioneJ property Gn oundtionpkeepho a PERIOD ISSUANCE
(We)agree td save,inJemnify and keep ha es the City otic chino against ELECTRIC PEE
liabilities,judgmrnls.costs anJ apenscs which may in ny way amu guinsl sail Cily ALTER OR ADD TOMECH. - PLUMBING FEE
in consequence of the graining of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLYAI.I.IIIiN-POINT AIR HANDLING UNIT(TO 10,00D CFM) MECHANICAL FEE
SOURCE RE I:ATIONS. / �/�
/ 'AIR HANDLING UNIT(OVER 111,010 CPM) CONSTRIJCl"IONlZX
Signomrc of Applicant/Comraeof •,.""`I EXHAUST HOOD(W/DUCT) HOUSINGMITIGATI 'EE
`HAZARDOUS MATERIALS DISCLOSURE
Wllllheapplcoup,name hullJimgooce,anto c or hindlu Inindnusmaterivl HEATING UNIT(TO 100,000 HE GO `
e'defined ny the Cupertino Municipal Code,Chapter 9.12.and the Hoillh and Safely
Code,Section 255320)° HEA'I'INC UNIT(OV ER 100,0110 BTI)
❑Yes - ❑No VENTILATION PAN(SINGLE RESIDE PAID
Date Receipt Will the air corm m furore building by the B ase equipment of deices which
.;•emit hauNous air conmminems as JefineJ by the Ray Arta Air Quality Managemem BOILER-COMP(3HP OR 100,000,BTU)
TlIAL:
Miami?
❑Yes 1-1 No HOLLER-COMP(OVER 100.000 B'I'U)
-
A�S��ya''may/p7
1h edza
the M1armaterials requirements d Chapter 6 9 fif
AIR CONDITIONER ISSUA f E
f mi Health ry h&Safety Code.Sections25505 25533 d 5534 1 :I J h 1"f Ne NRW RESIDENTIAL MF,CH. SQ.FT.
buil) Tr n pal '011y1 flnpam
r
ofrequirements whichh :a M.nUP�l rit)", eaftCenlulu of Oku:puncY
Ownc'minglodzed agent - Date T(3TAL:1 1ISSUEU BY:
OFFICE