28506 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO..28506^ ^O
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING.MECHANICAL L l8 �5
BUILDING PROJECTIDENTIFICATION
BUILDING ADDRE55i(,/sXSANITARY NO. APPLICATION SUBMITTAL DATE
OWN �(,kAJ O� S,OP NE: RACfOR'S NAME: LICN
R'SNAMME ' f #-
- 1Ills, sit,
!lN--ICss CONTNOLM
y1 ARCHITECf/ENGINVER: - LION ADDR SPIK
: DV
r
CONTACT. - .PHONE -
- BUILDING PERMIT INFO
❑ Consultant Fees Paid by.Applicant(Initial) BLDG , ELECT PLUMB MECH
LICENSED COM RACIDR'S DECLARATION Y QTY ELECTRIC PERMIT FEE ❑ ❑
I h
he
aIF nn call am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
C807
wit 1 .n]qp Sof the tlusincxs and Rofcssinns Code.wd my liccmeix
0l) in force andel Iv^Ion }� ) PERMIT ISSUANCE RESIDENTIAL
�Vr , iclose Class Liap�'3QOSPDWI. [I KITCHEN REMODEL
..a.-- Contractor APPLIANCES=,RESIDEMIAL El ADDITION. El PLUMBING RI PIPE,
pP.. o' . ARCHITECI"SDECI:ARAToss' - '�MULTIANIT, ❑STRUCTURAL
I onK _ ,PANELS -
I undeamnJ my plans shall he used as pmblic'rnicords MODIFICATION
OZ-- _ UPT0 20O AMPS
❑INTERIOR El CHIMNEY REPAIR
gAansa Professional - 201-IWBAMPS - IMPROVEMENT
O U OWNER exempt RDLCCont ON OVER 10k)AMPS 'VH REMODEUREPAIR El DEMOLITION
iGSI Ih by firmthat1am exempt ttheC i u sc:Any city
for the _
✓r 31+• fnM1 ch rryrca.dom iS t 70313 B :...it to ontravulIle. and Pr focvctls' nl Cule A Y .tY.t c¢re SIGNS FLFCI RICAL ❑OI HF.R ..♦{QyCyT�`
�10 prim LL istaince,alsomq them"manof chpa IInfilgnvd statement SPECIAL CIRCUHIMISC,
Nthat he is licensed muccuram the pmvns ons utile Conuamors License Law(Chaptcr 9 _
GOA (commencing with Section 7000)of Division 3 of the Business and Professions Code)(it 'TEMP.MURR OR POLE INST, COMMERCIAL:
q M Y that he is exempt thertfrum and the Twin for the allege exemption.Any rinlminn of - Q NEW BLDG/ADDITION ❑DEMOLITION
See ]OldSby y ppl tf perms subjects thet civil Penalty f POWER DEVICES ❑TENAM FOOD SERVICE
I„ y norm thamfive handled d II ($50l t - - IMPROVEMENT
L]I f p P pcnY Y ply lh ag.as lh s 1 pe ai I', 'SWIMMING POOLELECTRIC
O wll❑ the avrak.mdth t t t'namid,do,offiroldf -lude(S �](N4 Bmn v - _ _ 06IH17R M -
E and P f rte Cee The Contact :License Law does not apply to an 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 are not intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
sale.If.however.thc building or improvement is sold within one year ofcomplemn,the SQ.FT.FLOOR AREA $/SQ.FT
Her-builder will have the burden of proving that he did not build or improve torpor-
pose
arpar-pmse of sole
a
.
❑ 1,m owner of the properly,am exclusively contracting with licensed contractors or
construct the project(Sec.7044,Business and 14ofessions Code:)TIm Contractor's 1.1- -
cemeLawdouxnmapplytoanownerofPropertywhobuildsmrimprovesthereon,and QTY.. PLUMBING PERMIT FEE
who comracis for such projects with a w. contmclor s)licewe pumuem to the Contractors A
License La ' PERMIT ISSUANCE N
Elm I aexempt under Sec. ,H&P C for this reamn Iq
Owner Dore ALTF.k-DRAIN&VEM-WATF:k( 7 �S/ VALUATION
WORKER'S COMP17NSNI ION DECLARATION BACK FLOW PROTECT.DEVICE /
I hereby salon under penally of penury one of the fallowing declarations -
IhaveanJwillmaintainaCenificaleofComenttoself-inure lin Worker's Camper- DRAINS-FLOOR,ROOF,AREA,C( D. S'TO HIS TYPE CONSTRUCTION
lion,as provided for by Section 3700 of the Inbar Code,for the Performance of the
crk for which this pend,is issue. FIXTURES-PER TRAP Cis+
❑37W of he La
1 have and will maintain Workers Cmm vastuium Inaamove.as required by Section 1/y
to,Code,for the performanecof the work for which this permit is issued GAS-EA,SYSTEM-1 INC.4 OU' .ESS OCC.GROUP APN'
My Worker's Compensation Insurance carrier and Policy number am: _
Camera' Policy No.: GAS-EA.SYSrrnM-OVER4( A)
CERTIFICATE OP FAEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE - GREASE/INDUSTRI.WAST.INTERCEPTOIj BUILDING III VISION FI:L$
CThis section need not bclampleted iftheperm is forone hundred dolms$1 W) GREASE'IRAP
or less.) RAN HBC.FEE
I certify that in the Performance of the work for which this permit is issued l shall SEWER-SANITARYSTORMEA.]00FT.
not employ any Person in any manner so as to becomesubject to the Workers'Compen- ENE. JY FEE
satiom Laws of C.1lfmma.Dam
O z •� WATERHEATERWHEN .ECTR GRA
7 I
NOTICCEE TNG FF.E -
G fA NOTTO APPLICANT:If,after ranking this Cenificare of Fxcmprion,you should WATER SYSiEMITREATING' - -
- 5 I+ecome subject to the Worker's Compensaiol pmnsions of rhe hot CnJe,you marl _ SOI S FEE -
I� fonhwiN comply with such provisions orlhi.s Permit shall he deemed revoke. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB.' SQ. PAI
V Q I hereby affirm thmthere iso construction lending agency forme performanceof Date - Receipt
w ;-; the work for which this pemdt is issued(S..3097,Cie C.) '
I"� Lenders Name TOTAL:
finders Address - ". 'T.• TOTAL: '
1; 1 certify that I hove read this applicmlon and state that the move information is - BUILDING FEE
UJ correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
LJZ building connmction.and hemby audaorizerepreventativeso(this city wenterupon the SEISMIC FEE
aov>mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to cube,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iindaities,judgmenu,costs and expenses which may in any wiry name...mat said City
an me...e uenceaf the tin Rhis ALTER OR AILD TO MECH.
q gran ga 1x�rmiL PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Alk HANDLING UNIT(TO I(1,0NICFM)
SOURCE REGULATIONS. MECHANICALF
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signmurcaf Applicant/Co muchr Date F AUSTHOOD(W/DUCD HOUSING MRIGATIO PEE
1 HAZARDOUS MATERIALS DISCLOSURE.
Wiilan applicant orfdmre bandagoccupaut store or handle hazardous material HEATING UNIT(T0100,000 BTUI
•" as defmod b the Capcnino Municipal Cuda Chapter 9.12,'und Wu Health and Safety ,
Code,Section 25332(a)'!- `' HEATING UNIT(OVER IW,(IIN)BTU)
El Yes C�No. .•
• -�) -VENTILATION FAN(SINGLE RISID) PAID Dam kc ' tX
.Wall the applicant or future building occupant use equipment or devices which
emit hazmdous air comernmaro as defined by the Bay Area Air Quality Management BOILER-
COME(3HP OR 10IL000 BTU)
T TAG
District? BOILER-COMP(OVER 100,00(1 BTU)
❑vas ' �k' uimmen
iAIRCONDIT10NF,R'•a Ihavti read the hazardousHinder Chapmr693 of the Culi- rISSUANCEDAfomieHwllh&Samt,CI .Seo 34.I understhat if the. EW kiiSIIlCNT1AL MECH. SQ.FT.M1uildingd norm rad eeo bilitym ti the meaty rof me ml mem h' must bf Ceni Oce c - '
owner o saaftollridlefta, I ISSUED BY.'
a OFFICE