28964 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 9UILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28964
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRFSSSS: l SANITARY NO. APPLICATION SUBMITTAL DATE
1.7-11a PE/Gn/.i GT
OWNERSNAME b{�("�� PHONE: CON'TRACTOR'S NAME. 'LIC NO',
E d� O CCO //�'l b'- c/5-5-O GmAp.,7 • g. a7 N/C CONTROL#
RCMITECf/EIJGINEER:
LIC NO: till ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMI ECIT
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
4, I hereby ffirm de
Thal I am licensed unr provision of Chapter 9(Commenring TOB DESCRIPTION
LLqOl Z with Seaction]01g.f Division3ofthe Business and Profesiuns Cade,and my license is
FWO in full forte and effect. PERMIT ISSUANCE RESIDENTIAL
JO
�U�,) License Clas, Lic.4 �O ❑SEOWL ❑KITCHEN REMODEL
HEDme LL L Contractor APPLIANCES-RESIDEM'IAL 11 ADDITION ❑PLUMBING RF,-PIPE
E.prn ARCHITECTS DECLARATION
Z O ys z I understood my plans shall be used as public rectiNa
PANELS ❑MULTI-0NIT ❑STRUCTURAL
oz--
11PT0 2W AMPS MODIFICATION
L¢e...PrOutwourl ❑INTERIOR ❑CHIMNEY REPAIR
201-I WE AMT'S IMPROVEMENT
Sys ,
OWNER-BUILDERDECLARATIONCLARATION OVER!"AMPS
� 6 1 hereby affirm Nm 1 am exempt from the Cssionso License Law for the ❑BATH REMODBI/REPAIR ❑DEMOLITION
{p 3 F following reawa(Semon emalo Business and improve,
de Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
ttl O which rtquires n permit m conalmcl,a1¢q improve,demolish, fi repair any swment
m dull he its lensed Pursuant
10 the thovisio s stowt to,Conrch crmit not. le. Law
SPECIAL CIBCIII'f/MISC. / -- �
} Nal he is license)pumuantmthe provisions of.hc Conuumnh License Luw(Chapmr9
00 (com
mencing with Section 7")Of Division 3a(the Business amt Professions Code)Or TEMP.METER OR POLE INST. COMM 11
6 q m y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXI tr•
Section 7031.5 by my applicant for a pennitsuhjems the applicant It)u civil penalty of POWER DEVICES
� yhnot more than five hundred coffins($500). 1 ❑TENANT ❑FOOD SERVICE
❑1,asownerofihe Propc:y,rtrmyemployceswithwagesas Neirwlecomp nmtion. SWIMMING IDOL ELECTRIC IMPROVEMENT
y wJl do Ne work,and theswnureis notimendeJ moRertdfor sale lSecJtW,Business ❑OTHER
a a m and Pmmmons Code:The Comm roe's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Pomeroy who holds or improves thereon,and who does such work himself m through
his Own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ ET '
sale.If.however the building orimpmvemem issold within one yemofcompletion,Ne OORAREA $/SQ.ET
owner-builder will have die burden Of proving that he did not build or improve for pun y
pose of sale). O O
❑ I,as Owner of the property,all,exclusively commenng with licensed eommetnfa to
construct the project(Sec.]BW,Business and Proullu i Code:)The Cammmm's Li-
cense law does not apply to an owner of property who builds or improve,thereon,and QTY, PLUMBING PERMIT FEE
who om u mos fmauch inuffma with a contrecmr(s)licensed pursuant to the Conu:ctnes
License Law.
O l am exempt tinder Sec. ,B&P C for this remain PERMIT ISSUANCE
OwnerALTER-DRAIN&VENT-WATER(EAI 9S x1-y
Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE 6 V
(hand will..tain-under penaltyofp'ConnneofthOfnsumfi-dorker Co
❑Ihave and will farbyetion 37M of the Laoot r sale.saner fin-Workers Compete DRAINS-FLOOR,ROOT,AREA,CON
D.
smart:,as providedar hhi for by Section 3]00 of the labor Coda for the Performance of the STORIES TYPO CONSTRUCTION
work have
Nis maintain
is issued. e FIXTURES-PER TRAP
El 1 have and will maintain Workers Compensation Of thle w moan which
as require)n i Section
MyWrth¢e"sLa�bsor�Cend�e,.rf�or the
urance canecofd work for which thispcnnilisissued GAS-FA.SYSTEM-1 INC.40I1TLE'I:S OCC.GROUP APN
Caymerrk=S IR Ft]4.N)mnce carrier Poli Policy�ury�e4TA81P -95 GAS-FA.SYSTEM-OVER 4111)
Policy No.:_ 371 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDU$TRL WASTE INTERCEPTOR
or less.)(This auction need not he Completed if the permit is portion hundred dollars($ITU) GREASP.TRAP ING HUILDDIVISION FEES
PLANCHECK FEE
I-yomy thatinthe performany
of the work for x Meal II-permitlkers' dlshall SEWER-SANITARY-.
not employ any persun in any manner w as to M1ecome aubjecun Ne Walkers'Compen- STORM EA.200 EP.
Z ENERGY FEE
wtlnn Laws of C:Jiliania.Date WR'I'ER HEATER W/VENT/ELECTR
�r 0 2C12.is
NOTIAppliCE
GRADING FEE
.7 NOTICETOAPPLICANT.ILC@rmaking this visiosofof Exemption,you should WATER SYSIiM?REATING
F become subject m the worker',Cumpeor thin provisions of the Labor Code,you most SOUS FEE
forthwith comply with such provisions or permit shall he Deemed revoked.
Wti Q WATER SERVICE
CONSTRUCTION LENDING AGENCY '�J r,9g9y
UZ NEW RESIDENTIAL PLMH. SQ.FT PAID — o
V.
work
reby which tat that themmeati isacd(Ser,3097,Cis,agency for pcAormancnnf Date Receipt
0 F thework for which Nis permit is issued(Sec.J09],Civ.CJ
U Lender's Name TO AL:
� Lender's Adtlreas ]
4 I certify that I have read this application and state that the above inf smrarma is BUILDING FEE
V) co O comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE
L) z ding ronmm ion,nrd hertby nmhodze rcpresematives of this city menta upon theS113MIC FEE
aM1Ove-mentioned property for inspection purposes. •�
(We)agr •to save,indemnify and keep harmless the City Of Cu do against PERMITISSUANCE
Iain B ELECTRICHE
toes fcsmam titsecosts and pc soh' ay jenny wtiy eccmcageiaaid City gLTER OR ADU TO MECH,
inn �quenc Offer gmnf r pc PLUMBING FEE �
APP I 11 AN UNDER. 'S ILL COMPLY WITH AL1- ON-POINT AIR HANDLING UNIT(TO I Q000CFM
111 'GULAT S MECHANICAL FIiE
AIR HANDLING UNIT(OVER loge CFM) CONSTRUCTIONTRX
Si m Of ApplicaMC.if r - Date EXHAUST HOLD(W/DUCT)
HAZARI US MAT UAIS D CLOSURE HOUSING MITIGATION E
Will theapplicsncnrfutu ..1 atoreor handle haamoma,..feel.[ HEATING UNIT(TO 100,0(1()BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Hmhh and Safety
Cale,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) V C
Fl y,' No
VENTILATION PAN(SINGLE RESI)) PAID
Will ti the applicant m future building Occupant yuse A equipment Quality
or devices which Dan, eceipl p
unit animations oar con.minams as defined by the Bay Arta Air Quality Management BOILER-COMP CHIP OR 100,000 BTU)
NO kA T AL:
❑Y (p NO BOILER-COMP(OVER 100,001)BTU)
I hac rowl the ,rials .,.¢under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE.DATE
.is Beall &`,fafety of -255 25533 end 25534.1 undersand Nal if the NEW RESIDENTIAL MECH. SQ.FT.
Robots! Out cu I e titismyre, )nsibilitytonotifythemcupmt
ofthm ..at, dm OuNotanee Ofn Cenificmn tifOccu ancy.
r or submitted agent El—
ISSUED BY:
OFFICE