28752 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL 'PERMITNO. 28752
S ^ .a ^ A
BUILDING DIVISION APPLICATIONIPERMIT PLUMnmG-MECHANICAL 'LJ y8 1( 15 L
BUILDING PROTECT'IIIENTIFICA'I'ION
ILDINGADDRESS: - SANITAR NO. APPLICATION SUBMITTAL DATE
lol7o Cawtirko VIS }4 17rive-
NER'S NAME: PHONE: '/H 9�y TRACT'OR'S NAME: - LIC NO:
D avid /. �- WIa��Iy.g T: B i cE 9 ` 4 N/C CONTROLM
ARCHITECT/ENGINEER: LICNO:- A4DRESS: - �^
Robert W P C- 1525% o. 11PS n7ot 14
CONTACT. - PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by'lpplicant(Initial) BLDG E Pw MEPW
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under QTY. ELECTRIC PERMIT FEE
provisions of Chapter 9(commencing _� JOB DESCRIPTION
Kz with Secti .7")of Division 3.f the Bminessmat Professions Codaandmylicenuis PERMIT ISSUANCE RESIDENTIAL
00
m fu bredand ffttt.
�U� ' n CI Lic.eM L- ❑SFDWL [I KITCHEN REMODEL:
�+ ate _OZ_ t ctnr - APPIJANCFS-RESIDENTIAL %JAADDITION El PLUMBING RE-PIPE
!!�� ARCHITECT'S DECIARATI N /JMULTLUNIT' ❑STRUCTURAL
O 2-0 Z 1 understand my plans shall he used as public records PANELS MODIFICATION
UPTO200AMPS
1"G Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
� la] 201-1000AMPS IMPROVEMENT `
G3 'OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR )DEMOLITION
W I hereby affirm that 1 um exempt from the Contractor's License Law for the
O L U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F LL Eqa' which requires a Pewit to contract,almr,improve,demolish,or reair any structure In n n .�
0
..1 prior to its
issuance,alto reyuircs the applicunt(m such pennilmFla.ai
gradstatement SPECIAL CIRCUIT/MISC. 7 .♦ a C✓
p+ that be is licensed pursumnotheprovlslons ofrha Contractor's License Law(Chapter9
CC (commencing with Section]dl0).f Division)of the Business anJ Profneion CWe)0r TEMP.METER OR POLE INST, nSl
dy e y the he is exempt themfmm and the basis for the alleged exemption.Any violation of Q�G/ TI /y�f�j�"I,DEMOLITION
XMN 111110"]031,5 byaayapplicaat forapermilsubjetel Ne appRcanlleacivil-penaltyof POWER DEVICES p" •� 1:1 TENANT �`eNEJ FOOD SERVICE
yY1l +,., ata more than five hundred dollars($500). J MPROVEMEN
nn IT
G Q [,us owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL,ELECTRIC GlI
G wdl Jo thl work,andNeswnurcis not intended oroRered for ale(Sec.]1114,Rusinns
[3 HH
W,3 and Professions Ctd, The Contractor's License Law does not apply m m owner OUTLETS-SWITCHES-FIXTURES �v
Property who builds or improves thereon,and who does such work himself ar gh
his own employees,provided that.such improvements are nm intended or a 'red for NEW RESIDENTIAL ELECTR SQ FT.
sole.If,however,the building orimprovement is sold within one ycmofc Iddon,the SQ.FT.FLOOR AREA SISQ.FT.
ner-builder will have Ne buNen of proving that he did not build o Move for par-
pose of sale.). Cj, J L 07 bek
p 1,•as owner of the pepeny,am exclusively commctin licensed cantmnors to TOTAL:
construct the project(Sec.]044,Business and Fairest,
aire' s CZ)The Contractors Li-
aeneLawdoesnotap,"manownerofpt, o builds or improves thereon,and Y PLUMBING PERMIT FEE
wlmmardncesfersuchpmjectswithaco ogsUieenudpursuammthc Convenor's ,
License Law. - PERMITISSUANCE �—
❑ I.m esempl under S-- .B&P C far this reason
ALTER-DRAIN&VE W 7R(EA) "VALUATION
Owner Da
WORKER'S MPENSATION U?�ARAN ACK FLOW PROTECT
I hereby affirm under pen y of perjury one ac t
Fl Thaveandwilleaintaina Ccni ateof Conscmmrs Coepen- DRAINS-FLOOR,R P REA, D. STORIES TYPE CONSTRUCTION
sono.,vs...video fat by Section 3 00 of the Laborrminuenee oft - -
mkfarwhichthisproudtisissued. - FlXTURES-PLR TRAP1 have and will maintain Workers cementationuimdb ion)TOOofNe Labor Codd forthepe d. onceoft he wpe " roc issued. GAS-EA.SYSTEM-1 INC.40 OCC.GROUPAPN
My Worker's Compcnsatian lnmmncc randPoGAS-EA.SYSTEM-OVER4(EA)
Carrier: Te Polity Na:
CERTIFICATE OF PITON FROM WOR S'
COMPENSA ION INSURANCE GREASPANDUSTRL WASTE INTERCEPT) -
(This'a"umoeednothecomple if Ne Famnes fo rte hundred Dollars(5100) BUILDING DIVISION FEES
or less.) GREASETRAP P6ANCHECK FEE
I certify Nein theperfannnn of ewnrk fn ichthispermitis issued,I shall SEWER-SANITARY--STORM EA. FT.
not employ any person in moa r o hec subj Iyshe Workery Co.,.- ENERGY FEE
o z cation laws of C if i am J WA ER HEATER WNEN/ELEC R
Applicant GRADING
.zs NOTICE TOA PLC :If,alter making this Certificate of Lxemptinn,you shout) WATER SYSTP.M/TREATING
become subject to the mlam's C.mpenutin.provision of the Labor Code,you must SOILS F '
foahwiN comply with such Provisions m this pemdt shall be deemed rcvuked WATER SERVICE y G ec.�4�'3
Uj O 0`6
U z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLACE. SQ.FT. PAID
to Receipt M
F-' _
Thereby tiff roe that Nerc is vconswminn lendin6 agenly for the performance of
4, the�work for which this permit is issued(See.3097,Civ.C.) '
0 Lenders Name TOTAL:
Lenders Address TOTAL: V-72.
1 certify that I have ad Nm is application and sethat the above information is BU
mI G
hcorrect.l ugree br comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
Liz building ammuuction.odd hereby carbonate represemetivnof this city t.entero...the �a SEIS FEE
above-nummarW progeny for inspection purposes. PERMIT ISSUANCEy^ ELECIRICF r q
(We)agate m save,ittdcnmify and keep harmless he City of Cupertino against
liabilities,judgments.costs and expenses which may in any way acerae against said City ALTF.RORADDTOMECH.
in consequence of the granting of this prandi PLUMBING
APPLICANT UNDE TAN AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTD W."CFM) - - �y
SOURCED J'.AT S. MECHANICAL! 70 71
AIR HANDLINGUNIT(OVER 10,0011 CFM) CONSTRUCHON TA
Signature of Appl' t/Con ecmr Date- EXHAUST HOGD(W/DUCT) HOUSING MITIGATE) FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant arm or handle hnrent material HEATING UNIT(TO POR"BTU)
as defined by the.Cupertino Municipal Code,Chapter 9.12,and the Health and Safety t
Code,Section 25532(a)7. HEATING UNIT(OVER 100,000 BTU)
❑Yes f-1 No VENTILATION FAN(SINGLE RESID) PAID
Data R dip M
is .
Will the air contaminants
infurore building by the Bl ecu equipment or devices which _
emir hamNous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(JHP OR 1011,1X10 BTU) - _ TOTAL:
DIsv1.tP BOILER-COMP(OVER IfX1,W(I BTU)
❑Yat - t`Z)No r
E have mad the haaatdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 25505,25533 and 25574.I understand that if Ne NEW RESIDENTIAL MI CH. SQ,FT.
building does not currently have u team,that it is my ras,mobility to notify the occopunt
of the requirements which must he met prior to ismmea of a Ceni leahe of Occupancy.- '
Owner or authorized agent Date ISSUED BY:
OFFICE