28734 APPLICANTTO FILL IN INFORMATION WITHIN REM LINES•USE BALLPOINT PEN ONLY ,-u '
• CITY OF CUPERTINO •' - -• ' "BUILDING-ELECTRICAL y - PERMIT NO /�/� �/ ^ q a
BUILDING.DIVISION �APPLICATION/PERMIT' PLUMBING=MECHANICAL i - */8 I�•.{4
BUILDING PROJECT IDENTIFICATION �, -L V 3
BUILDING ADDRESS:- + SANITARY NO: APPLICATION SUBMITTAL DATE
if 0'1
•
OWNER'S NAM4 7 L( 'PHONE. NTRAC"IOR'S NAME:' LIC NO: -
1'1111 • ('lµ.�,' 'I.�awblw OS N/C CONTROL#
ARCHIT CT/ENGINEER: LIC NU AD RESS:
. 10591 S. SbRD a "alud�
r
CONTACT PHONE y, BUILDING PERMIT INFO
❑ Consultant Fees Paidby Applicant(Initial) "BLDG - ELECT ,PLUMB .MECH
LICENSED CONTRACTOR S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herehy ffrin that I 1 nsed u d p tons f Ch pt r 9(commaing JOB DESCRIPTION
WapO withSection 7")of Di rasion 3 ofbe Business and Porme on Cad and my license is -
Fad r in full force and effect. - PERMITISSUANCE' 'i '' RESIDENTIAL
' UZ[t�] License Class - - Lic# • ' - - - 0SFDWL ❑KITCHEN REMODEL'
pQp, Date Contractor APPLIANCES.RESIDENTIAL '' ( ❑ADDITION ;' ;iOLUMBING RE-PIPE
p Mn ARCHITECTS DECLARATION ❑MULTIUNIT r 1 ❑STRUCTURAL
C 0 I understand my plans shall be used p bim PANELS
recons
p UP TO 200 AMPS MODIFICATION
`P 4�111 Licensed Professions] - ❑INTERIOR •_ -El CHIMNEY REPAIR.
OWNER-BUILDER DECLARATION i 201-IOMAMPS IMPROVEMENT
I hereby affirm that I am axe pt f m Ne C-t actors License L a for the OVER 1 W0 AMPS - Cl BATH REMODEL/REPAIR-❑DEMOLITION
0 6 follow reason.(Section7031 5 Business and P f as Code:An city o county' I
which requiresa repairY y - y SIGNS ELECTRICAL - '( r ❑OTHER'
E^O Permit m t t pita prove,demolish y wcinre - -
m isnot rece alsoreg the appi of the
Contractor
rg We signed statement SPECIAL CIRCUIT/MISC v
y
that he licensed paean Nap fthC vats (Chapter9
1 G (cambe g with Section]Wil)of DivisionJ f th B a d P f C de)or ETEMP. ETER INST. COMMFR_ CIAL:6 e that M1 i e e pt th ref d th k sis f thexlleg d mist n A y lation of Semon]0315 b any a licant fora ❑NEW BLDG/ADDITION ❑DEMOLITION
Y pp perm tsublects the apish it a Ip Ity of DEVIC _notm than fl eh Bred dollars($500) ❑TENANT '' ❑FOODSERVICE❑Ieopemy,or my employees with wages as the 1- pensat on, NG PO - IMPROVEMENTwilldoth rk and the structure is not intended attracted for sal,(S .?(N4,Business ElOTHER s,
and P fess ons Code:The Con Tactors License Law does,not apply t an owner of S-SWproperty who builds or improves thereon and whir does such work h' If or throughhis own employees provided that such improvements are not tended r ffered for SIDENSQ FT.on yart fc chain,the Y� SQ FT.FLOORAREA S/SQ.FT.
ter-bmlder will have the burden of proving that be did not build or .improve for pur
pose of sale) -
❑Leas owner of Ne property am exdusiv ly c nt act g nth licensed convacmrs to TOTAL: / rr `I
consumer the protect(Sec ]044,Business and Profeasiays Cale)The Conuxcmes Li- - L� " �9
-cense Law does not apply to cor owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE y
whocovveas for Inch pr jxts with acwvxnor(s)licensed pursuav
License Lew uothe Contractors PERMITISSUANCE - ����' , 1,
^ sj'nV.tl
❑I am exempt under Sec. ,B&P C for this reasun
i ALTER-DRAIN&VENT-WATER(EA) Gin V1,L;IVI I.ITI II�U'
Owner Date - V1 V�' #ATI
WORKER SCOMPENdury ar DECLARATION BACK FLOW PROTECTDEVICE
1hnd willdmu n penalty fp Coroneofthefollowing decWorker a Co r
❑Ili and will faints aCerffcato Mnf the Labor
brCode to sure for
ermarai Comf the DRAINS-FLOOR,ROOEAREA,COND STORIES TYPE CONSTRUCTION
I work
r provided for mi Section 3]00 of the Labor Code for the penformaiice of the - i
I work for which this permit is issued. FIXTURES-PER TRAP e -a•
1 have and will mawxm Workers Compensation Insurance,..required by Section J -
_370(1LaborCode,f he performance oftbe work for which this permit is issued. GAS-EA.SYSTEdFl INC.4OUTLETS OCC.GROUP
' My Work ri 1B mile a d f numbery numb
Cartier . F-aPlcy NoGAS'-EA.SYSTEM-OVER4(EA) n -
CERTIFICATE OF EXEMPTION FROM WORKERS' "
COMPENSATION INSURANCE GkEASPIINDUSTRL WASTE INTERCEPTOR - -
BllILDIN661VISIONFEES
.(This section veed nothewmpkted ifdie permi[is Porone handled dollars(SI00) GRBASETRAP
or less) ` PLANCHECK FEE
Icrifythxnntheperf emance oft he work far which this peffrtis issued lshell SEWER-SANITARY-STORM EA 200 FT
not employ -y p on iii any net sn as to haume subject to the Workers Compen- -- ENERGY FEE
,'7. satmn La fCalifomia Dat
WATER HEATER WNENT/ELECTIR - -
C) Appli ant u
i.y - - GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Eaemptioo,you should WATER SYSTEM/TREATING
become subject Io the Worker's Compensation provisions of the Labor Code,you mus[ SOILS FEE < +'
W,Q forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE _
CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ,FT. i PAID -
(, I hereby affirm that consumed..them is a c on leadingagency for the paforce nanof r, - Dt ."Receipt#^
us 1,, the work for which this permit is issued(Sec 3TB7,Civ.C.) 1s.
0 U Lendets Name
yyyLendets Address• A ' TOTAL:
Ili r I comfy that I haveit this application and smm that the above unfition is n BUILDING HE
V) correct Iagree in comply with all cityand county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
Vbudding construction and hereby authorize repmacrantves of the city toenter upon the SEISMIC FEE' .
shove-menacncd property for inspection purposes. -
(We)a PERMIT ISSUANCE -
gram m save,indemnify fy and keep harmless s Ne City of Cupertino against ELECTRIC HE.
liebihnes,)vdgmenta costs end eipenses
which may in any way aceme against said City ALTERORADDTOMECH. -
consequencein of Ne grant g f ras permit. - - PLUMBING FEE
a 'APPLI ANT UNDERST NDS AND OMPLY WITH ALL O T AIR HANDLING UNIT(TO IO,fN10 CFM) s
1 SOU 'EREGU TIO MECHANICALFEE
AIR HANDLING UNIT(OVER 10,000 CFM) 'poi CONSTRUCTION TAX
OV /�
Si fro fApplicanUConare
t :, r Date EXHAUST.MOD(W/DUCI) I ., HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE - i
Will the applicant rfuture b ilding occupant stare or handle hazardous materiel _ HEATING UNIT(TO 100,000 BTU) .
s defined by the Copertino Municipal Code,Chapter 9,12,and the Hear and Safety
ode,Section 25532(x)? , HEATING UNIT(OVER 100,000 BTU) -
❑Yes ❑No _ .• I
'1 � i VENTILATION PAN(SINGLE RES[D)" . PAID' '
Wild, applicant or fmure hmlding cups nt use equipment or devices which ` Data #
mit h Mous air isomer?
cpmammanIs as defined by the Bay Am.Air Quality Management BOILER-COMP LIM OR 100,000 BTU)
+
❑Yes �', i ,Otho „), ^ r 1 BOILER=COMP(OVERIW,WO BTU). `' - ''-. TOTAL:
I have caudde,huzai materials requirem t dtt Chapmr695 of Ne Cali- AIR CONDITIONER - -
•itt+ ISSUANCE DATE
foram Health S,Safety Code Sections 25505 M533 and 25534.I undersand that lyric NEW RESIDENTIAL MEC
H
currently PI' t
ailding does not cuntly have a tenant,that it my mspoesblllty to notify the occupant _
of the requirement,which must he met prior to issuance ofa Cedifieamof Occopxncy.,- - -
5vow authorzed agent i .Date - TOTAL: ISSUED BY:
^ .i. F . -
OFFICE