28494 ., APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 28,494
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS:•- SANITARY NO. APPLICATION SUBMITTAL DATI
3 X s ES A) I
O .R'SN MT/kO PHONE: CgEGRACT_'S NAME: LC 7? 37;-
7 N/C - CONTROL#
C CT `G„IINNEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) �LDg ELECT PLUMB MECH
I� '❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1.m licensed under provisions of Chapter 9(c.mrnencing JOB DESCRIPTION
Cz wiNSection]0(q)of DiviWon3offle Businessand Professions Code,and my license is - RESIDENTIAL
00 - ' PERMIT ISSUANCE
m full force and cD - ❑SFDW L ❑KITCHEN REMODEL
License Class Llc.p APPLIANCES-RESIDENTIAL ❑ADDITION - 11 PLUMBING RE-PIPE
W Dete Canuacm
I,,,pran>l ARCHITECTS DCC AION 'PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z Oy A 1 understand my plans shall he used a public records MODIFICATION
OZJQ UP102WAMPS ❑INTERIOR [I CHIMNEY REPAIR
W Licensed Professional 201.100(1AMPS IMPROVEMENT
"'i OWNER-BUILDER DECLARATION
a 1 hereby offop Nat 1 um esempl from the Contracmr's License Law for the OVER IOW AMPS ❑BATH REMO E R Q EMOLITION
4 O y VE following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL - OTHER
O.] which requires a pemdt to corsVucl Wier,improve,demolish,or repair any structure
prior to its iomnce.also requires Ne applicant for such permit m file.intrust smmrant SMCIALCIRCUIT/MISC.
Ythat he is licensed pumuanuo Ne provisions of he Canttuctor's license Law(Chapter 9 '
GO (commencing with Section 70(go of Division 3 of the Bust nd Professions C.de).r TEMP.METER OR POLE INST. COMMERCIAL:
6 ca C that he is exempt therefrom and the basis for the Wle eve prion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
to Section 7031.5 by any applicant far a permit sum he appl ant to a civil penalty of POWER DEVICES
Mtn ❑TENANT ❑FOOD SERVICE
t mare that five hundred dollars($S IMPROVEMENT
O ❑Lothe as work,flueand
pmpra, or t mumdaswMamed I.wages s It,(Selecumpcnsiness SWIMMING POOL ELECTRIC
wind.Ne war.,and the arra I,not tendedoriNyai for Ic(SaA6W,Business ❑OTHER
2_ aid arty who
b Code: oyes he ad
Licntseq'I'docs n t apply m ff owner of OUTLETS-SWITCHES-PIXTURES
4i property who buil improves thevem1. h�v ch or.aded caf or through
his own<mplo ,provided tho9�u"sat_ riot'n.m.f or.Bore fire NEW RESIDENTIAL IiLECfR SQ FT.
sale.If.howeve Nel, hin�e w c �#'tun m"n year of completion,the SQ.FT.FLOOR AREA SISQ.PT.
owner-builder 11 he u a td lids improve for Wr - -
pose of role.). (' Y .
❑ 1,as owner o th55 u rv�l taro ctmg with icenscd comr.cton to TOTAL: -
conaw 10mu"0 s1t Bu tic fessionsCode:)The Contractors Li-
cense Law does t., 7, wince mpery who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
rmt
wimempaf hip I- contrecasnWhansedpmsuanuoine Contractor's
License law. PERMIT ISSUANCE
❑l am exempt ,B&P C for this rumn
ALTER-OWPROTEVENT
DEVICER(EA) g `+— " ON
Owner Date
Wm under
SCOMPEpermy on DECLARATION BACK FLOW PROTECT.UEVICE
1 hand affirm under pealryofperjuryoneofthe imme following decmmti Ca
❑IM1ave andwill eror by ection Scam ofConseborCod.forthe performance
of the
DRAINS-FLUOR.ROOF.AREA.COND. STORIES 'TYPECONSTRUCTION
.tion,ar provided for by Section 3]00 of Ne Labor Code,for the performance of the
..it ficarwhich this permit is issued. FlXTURES-PER TRAP
❑1 have and will maintain Workers ante of as,w Insurance,h his p,rn by Section
My ork Labra Code,foal perfornavaof the work for which this Parodi is issued. GAS-EA.SYSTEM-1 INC.d OUTLETS OCG GROUP APN
My W.rk Co n n1'Pk Polirand cy nymMr ate: GAS-EA.SYSTPNLOVER A(EA)
Carrier' _ Polic N..: LR�-7 7
CERTIFICATEOE COMPENSATION
NFliAM WORKERS' -
lCOMP replete ON INSURANCH GREASF/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION ES
(]Tu secu.n seed not becnmplaedifthe permit is(.none M1umlrcd doled(31001 GREASETNAP
or lus.) PLANCHECK FEE
Ioy any Nminthe myPerformance afthe work for which thePermitWrkerV ed,IshW1 SEWER-SANITARY- EA. W
not employ any person in any manner w u to become wbjecuo the Workers'Compen- ENERGY
Oz sation Laws of California.Dote WATER HHATER WNENKLIYA
Q Applicant - GSA FEE
y NOTICE TO APPLICANT:If,atter making Nis CeriOmm of Exemption,you should WATER S2i=
a [' become subject to Ne Workds Compensation provisions of the labor Cods,you man SOILS FE
W [ forthwith o mply withmch provtdo..or this permit shall be decmcl revoked. WATER SE1
0
] z CONSTRUCTION LENDINGAGENCY NEW RESID I.PLMB. SQ.FT. Il1N Recei l#
V r'S liamebyaf nd,thatthem is a construction lending agency for e performance.( 4 p
V. [yy the work for which this permit is issued(Sec.3)9].Civ.C.)
Lender's Name - TO L:
Landers Address TOTAL:
-1 canny Nat I have reed Nis application and amts that the above information is BUILDING FEE
In correct.l as=to comply with all city and county ordinances aid state laws relating to QTY. MECHANICAL PERMIT FEE
V 4 building contraction,out hereby authorize repreummocs,of Nis city an enter upon Ne SEISMICFEE
.hove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)Norte to save,indemnify and keep harmless the City of Cupcdina agatmt ELECTRIC FEE
IiabiRfu,judgments,costs and expenses which may in any way wrote against said City ALTER OR ADDTO MECH. -
in consequence.(the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH A NON-POINT AIR HANDLING UNIT TO IO,n CFM)
'
SOUR t0' MECHANICAL FEE
AIR HANDLING UNIT(OVER IOdXp CFM) CONSTRUCTION TAX
Si ata ApplicenVContrmtor a¢ EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
Willthem,acamorto..building eventual stomoluente hazardmu mdentil HEATING UNIT(TO 100.000 BTU)
as final by the Clnpentno Municipal Cede,Chapter 9.12,and the Hcahh and Safety .
Cede, orlon 25532(0)7 HEATING UNIT(OVER 100,000 BTU)
C]Y's - Fl No VENTILATION FAN(SINGLE RESID) PAID
• "
Will the rou applicant m future building occupant taA .r devices which emit hurardous air contaminants u defined by the Bey Areaea Air r Quality
BOILER-COMP QHP OR 100,000 BTU) Data Receipt#
uality Management L:
District? BOILER-COMP(OVER 100,(100 BTU)
❑Yea 11 No '
Ihaveread the ha)afdau materials requtremenm under Chapter 6.95 of the Cab. AIR CONDITIONER - ISSUANCE DA
(tans Health&Safely Cole,Sections 23505.25533 it 25530.I understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a tent,that it is my responibiliry to notify the occupant
of the requirements which must be met prior to issuance of a Cedlfcate of Occupancy.
Owneror authorized.gem Date TOTAL: ISSUEDB .
OFFICE