28487 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 1/
l8^ ..•a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
M ILDINGADDRES$: SANITARY NO. APPLICATION SUBMITTAL DATF
20br ✓-e— s, , G.IotaE?yLo , CA 9-%:v1 `O�Z�I
WN�N�ECµR,•S'NAME: - PHONE: q p,, ONTRACTOR'S NAME: LIC NO:
� <-141.an L [I�JNq'� — 1Qil WC 1 CGNTROLM
ARCHITECI' GINMR: - 2a_ s�/LPT ADDRESS: ❑ '
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG EL PL MEcy
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afro tat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�Z with Section 70(01)of Division 3 oflhe Business and Professions Code,and my licemeiv - RESIDENTIAL'
full force andff
effect. PERMIT ISSUANCE RESID
W� ' ❑ W L ❑KITCHEN REMODEL
JUL License Class Lir., APPLIANCES-RESIDENTIAL "a'as"' DITION El PLUMBING RE-PIPE
W Date" Connector
ARCHITECTS DECLARATION MULTI-UNIT ❑STRUCTURAL.
F.Om IMideWandm I hull W used blit records PANELS MODIFICATION
ZOO my as public
OZF Q UPT021XIAMPS ❑INTERIOR [-]CHIMNEY REPAIR
rMLqq.. Licensed Hofeasinnd 201.1000AMPS IMPROVEMENT
�bg i Oe,I at eU1LDEk DECLARATION Course
OVER IUIIUAMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
OOWGG Q 1 hereby.(Sect that 1 03 1. excmps from Ne Cssions o License Iso none ❑OTHER
' gOyU following mason. ermiton]onstr Business and improve.
demolish,
Code:Any city Or SIGNS ELECTRICAL
LLC which requires a Pewit re construct,Me elten improvti demolish,m e 4 sr"any swmurc
prioms fire ed Pronto tto the Novisio sof for Cmicanwit license Law(Chapter
emenl SPECIAL CIRCUIT/MISC.
(col heir licensed pursuant to the of Disiam of the Conusines'a LicenseeLions Code)
GC
(commencing with Section]IlpO)a(Division]rf the Business and Professions Code or COMMERCIAL:
g ) TEMP.METER OR POLE INS
y" (% Nat he is exempt therefrom end the basis for the alleged ewicant 1.Any violation of [:1 NEW BLDG/ADD1770N ❑DEMOLITION
Section 701 IS by any applicam fora pewit subject,Me applicant 10 civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
6 not mart Nan five hundred dollars WOW. IMPROVEMENT
❑ 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL EL 1
0 will do the work,and Ne swcture is not intendedrreffcredfor seI IS 70,4.Business ❑OTHER
sail reit Professions Colic The Connectors License Law Ices not apply to on owner of OUTLETS-SWITCHPS R
property who builds or improves Nereon,and who docs such work himself or through
his own employees,Provided thus such improvements are not intended or offered for NEW R.ESIDENTIAL ELECTR Ff. '
sole.If,however,the building or improvement is sold within one year ofcomplefion.the - SQ.FL FFFlll111yyy111�g000���R ARM VSQ.EL
neldcr will have the burden of proving that he did not build or improve for par /�^
posse of sase of sale.). L [/
❑I,as owner of the Sec.prop,my70,1 um exclusively crowning with Ileeheed contractors m L'
vemtruct the project(Sec.]044,Business and Profusions CaleO The es themors Li- '
cense Law does not apply toan owner ofpropcnywho
caneaddsor stmat othrCermseand QI'Y, PLUMBING PERMIT FEE
who wmmatx B,r,vdl Projcas wiN ecrnvamnr(s)lieensed Pursuenuothe Convanors
Lt..Law. PERMIT ISSUANCE
❑ 1 um eacmpl under Sec. ,B&P C for his reparn
ALTER DRAIN&VENT-WATER CEA) VALUATION
Owner Date �g�a
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 /� �� ��
thereby eDon under Penalty of perjury one of the following Michaelmas: Y {v
❑LhaveandwillmainNinaCenificateofConxennoself-insure forwurkera Compen. DRAINS-FLOOR,ROOF AREA,COND. g� � STORIES TYPE CONSTRUCTION
®tion,es provided for by Section 371X1 of Ne Labor Code,for the peofowance of the 1''�_
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and wi muinsuin Worker's Compensation Insurance,as requited by Section
37M of Ne tubo rlheperfowance of the work for which this permit is issued. GAS-M.SYSTEM-]INC. OUTLETS s►� ,a- r�,nppp ApN
My Warkels Cn 1pemmioni Policy tougher art: GAS-❑A.SYSTEM-OVER4(EA), N%I�195
1 Cemiee m Folic o.:
CERTIFICATE 0F EXEMPTION OM WORKERS' ell y
CO PBNSATS� INSUR E GREASF/INDUSTRLWASTEII, RCEPPOR U L
This historian p I INSURlli o wehundreddollers(SI(q) L DING DI SION FEES
at ° nn GREASETRAP
or less.) PLANCHECK FEE'
Ic ify that int p Ko I t eworkf hich this permit is ixxued,lshall
SEWF.N-SANITARY-STORM EA.200 FT. `
net empl any perso t''e' t to bac a subject m the Workers Compen- ENERGY FEE t♦✓
zZNation wsof Cal rota WATER HEATER WNENT/ELECfR
O App'aril '�� - GRADING
•1 NO CE TO A 1 - ter Faking is Cen"cam of Eseugpdon,you should WATER SYSTE•MITREATING
f"e hero esvbjml on Q6inpensati provisions of the Labor Code,you must SOILS
�i firs c ah a JI"y"'�-ns or s Pewitshallhedeemedrevaked. WATER SERVICE
UO ._,jCONSTRUCTIO LENDING AGENCY NEW RESIDENTIAL.PLMD. SQ.ET. PAID De Rcmipta
I hem wthat Nereisaco ochre lending agency forthepurfomnnce of
the work for who this pewit is issue (Sec.3097,Civ.C.)
0 E-' Lender"Name TOTAL.:
0 Lender,Address BUILDING FEE
1 certify That 1 ha read application and amte that the above infowmion is 177 ret
t4A carets.l agree to comply city and county ordinances anal state laws relating to QTY. MECHANICAL PERMIT FEE
LJ z building cmatuctioa.and hereby am once representatives of this city to enter upon Ne SEISMIC FEE
above-mentioned property for inspection purposes. ILPERMIT ISSUANCE - ELECTRIC FE
(We)agreem save,imlemnify m d keep hawless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in roequ
nsence of the mooing of this pewit. PLUMBINGF E
all
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00()CFM) MECHANICLHE
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER 1R000CFM) CONSTRU ION TA%
Sigrumie of ApplicnnVCrnwctor Date EXHAUST HOOD(W/DUC]7 HOUSING TIGATIO 9
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle locations material HEATING UNIT(TO 100,0100 BTU)
as defined by the Cepenim Municipal Code,Chapter 9.12,ural the Hall and Safety
Code,Station2553260? HEATING UNIT(OVER 100,000 BTU)
❑Ye, ❑No VENTILATION FAN(SINGLE RFSID) PAID
Data ReceiptWill the applicant or future building occupant use equipment or devices which -
•emha
it rnrdeas air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR I00,M)BTU)) ,
Distrid7 05
BOILER-COMP(OVER 100,000 BTU)
E]Yet ❑Nr
AIR CONDITIONER
I have mad thellaeurdous materials requirements under Chapter 6.95 of me Cali- IS-- DA
fonds Health&Safety Code.Sections 25505.25533 and 25534.1 understand tem if Ne NEW RESIDENTIAL MECH. SQ.FT.
Wilding does not currently have a tenant,Nat it is my respnnsibility to notify Ne occupant
of Ne lequiremems which must be mel prior to issuance of a Canticle of Occupancy. IV
Owner of mahodud agent Data ISSUED BY:
OFFICE