28741 Moll
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL L
8741
BUILDING PROJECT IDENTIFICATION
IAING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
l mol r►. SL4o .b e 73
W ER'S NAME. PHONE: OC N E LIC
J �/^ NIC CONTROLM
ARCFJT ['1'/IiNGI^Ba H^o w ADDR111
�.P� 1 / / U- ❑
CONTACT. PHONE: - BUILDING PERMIT INFO
J408 ❑ Consultant Fees Paid by Applicant(Initial) BLDG a PLUMB MEC
A
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
J
1 hm ereby affirm N1 am licensed under provisions of Chapter 9(commencing JOB DESC IPTION
OcaZ with Section 7000)of Division 3 of the Business and Pmfessi^ns Code,and my license is RE. I�pD NTIAI
00 PERMIT ISSUANCE
F W full force mertect. SFDWL El KITCHEN REMODEL
�U License Class Cmit APPLIANCES-RESIDENTIAL. ❑AUDITION ❑PLUMBING REPIPEV
LF..ZZ Date GnlDECL
NQ - MULTI-UNIT � El STRUCTURAL
ARCHI eC9'5 DECLARATION
Z07y7J. land aon anss as public rccurdv PANELS - MODIFICATION
OZ%J UPT02W AMPS [I INTERIOR [I CHIMNEY REPAIR
[^ L nsadP f lona. 201-IOMAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION Com ION OVER IOW AMPS ❑BATH REMODEIIREPAIR C3 DEMOLITION
O U 1 naso .(Sous that 1 1, exempt from the Cssion,nlr5 LicenseLaw for the
iW5 following reason.Isecllnn 703L5,Business and .c,deions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
sR w 01"' which its issuance,
s permit re cnnmma,aper,improve,demolish,ar repair any anunurc
that hoitsendporssoreto the the
ovisio so for such Contra snit mrite aicense Use
statement SPECIAL CIRCUIT/MISC.y thus he is licensed pvnuununthe provisions of the Contractor's License law(Chnpar9
<� (co he is exempt
Sedfrourn d m ha ss or h t.11e,tcinexempt o..A.,oneCMe)or TIiMP.METER OR POLE INST. COMMERCIAL:
d o C Nm he is exempt therefrom and Ne basis far the alleged exemption.AnY violation of El NEW BLDG/ADDITION El DEMOLITION
Section 7031.5 by any epplicam forupenniuuhjects themalcirt..civil penalayof POWER DEVICES ANT ❑FOOD SERVICE
m not mare than five hundred dollars(SSW).
"ZI r-1Lenownerofthepropeny.nrmcs yempl^yee 10 as Burnside compensation, SWIMMINGP ELECTRIC IMPROVEMENT
HO will do the work,and the structure is ma imc oroffe f^rsale(Sec.J04q Businexs ❑OTHER
MRS and Prof.'rem,Code:The Contractor's a.law Joe not apply m m owner^I OUTL SWITCH -FIXTURES
�' property who builds or improves thereu and who does sue work himself to through
his own employees,provided that su improvements me nn 'mended or offered for NEW ES IAL ECTR SQ FT, xµAR sss/// n
.wre Lhoweveotheve,h louri vement ix sold within one) o(completionthe V�'H'�" \A ^ P'
owrmnbuilJer will have the bur rfprovin Na thuild prove for pun, / {..�I 4
,me.f sale.), (/'
I,as owner of the rty,a n esel cling with li toed emmicusrs to
cansWet the projet cc.7044,Business a cu fess on,.Cad The Ci n osemr's Li-
cemeLaw does net ply mwo rnywhobuild mimprovesthemonand QTY PLUMBING PERMIT FEE
whamarraccsforme Injects c (I)license ....at.,he Conuacm's
Lice.Lo, PERMIT ISSUANCE
❑I am exempt und— .B&P C bards rcawm
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Owner Date els)s
WORKERV�COMPF�NSAI.1.0TIO DECLARATION BACK IH,OW PROTECT.DF,VICE
I hcrcbYaffirm underury rte of the following dedamions:I viscer!will maineina ^ nt m selbasute for Worker's Compen- DRAINS-FLOOR.ROORARE.A.COND. STORIES TYPECONSTRUCTION
sation,us provided for M1y g t LaborCade,furtheperfomuoce of the
work for which this permit is FIXTURES-PERTRAP
I have and will maintain penmtion Insurance,nv required by Section
3700o1fdalabor Cole,fitnhe performance oflhe work for which lMs permit is ixsuW. GAS-EA.SYSTEM-I INC ETS OCC.GRUUP APN
y Wake � tp 1 rtJ� ym_ jfr Policy No:an r 3'�b GAS-EA.Sy • x (EA)
artier, r II/4/ OP EX`MPTION O
IFICATE FROM WORKERS' GREASEANDUS WA •RCEPTOR
COMPENSATION INSURANCE B DI DIVISION FEES
(This section need not be completed if the permit is for one hundred dollam(S1 Of GREASETRAP ,
or less) - CiiiI` PLANCHECK FEE
Icenify ma in the perfonnance 6f Ne work fnr which this permit is issued,ishell SEWER-SA TARP-S EA. ) O
not.many.,person in any manner sows m become subject to dm Workers'Compen- ENERGY FE
z satin Lawsof California.Date WATER HEATER `NT%EL GRADING
O O
Applicant
Fl NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should WAMR SYSTF.MIIREAT �' ` SOILS
hceoae subject,^the Worker's Cian,mminn provisions of the Labor Code.you must
�t ❑Maida comply withsuch provision,or this pnmitshall 6e deemed revoked. WATER SERVICE -
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. QFf. PAID Data Receipap
V z I hereby affirm and them is o construction lending agency for the performance of ,
Da [[[carr the work for which this Permit is issued(Sec.3097,Co.C.) .TOTAL:
Q V Landds Name -
Lenders Address BUILDINGFEE
Ir Pr 1 certify o comply
1 hove with
this application county
ordinances
nam that the above information is /a
Uy buildingegreemco,and herebylstumnd cnunryovllnuncesend statcity to enter
erupon due QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V� building construction,saW hereby vulhonre rcprcsematives of this citymrnmrupmthe
above-menlamedprapcny for inspection purposes. PERMIT ISSUANCE / ELECTRIC FE
(We)agree m save,indemnify and man hornless the City of CuPenino against
liabilities,judgments,costs and expenses which may in my way same against said City LTERORADDTOMF.CH. PLUMBING
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS Aytf WILL COMPLY WITH ALL ON-POINT AIR HANDLING UNIT GO IO,WO CFM) MECHANICA FEC
SO EGULAMONS. (/ t
/ _ AIR HANDLING UNIT(OVER IO,mk9 CFM) CONSTRUCTION TAX
Sign of Applicant/ mm r ate FAHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant smrc or handl harardousmaterial HEATING UNIT(TO IW.003 BTU)
as defined by the Cupenino Municipal Cale,Chapter 9.12,and the health and Safety
Co le,Section 25532(a)T HEATING UNIT(OVER IW,l1W RTC) LOA B
. ❑Yes - [D N. VENTILATION FAN(SINGLE RESID) PAID Data Receiptp
Will the applicant or future building occupant uu equipment nr devices which BOILER-COMP(3HPOR -
7
W09000 BTU)
emit hazardous air contaminants as dcfned by the Bay Arca Air Quality Muaogcmenl TOTAL:
BOILER-COMP(OVER IW,
Disuim'1 OfM)RN)
❑Yes No rjl f'J r . .
I have reed the hazardous materials requirements under Clamer 6.95 of an Cali.
AIR CONDITIONER r TIS$ A CE DATE
fomia Health&Safety Code.Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does ten commonly have atemm,that it is my'respmsibility to notify the occupant
of Ne rcquiremenu which masa IN,met fore,'a issuance of u Cenifcate of Occupancy.
Owner or euth^rized agent Dam ISSUEDBY:
OFFICE