28753 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECTRICAL PER.MITNO. 28753
8 raffia
BUILDING DIVISION APPLICATION/PERNIIT PLUMBING-MECHANICAL / 8 7 '1 3
BUILDING PROJECT IDENTIFICATION N VVV VVV
OUILOING AUURESS; SANITARY NU. APPLICATION SUBMITTAL DAT'.
'O 6 Exp . el 14 vZra ilx!
OM'NFR'S NAME: PHONE: CONTR�� SN ME r NIC CON��
RCHITECT
�IT/ /EN ryEER. / 7& LIC NO: ADDRESS: aN ars ❑
CONTACT:•,L`'s-•11L!/• PHONE: BUILDING PERMIT INFO
� C //�/ �`GJ/6/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
I"V
/'(
LICENSED CONTRACTOR'S DECLARATION C ELECTRIC PERMIT FEE I Ui\ ❑ ❑
1 hereby affirm that I am licensed under provision,of Cbmt.,9lermmrncinp QTV JOB DESCRIPTION
=xZ with Section 7000)o(Division 3 of the Buaincrr and Pmfesrions Code.and my license i.
Op G-1.yy�p PERMIT ISSUANCE RESIDENTIAL
Y a:F to lull fox,and effect. n //�/ ❑SFDWL ❑KITCHEN REMODEL
<ZU Liunse fJ Lic.a APPLIANCES-RESIDENTIAL ❑ADD N ❑PLUMBING RE-PIPE
V Dau /, _ Con(ru(ar
:�=ri�j ARCHTTECI-S DECLARATI N PANp15 ❑MU I-UNIT [j STRUCTURAL
'�.u-Z lundentand my PI hrusedvs public retards MODIFICATION
Zn7 UPTO 200 AMPS RIOR ❑CHIMNEY REPAIR
tattooed Prefesaionel 201.1000AMM IMPROVEMENT
Ynj OWNER-BUILDER DECLARA OVER Ig111AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
Y < I hereby offir Nat 1 em utmpt from the C she's Liene Law for Ne I ❑OTHER
a U (ollowin,reason.(Satuon 7071.5.Business cat sssiaa.Code:Any i(y or county SIGNS ELECTRICAL
Cwhich requires a permit,o comeuct.dtcr.ion ver demolisR n repair ny reunion,
g pnormtu inmi dw rogdres Ne appli fmhchpermihbfile.sig mremenh SPECIAL CIRCUIrIMISC.
tatheislicansecipunuanththeprov hof Ne Comminr'n LlcenseLa (Chapw9
(mhmhoneingwithS,euon700) ''ishan Jof Ne Buaransand Proftnl asCotleln TEMP.METER OR POLE INS(. COMMFRCIAL
Nat ha i.eaempt Ncrt the bssis for Nc alleged exemption.Any iolaum of ❑NEW BLDG/ADDITION DEMOIlT10N
%^ Section TW, vaY applicant for a permit uti are aP he.,In v civ petulty,of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Z y rot,am tun fi a handed dollen(55001. IMPROVEMENT
< ❑Luowhher the prop,ny.ormyemployees with writes anthorrate co pcnsmion. SWIMMING POOL ELECTRIC A& /j6Jq!/ S
fy,=0 will dotlhewn'and the muniure is rot inundrdoraRered for We(Sec.7 .Basin... I ❑QTTffR
3 and Prefession Code:The Contractors License Law dos n..pply tb owner of Oumm-SWITCHES-FUTURES Q(/hpV G A L.//W
progeny who Ids or tmprovu Merton,and who data rush work himxl en NrouPh
his own rural Provided hha Such impro mens -nhended or Bared fa NEW RESIDENTIAL EIECTR SQ FT
sYe.ILhoweverdalmildingorimp vermin Id witi omy of co Icuon.hha SQ.FT.FLOOR AREA 56Q.FT
-oildaw 1 have one burden o Si g he nm build m i ve for aur ��
pose o(dcl.
❑1.euowaa Ni a Sly conoanis,with( mm etas. h
Slat
maseud the prof t 1 sinus and Profaai mi C u The,su da .Li-
ttnse Lw dons n apply to 0 of progeny who buil or improve Crema,e, QTY- - PLUMBQNnG PERMIT FEE
License
Lace(m hproja Naconvac,nfs)liu punumtrathe Conuachors /
Lactase Law. PERMIT ISSUANCE -
❑Ion eaemp,u rsa. ,B&PCfor Nis rtaran
ALTER-DRAW@VENT- ) N
Owner Dere
W KER'S COMPENS ON DECLARATION BACK FLOW PROTECT. E
1 army, in rpcndtyof dir,oneofthefollowingdechntied:
_ ❑Ihav,avd w0l maimain of,.
f Contscnntmself-amort for WorkKs Compm- DRAWS-FLOOR ROOF. O STORIES TYPE CONSTRUCTIO:
swim.as proJden fa by Seen.37M of Nc Latin code.lar N,1...... ace of--
.,it(n which this permit is issued. FIXTURES-PER TRAP
❑ I have and will contains Workers Compensation Insurance.as required by Sauon
77M of the labra Code.far Nr performance of the rank for
r.t�hheimrchthis pcmN u issued. GAS-EA.SYSTEM-I INC..OUIL OCC.GROUP APN
My Warkerk__GorypewtiVy' cturnerolicy Noand y—/'r'���33 9S9s GAS-EA.SYSTEM-OVERilE1)
Cartier. ..SST�aroiFNK ffVVar
CERTffIC11
COMPEN COMPENSATION
INN FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WAST911NTERCEPTOR BUILDING DIVISION '
(This section nada be,completed if the peri,is foram hundred dell.IS 1001 GREASE TRAP
or has.) PLANCHECK FEE
IeaufY Nn in thepMomtance a(Ne wort(or which Nis permit isiuued.I NJI SEWER-SANITA -STORM EA.200 Fr.
nn employ any person u N
on in my mso to become Subject to e Workeri Compen. ENERGY FEE
Z uuoo Laws of California.Data WATER HEA WNENfyFJECfR
ZApplicant GRADING FEE
? y NOTICE TO APPLICANT:If.after making this Certificate of Exemption.You Should WATER S TING
k-' became subject to are Workers Corepreca,ion provision of On Labor Code.you run I SOBS FEE
forthwith comply with Inch provision.or Nis pemuuhdl be deemed rovaked. WATE SERVICE
= Z ONSTRUCTIONLENDINO AGENCY NEVIIESIDENTIAL PLMB. SQ.FT.I PAID pati Reeei N
U O I haebyaffum thm Nen,is acmmuc(im lending agency for the pie omuncra P
— the work tar which Nis partner is aided(Sec.7097.civ.C.) TOTAL:
Landers Name
U lenders Adtlrtss TOTALkip
r I certify that 1 have read thisvpplicaion and Sera thm the move inforaniun is BULLRING FEE
fy emrtct.l ague to comply with till city and county nrdmane,s and time laws relating h QTY, MECHANICAL PERMIT FEE SEISMIC FEE
U Z building comeuction.and hereby suthonae represomauves of Nis edym snit,upon the
move-m,mimmd progeny W oupecuon lwrpn,.t. PERMIT ISSUANCE
I Wel ogrte h save,indemnify and keep harmless the City of Cupertino amino
ELECTRIC FEE �
Iiabiliues.judgments.msu real expenses which may in any way accrue aquina Said C'nv ALTER OR ADD TO MECH. PLUMBING FEE
in canseq.t.of the pounds,of Nis Pcnd(,
APPLICANT UNDERSTANDS AND WILL OMPLT'WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFMI
SOURCE REGULA F . C S MECHANICAL FEE
AIR HANDLING UNIT(OVER 111.0011 CFM) CONSTRUCTION TAX
Signanreo(Applicmh/Conm or Done EXHAUST HOOD(W W/O I HOUSING MITIGA NFEE
AZC OUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant Shim or handle hazardous material HEATING UNIT( IM."DTUI
as defined by N,Copeman Municipal Code.Chapho 9.12,and Ne HS.lhh and Safety
Code,Section 25572(.)" HEATING U. (OVER 100.000 BTU)
❑Ye. (2 No VEN7TLyf0N FAN(SINGLE MID) PAID
•
Will Mev hemar future buildm huse, t or devices which Data ,..Recarylt;�li
pp dbythen gmphncn BOILER-COMP(NIP OR 100.000 DTU1
emit et'? s aircamuminanhs as JefineJ by the Bay Ara Air Quality Mmnagcment TOTAL: -
Distric�!
0Y. ❑No BOILER-COMP(OVER 100.000 BTU)
I have read Ne hnardoh mandal. AIR CONDITIONER ISSUANCE DATE
regmrtmemx under Choate 5.95 of Or Coli-
forms Health k Safety Code.Sauon.155U5.3577 and 155.4.I meenhmd Nm if Ne NEW RESIDENTIAL MECH. SQ.PT.
building oras Mt Samoan,ave a henNL Nm it it my re.pnnsibibhy at unify the—I--
of Ne requncrom.which moa he tan no,to iswvnce of a Cenifiem,of Occupancy.
Owner n mth mead spent Dae TOTAL: ISSUED BY::Sj::tjjj�e�
OF=ICE