30474 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ` BUILDING-ELECTRICAL. PERMIT NO, 3 O ^ 7 /1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3 !.� [�
BUILDINIG PROJECT IDENTIFICATION
BUILDING-1 ADDRESS: uZA ��, `�- �s - `^`/ ^ -,�� SANITARY NO. APPLICATION SUS0270BMITTAL GATT
OWNER'SNAMI_E71:S PHONE Vp CONTRACTORS NAME; �/Vrl-_Td�V_`I,ICLNO: �" `�
1+7W S/�LryeN� L d7,lm (�_j j6W S1()T•JJ �p SGCpS NIC CONTROL#
\RCHEITCUENGINEER: LICNO: ADDRESS- El
i0l /� LiawfiAr-Iij PLO
CONTACT - PHONE: BUILDING PERMIT INFO
❑ Cansultant Fees Paid by Applicant(Initial) pLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arnrm mat I am Baamed under,provisions of chapter 9(eanttdeacmg JOB ESCRIPTION
❑ Z
00 with Section 7").f0ivisian3ofda Busmassand Profusions CW,...d my Been.isPERMIT ISSUANCE. RESIDENTIAL'�'�.. in fun mreetma erceet.
� F License Cloy} Lia# .49 V. i O SFDW L ❑KITCHEN REMODEL
Dote 73' Convuc n� l -NEOrJ APPLIANCES-RESIIlENT1AL ❑ADOTTION
M C3 PLUMBING RE-PIPE
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
Z O❑Z 'I understand my plans shall he mad us public ruoNPANELS s MODIFICATION
UPTO 20BAMPS
❑Z ❑
❑ - INTERIOR ❑CHIMNEY REPAIR
(-��9pW Licensed Professional 201-IfkXIAMPS IMPROVEMENT
KUOWNER.BUILDER DECLARATION OVER 1010AMPS ❑BEVREPAIR ATH REN ❑DEMOLITION
0044 ty�d I Thereby affirm that I am exempt from the Contractor's License Law for the
3 4 U following reason.(Section 71131.5.Business and Professions Code.Any city or county []OTHER
�N4 which reclaims a permit m so amn.ellen improve,demolish,or repair any notation, SIGNS ELECTRICAL
}
prior to its issuance.alsofequirea the uppllcumfo ,toll#analis,,rile a signed mnement SPECIAL Cl RCU1T/MISC.
;!Ithe he is licensed pursusnuo the provisions of the Comracrors License Law(Chapter 9
m..00 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST, COMMERCIAL:
4 q door he is exempt therefrom th
and the basis for e alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
yy�S 4W,
Section 7031.5 by anyapplicant fora permit suhjcctsthe applieannn a civil penalty of POWER DEVICES
u1�rn ❑TENANT ❑FOOD SERVICE
•�.�}
not roue than five hundred dollars(5500). IMPROVEME
g ❑hes owner of the propeny.or my employee with wegenutheirsulecompensation, SWIMMING POOL ELECTRIC
will du the work,and the ewcture is not intended oroffered for sale(Sem7044,Business - ❑OTHER
and Profession,Code:The Cammcme,License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES t
property who builds or improveslhe..,and who does ouch work himself.,Through
his own employees,provided(hot such improvements are not inertde l or offered for NEW RESIDEM'IAL ELECTR SQ PT.
sale.IL hawcven the building or improvement is sold within one year"completion,the - SQ.F17.FLOOR AREA 5/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for Pur- - L I ^•
you of
a,soled. TOTA
❑ I,us owner of the propeny,oro exclusively contracting with licensed con_,s m J'1
ronstmdthe projectpplyo an Business and Professionssdsor improves Thetherean. nd
c ,,Lawns f mM1applr tons.woerofpropensoohe bei ldsnradorthContran,and QTY. PLUMBING PERMIT FEE 19(76
who commets for such projects with a cnnwcmns)licensed pursuant m the Commcmrs J
w.
❑c l em caampt under Sec. ,B&PCforthisreenn PERMIT ISSUANCE ;(Iy 4wl V'Ut'�(1(71411
Owner Date
ALTER-DRAIN A.VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affimn under penalty of perjury one of the following declarations: iGROIJP
I have and will maintain a Certificate ofConufom to self-insum rWorkers Comped- DRAINS-FLOOR.ROOF.ARIA,COND. TYPECONSTRUCTION
Nation,as provided for by Section 37M of the Labor Cac e,for the performance of the - /work fm which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700ofthe Labor Cale,for dte Performance.(the work for which thmis petit is issucA. GAS-EA.SYSTEM-I INC.4 OUTLETS APN
MyWorkNPnGtp .ad Pulie
U eEAVEComernPolcy NoW
GAS-HA.SYSTEM OVER 4(EA7
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASDINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCEn5LG DIVISION FEES
(This section need not be completed tithe permit is for one hundred dollars(51 W)
or loss.) � GREASE TRAP pLANCHECK FEE
I certify that in the performeaccofthe work far which this Mount is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become subjer�t cyyprygs Comped- ENERGY FEE
,Z Nation Lawsof C.1ifnmiaateT/E
. _ 't'I� V"I f/f
rqq WATER HEATER WNENLELTR
Z Applicant IJr- 4 GRADING ME
h NOTICE TO APPLICANT.If,after makin dor Ccmf¢me of Exempbnn,y..should WATER SYSTEMITREATING
1"! hecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
LW5 fonhwiNcomply vithsrch previsions m ilid,permit shall be deemed revoker. WATER SERVICE
��QQ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
IherebyaPorm that then is a conswcdon lending agency for the performance of Data Receipt#
the walk or wmi
hichthis pert is issued(Sce.3097,Civ.C.)
�/•+ Lenders Name TOTAL:
5 Lendae.Address TOTAL:
as 1 certify that I have mad this application and state that the above information is BUILDING FEE
h correct.l agree to comply with all cityand county oNinanceaondsmte lows returns to QTY. MECHANICAL PERMIT FEE
U hiiliingc.nswction,and herehyauthimize represcnmtisce.fthis aitym enterupon the SEISMIC FEE
above-men4oner propeny for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Column,againstPERMIT ISSUANCE ELECTRIC ME
liabilities,judgments,cons and expenses which may in any way scare against ssid City ALTER OR ADD TO MECH. PLUMBING FEE .
in asequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SO RCE ',UTA'fl NS. - MECHANICAL FEE
(%•��G?� AIR HANDLING UNIT(OVER Ib,Onn CFM) CONSTRUCIONTAX
Signature ofAppllcaffla_ n,9 v Date EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the,applicant or fume building occuManamre or handle hazardous material HEATING UNIT TO 1100,000 BTU)
as defioed by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 255320)? HEATING UNIT(OVER 10.0010 BTU)
❑Yes - []No VENTILATION FAN(SINGLE RESID) PAID
WBI Ne applicant or future building occupunt use aquipmem or devices which Dole Receipt#
t hazardous air conaminant,as defined by the Bay Area Air Quality Management BOILER-COMP OIIP OR 100,0011 BTU)
TOTAL:
isWmE
El Yes No BOILER-COMP(OVER 10n,"BTU)
•' ❑ -
I have read the hazardous materials rtcluirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DAT
fumiu Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH, SQ,FT. '
building does not currently have a tenant,that it is my reaM sibility to notify theaccupant
of the requirements which must be met prior to ismonae of a Cmificam of Occupancy.
Owner or audimsel agent - Dam TOTAL: ISSUED BY:
OFFICE
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OFFICE44//COPY
CHANNEL CLASSIC `-tc,rt tc� dTlc�
LETTER EDGE
PAN CHANNEL FVc-I,,l-T ELF_ vATtc�-
REV.PAN CHANNEL (HALO)',
EXTERIOR NEON
INTERIOR NEON -
CABINET
WOOD SANDBLAST
ILLUMINATED z
NOWILLUMINATED o
PLASTIC
Q
ALUMINUM G 0
SHEET METAL "'
v
ROUT OUT THIS IS AN ORIGINAL UTA'UBLSHED DRAWING w
��� — CREATED FOR YOU BY GAL-NEON SIGNS.ITS JOB NAME r�AF I- u re SCALE ,d F� )=p DESIGN NO. I2iZs r
FLAT CUT OUT `/"E= INSUNI S I G N BEING SUBMITTED FOR"E PERSONAL USE M �`�'
BACK DECORATED CONNECTION wrrr+A PROJECT BEING PLANNED ADDRESS !07 4 r ��vL1Ti-1 riE /d I-�Z:/1 ►t ' SALES REP.V P12,,_ L,d DATE 2b-z-4-q to
PAINTED FOR You BY CAL-NEON SIGNS.IT Is NOT TO BE BE
VINYL 1577 ALMAD EN ROAD, SAN JOSE 95125 TION,NOR IS TO ro BEERRE E IDE YOUR�o C L !'F STI I`�' ' C��`I DRAWN BY �,FtZ T�) za
LEXAN OR EXHIBITED IN ANY FASHION SHEET m
MODULE ( 408 ) 289- 1883 fax : 289-8024 uj
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OTHER CAL_ CONTRACTORS LICENSE 385665 I OF