28647 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEMPINO BUILDING.-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBING-MECHANICAL 28647
BUILDING PRJic r IDENTIFICATION
ILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
of 0f`L_ q�4�iS
so NAME: 1 1 ^ _ PHONE: CONTRA R'S NAME: -LIC NO.
,1111101.
� ` O, NIC COfMR/OL X
ARCHITEC A:NGI .V U 2155 LIC NO: ' ❑ 7 [
ONTACT. PHONE: BUILDING PERMIT INFO
5',Z>
6z3_(3(880 ❑ Consultant Fees Paid by Applicant(initial) BI G. ELECT PLUMB MECH
LICEbISED CONTRACTOR'S DECLARATION v QTY ELECTRIC PERMI'P FEE r��(\ ❑ ❑
1 herthy affirm than 1 am licensed under pmvisinm of Chapter 9(commencing JOB DESCRIPTION
Dc0 thSection Taro)of Division 3 ofthe Business and Pmfcsomis Code,and my license is RESIDENTIAL'
F O with full facet mWd PERMIT ISSUANCE
Y W H to � qq7 ❑SFDWL ❑KITCHEN REMODEL.
aUU Licc Close, Lic.M -
�aW Cnnuanor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS LJMULTLUNIT ❑STRUCTURAL
ZOyZ I understand my plans dealt he used as public records MODIFICATION
OZ—p UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Professional 201-I(KOAMPS IMPROVEMENT
'4 OWNER-BUILDERm DECLARATION OVER U)00AMPS ❑BATH RF,yDDEV_ RfyPQI1jA (TION
Y ,,
aa�o 6 1 hereby nfYnn than I um camuPl from the Conuunor'x Liccnxe haw for Thu•
tee 3 L FU- following reason.(Section]031.5.Business and 1'rofosions Code:Any city or county SIGNS ELECTRICAL - ❑OTHER
LLLL17 u.y which rtquirtn u permit m cmiuvro 1,alcor,improve,demolish.or repair any slrvaua
pnorm its issuance.also requires the applicant lorsuch Permit o file a signed statement SPECIAL CIRCUITAIESC. rte} Aw
Wythat he is licensedpunuannalhe pr000mns ofthe Candacus,License Low Cloprer9
CCO (commencing with Section'I(MM))of Division 3 of the Huarc.x and Professions Code)nr TEMP.METER OR POU:INSTI COMMERCIAL'
1 a e ce that he is caempt therefrom add the Iasis for the alleged cacmp km Any violation of ❑NEW BLDG/ADDITION DP_MOLITION
W^ySection]031.5 by any applicant for a Permit subjects the applicant to a civil penally of ROWER DEVICES
m mom than live hundred dollvn(55a1). ❑TENANT ❑FOOD SERVICE
.~.=6 Lasowacroflhe rel +ensation, SWIMMINGPOOLELECFIiIC IMPROVEMENT
❑ Prole'nY,of
E DyCLTto Yccs with wage,ws their sole ennit
F- willdo the work.and the nmmurt is nal inrendW nr nffcrN for sale(SeeJUW,Business ❑OTHER
W—se and Prefesaioni Code:The Contractors License law does not apply to an owner Ofzx
OVILEI'S-SWITCHES-FIXNRFS
property who builds or improves thereon,and who dues such work himself or through
his awn employees,phoulod that such intprovemmitn are not untended or aH2red for NEW RESIDENTIAL ELECTRSQ Fr.
sale.If,howeverthe building or mrpowcmem is sold within one yearofeumpletion,the SQ.FT FLOOR AREA LSO FT.
ser-builder will have the burden ofpmving that he did not build or improve for put-
prx of vale.;,
❑I,as awnur of the pmperty,am vselusiv,ly on,ee ing with licensed cam raaonv m
ms4vct be pmject(See.7()44,Business sad Pndeudon,Code:)The Com raemr'x Li-
cemelawdoesnotapplytoinownerofpropenywhobuBdsorimpmvcsthercon.and Q'IY. PLUMBING PERMIT FEEnwho contracts for such projects with ormusuroodlivenud pursuanuo the Cmanar rs
Lie cmc Low. PERMIT ISSUANCE
�l am eaem,u under Sec. ,B&P C lir this lawn
Owner Date ALTER-DRAIN&VENT-W'ATER(EA) VA IDN'
N'ORKIiIU1COMPF ON DECLARATION BACK FLOW PROTECT.DEVICE 1TN�
Ihen:hy alHnn under pennhYo yore Of the following dcclurutinna CII t, UI- .o 1 s�U
']Ihave and will maintainaCenificatc of menus elf-insula for Worker's Comped- DRAINS-FLOOR.ROOK AREA,COND. STORIES 'TYPE CONSTRUCTION
` ,ion,as provided for by Section t]DI of the Labor Cade,far the pcnfommncc of the
ort for which this permit is issued FIXTURES-PER TRAP
❑ I have and will maintain Worker's Cnmpensatlon Insurance,as required by Section
37IOof the labor Cade,for the Performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.Y OUTLETS OCC.GROUP APN
My Work4 tpnn Inncm
Cunic? PolicyPoNacy:nu M1r
, s44 GA ASYSTEM OVER 4(EA)
CERTIFICATE OP fxfdo ON�WORKERS'
COMPENSATION INSURANCE GREAS INDUSTRL WASTE IN]ERCHFI'OR
(This section need not becompletM ifthe permit is forum hundred dollar ) nuiLD ( VISI( PEES
nr lea) GRFASE AP PLANCHECK FEE
I¢nifythat inthe porfamoowe ofthe work fir a'hielthis perm" suled,Ishald
IiNLRGY PP
nor t employ any person in any manner a)us ja to become subject nrkcrM Com SEWER-S ITARY-STORM EA.2001 FT.
Z cation laws of California.Date pen-
z O Applicant WATER HEA :R W'/VF.NT/ELF.CTR GRA
0 NOTICE'IO APPLICANT:If,afr.,okincindficam,cnificam,f Ecmptian,you should WATER SYSTE T]UixHNG
7 bec me sahuo of m the Worker',Coro,,imsof the Labor Code,you nm,l SOILfonhwitheamplyithxuchprovnrinkthallbccccrimdm oked. W SERVICE ofC Q CONSTRUING AGENC Z S tNHAL PLMH SQ.FEU OI hereby affirm that there islendmg agency ;t e arm D Receipt0
F^ the workfor which this pennil is i .Civ.C.
Uri Name TOTAL:
W Lenders Address - TOTAL:
a 1 certify that 1 hove mud this plicatio .i 'tee than 0Ms1 vc n ormatinn is BUILDIN o FEE O
pp a mocu l agree 10 comply with all cit and condo Ii once.an . ao,claing to QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby both no,mpmxni vesofihiss tymcnrerupon SEISMICF:'
above-memioded pngeny for impsai , anaae PERMIT ISSUANCE
ague to wve,indemnify a keep harmless the City of CtuaOu against ELECTRIC FEE -�
Iia -uiex,jug ntv,castsand expense, hichntayinany wayaccreca rel saidCit,' ACTERORADDTOMECH'
in denee of gmntingofthisfamn . PLUMBING FEE
AP ICA UNDE TANDS AND WI PL WE LLN N-POh1 AIR HANDLING UNITfF010.000CFM) MECHANICAL FEE
SOL CE iGULATiO
of AIR HANDLING UNIT(OVER 10.Ig0CPM) - CONSTRUCIONTAX
Signa o Date EXHAUSTHOOD(W/DUCf) HOUSING MITIGATION E
HAJ.ARDOUS MATERIALS DISCLOSURE
Will the applinml or future building occupant,core or handle hazardous macrial 1117 TNG UNIT(TO110,1X0 BTU)as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)'! HEATING UNIT(OVER 110,1100 BTU)
❑Yee ON. PAID
VENTILATION FAN(SINGLE RF.SID) Dale Reeipl0
Wi1ltM air contant minants
a building by the niuttca Air ent Quit Management
BOILER-COMP(3HP OR 100,000 BTU
emit Kvvdom air contaminants tax deflated by the Bvy Area Air Quality Munagemcm )
hstnctT Oyes ❑Nu BOILER-COMP(OVER IWodo BTU)
,
IF
I have lead ry
the harallous materials ruimmu cnunder CTupter 6.95 ofthe Cull- AIR CONDITIONER ISSUANCE DATE
fomia Heald&Safety Cade.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MEECH. SQ.Fm
building does not currently have a tenant,that,,k nfy rteponxibi ay m n edify the acupum
Of rmuinmem,whichmaa heow,Fui rIoi,iaanee of a Cent fence 0 Occupancy.
Owner it authoneed agent Date TOTAL: ISSUED BY:
OFFICE