28758 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL 28758
BUILDING PROJECT IDENTIFICATION
BILDING��E� Ed,,va �� �� SANITARY NO. APPLICATIONSUBMITTALDATE
OWNER'S NAME: PHONE CONTRAC'IYIR'S NAME: /� LIC NO: �� `�
-(rt5, p.s�. Z - 5 r j l Q''d S III. NIC CONTROL a
�A H ELT/ENGINEER: LICN ADDRESS:
I 1
Z � ^ 5I.�. 9�
O'�`CtJ T f Z
CONTACT: PHONE: BUILDING PERMIT INFO
❑ ConsBHanl Fees Paid by Applicant(Initial) R.LITG ELECT PLUMB MECH
lL/l�Y'. ❑ ❑ ❑
LICENSED CONTRACTOR'SDECIAR QTY. ELECTRIC PERMIT FEE
1 thereby affirm thin I am licensed under pmvisiuns off Chapter 9 fc.mmcncing JOB DESCRIPTION
�oZ with Section 700kno Division 3ofere Business and Profcasions Cale.end my'iccnsc is RESIDENTIAL
F,= in full force and rRcc PERMIT ISSUANCE.
F �s $ZI q�-I ❑SFDWL
a
__i_
O License CP Lia.a 5 ❑KITCHEN REMODEL
HQL Dam Cornracx.UG4_ic'r- ^1.4 ❑
4 APPLIANCES-RESIDENTIAL ADDRION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULT6UNIT ❑STRUCIVRAL
ZOyZ I understand my plamuhall be used as public records MODIFICATION
O Z.. UP TO 2W AMPS
r4tcwxl Licensed Professional C1 INTERIOR ❑CHIMNEY REPAIR
gx'f� OWNER-BUILDER DECLARATION w<
IMPROVEMENT
C C 6 1 hereby nffirm that 1 nm exmnpt linin the Contractor's License Law for the OVER 1000 AMPS ❑BATH REM DEIBEPAIR EMO 1 N
3 a H following Mann (Section 1031.5.Business and Professions Cale:Any city or county SIGNS ELFCTRICAL QOTHER JAV
F^O m which requires a permit m cons.ucb alter,improve.Jem.lishma
,or repair any sturc
prion.its isuance,uds.req.irn lheii,licanl for such permit 3o file.signedstacment SPECIAL CIRCUIT/MISC.
that he is licensed pursuantto me pmvisions.fthe Contractors Liceme Law(Chapter 9
IF�aC CC (commmemilwith SeationlTax)) fUivision Sof the Business umd Professions QWe)or TEMP.METER OR POLE INST OMM R IA
6'y a that he is exempt therefrom and the basin for the alleged exemption.Any violation of ❑DEMOLITION
X�N Section 703ISb [I NEW BLDG/ADDITION
W yhundre d.11tlor.Permit svM1jedsthe epplicammacivil penalty of POWER DEVICES
not marc than Ove hundred dollars 155001. ❑TENANT ❑FOOD SERVICE
(]Las owner of the propcny,nr my emplo swiN wages as their sole compenwtinn, SWIMMING POOL ELECTRIC IMPROVEMENT
y(.. will doth,w.rk,and thenvucmre is Immo •J n ffcreJ fur sale(Sec.]616,Business []OTHER
a3 and Prafessions Calc:The Cone. 1' a 'uw tlocs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmperty who builds Or improve'Cher d.,,.r k IF If IF h
his own employee,,provided m such Peace'rma.ver JN m offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If.howver be huildi consist n'''@{{P1dwnhi oxeye of comPlninn.lhe SO FT FLOOR AREA VSQ.Fr.
cnhuildcrwe. b.ranoI proving, bull improve for pur-
e Fi s.Y
nun vv
,,a of srlc.).
❑ 1,as raw err f ray,a w0y crantra ing with licensed contractors m T
<onswcl the Protect c.10W,B as J Professions CrMr:)The Qmtracmr's Li-
censelnwdasnita townwnn O property who builds OFimPawaxmcrton,and QTY. PLUMBING PERMIT FEE SEP 20 1995
,he ,such ojectswitha mnwroup,)boarned pars......the Committees
License Law. PERMH'ISSUANCE CITY
UI- L;UrtH fINt7
❑lam exempt under Sea ,p&PC for his mason
ALTER-DRAIN&VENT-WATER HA)
(decoct Date VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DE WICE ' `
1 hereby affrm under penalty of perjury,one of the following declardiuns: coo
❑ Ihuve and will maintain aCertiticae of Cnnsantmxlf-Insure for Workers Compen- DRAINS-FLOOR,ROOE AREA.COND.
scion,as provided lot by Section 3710 of the Labor lisle,for the pm
crfompce of the STORES TYPE CONSTRUCTION
work far which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
31W of Ne Labor Coda forth,ferformanceof the work far which this permit is issued. GAS-EA.SYSTEM-1 INC.a OUTLETS OCG GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier Policy No.: GAS-EA.SYSTEM-OVER 0(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA]'ION INSURANCE GREASEJINDUSTRL WASTE INTERCEPTOR
(This xction aced not be completed if Ne permit is furore hundred dollars($100) BUILDING DIVISION FEES
m less.! GREASE TRAP
I certify That in the perfomance of the work for which this permit ix issued.l shall PLANCHECK FEE
not employ any person in any manner teas tnhecnntesuBBIr5ct the Workers'Camper. SEWF,R-SANITARY-STORM EA.20D FT.
,Z xction Laws of 1 California.Date 9- LO �q> perm ENERGY FEE
Z O Applicant 6 LQ �`is-s L WATER HEATER WNENT/ELECTR
QS GRADING FEE
� NOTICE TOAPPLICANT:'Lufmr makingthis Ceitifcae of Exemption.you should WATER SYSTEMITREAHNG
a , become subject mthe Worker's Comprmauonprovisionsof the Lla,Cade.you must SOILS FBE
forthwith comply with such provisions or this proud shallh deemed invoked. WATER SERVICE
aQ
iU. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB, gQ,FL PAID
V 0 IMr by which
Ivermhat ere iaousdIS ion lending agency for prGsmwnce of Data Receipt
C) Ur. the da,',N r which Nis pemdr ix iswcd(Sec.309],Civ.CJ
U Lender's Name s - 1
� �
LendersAddress TOTAL: TOTAL:
Iy I cenify That I have read this application and eterc that the above In"men can EMECHANECAL
G FEE
y correct.l agree to comply with all city and county ordinances and state laws mlating to QTy, MECHANICAL PERMIT FEE
U s� building mnsmai.n.and hereby anWnriec represenutives of Nis city mentor mpon the FEE
above-mentioned prnpeny for inspection purposes.
(Wc)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE IC FEE
Iiabiluien.judgmcros,a.,esiod expmxs which nay in any way accme against said City ALTER OR AUD TO MF,CH.
in consequence of We granting of this permit. NG FEE
APPLICANT UNDERSTANDS AND WILE.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQIX10 CFM)
SOURCE REGULATIONS. FEE
`.LO ^Qs f AIR HANDLING UNIT(OVER I0.00)CFM) CONSTRUCTIONTAX
nmomo Applicant/Com cin' Date EXHAUST HOOD DVTUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle haricrdous material HEATINGUNIT(TU ES"M BTU)
as ddned by the Cupenims Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2.5532(e)? HEATING UNIT(OVER 100.000 BTU)
0Yes CNo
VF.N'TFLATFON FAN(SINGLE RESID) Date Reaciptk
PAID
Will me applicant s fear.building Occupant equipments devices which
milus air cnntaminams as refined by the Bayy Area Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
District?
TOTAL:
❑Yes E3 No BOILER-COMP(OVER 100,(g0BTU)
Iread haotanneriesreqsnments.der Chapte,695 of than Cali-
CONDITIONER
fatae. alth&Safer Code.Section., 55a25533 and 2553q1undersand that if NEW RffiTOENTIA.MECH. SQ.FT.
ISSUANCE DATE
buildingdoesnot Formally
have a tenant,that
itismy . nEmnotifythe.cupm
ofhe myurcmems whichmehe and peroiwance of CadOcate
of Ocmtpuncy
Owners authored agent Data TOTAL: ISSUED BY:
OFFICE