28702 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ ^ O'2
BUILDING DIVISION APPLICATION/PERMIT281 PLUMBING.MECHANICAL
BUILDING PROJECT IDFNITI'ICATION
BUILDINGADDRESS: - SANITARY NO.--l[APPLICATI)I)SISUBMITTALDATIE
OWNERS NA
4 VY� � CUNTRACOR'S NAMELIC NO:
DG
NC CONTROL
ARC M
ADDRESS: ❑ / W�
CONTACT. PPHHONiE`: - BUILDING PERMIT INFO
t
Jim• /A/'/�' 739-"AA//-/
39—" �/ �/'/7� El Consultant Consultant lr Paid by AppliCent(initial) B DG ELECT PLUMB MECH
„`
LAC[iNISHDDLCO—v1RR
ACID 'S DELI-ARATIIONN QTY ELECTRIC PERMIT FEE
1 lemhy affirm 0.11 an llamnl under o,,kio.of Chapter 9(ornmendng JOB DESCRIPTION
Qwith Section 7000)of DivitioP lof the Hua.mu Professions Code,aM my licenx is
WC, PERMIT ISSUANCE RESIDFNTLA I n
F inculle sand cRm.
Py�F ❑SFDWL � r [I KITCHEN RI1.10DEL
l<..U D. Ctvu I.ic.N
r QL Duc Cmmxa« APPLLINCES-RPSIDF,N'TIAL []ADDITION ❑PLUMBING RE-I'IPF.
'po, ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
ZCs�Z I undmtmrd my pluu shill he mod!u public rtoaaft PANELS ,- MODIFICATION
OZQ UP TO 200 AMPS
El INTERIOR [I CHIMNEY REPAIR
License!Pmfessiorul 201-1WHAMPS IMPROVEMENT
aSX - OWNER-HUILDER DECLARATION OyT:R IIMIOAMI'.S RATE REMODEUREPAIR DEMOLITION
y C Q 1 hereby�rrn That I em cocoon from the Cmooactuf.Tire—Law for the
x 3 a U fallowing reason.(Section]0315.Business ud Professions Code:Any city m county SIGNS ELECTRICAL El OTHER
u1 4. which ria ion a Permit to conaruct,ale,improve,demolish,or repair any vruoure
l 1"'LLC priiD
mra i,saarce,u.o mqu'ves the"glcaut farmch pertnitm0lcasigtted nmemem SMCIALCIRCUITIM1SC.
,U m4-0 dW he ix liaved purvuNm Ute pmvi.ion,o(de CourcroYa Liana haw(Clmpa9
W Q0 (am tine wild Sectiorr'!(p0)hd Divisionlof the Busirc.0 ud Prof«sihn.Code)ar '1'FAIR MITER OR POLE IN COMMERCIAL:.
a ay Wet he u exempt Waefrom trod the burl,fm de dhgd csatpoan.Any vidation of ❑NEW BLDG/ADDITION [I DEMOLITION
X.9h li
Section 7031-5 by any applicant for apcmdt objects the epplicn I to a civil penalty 4 � POWER DEVICES
F- m must more Wan live haodsd"im(S50O). ❑TENANT El FOOD SERVICE
2 D !,mow«sof We
IMPROVEMENT
c pmNo,wmy cmpinyces with wages as their.wle cmapcmuio0 SWIMMINGPOOLELEMB,.
Qwill do the wwk,ud the st..is ru intend i moRcsW Ice to(Sce 7(1414,BraiN.s ❑OTHER _-
Ial lad Professions Calc:The Contractals License Law doe,n«apply to an owner M OUTLETS-SWITCHES-MX IJ
a3— pgeny who bui,Bor impruvnmvnm,ad who dhc.,adh work himwlf or tluwgh
his own mttpbyes,pmvidal War such imPnovmrcns are m inseadrd or offal far. NEW RESIDENTIAL EIEM SQ - .
ale lL however,the building«inhpruvenemi.wild within one yea.of cornpldian,thSQ.FT.FLOOR AREA i50.IT
m-builder will have We hwlen of proving find he did nu build«improve for pui-
pow ofeulw). '
Lrut the mf the propmty,stn udmivdy amt oicant with )The Can &, J- - TOTAL
«rwmn the project(Sec. an ameBusaof, of rty N)tbm Code)The Conractvls Li- .
cocann drmrs epplywon owner of pnhpcny wMh builds or improvathrrnamaml QTY. PLUMBING PERMIT FEE
who arParufmwch projttrs with.<«Nactor(.)Hcensedpwuaot to the CmPtranrhf.
Locnu Lhw. PERMIT ISSUANCE
❑Tun eamnp under Sec. ,H&PCT«thisii
Owner Ilmc
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE `^�OO.
I herebyeRrm ander penalty of perjury one of We following declarations: Y.J
❑IhaveudwiUm main.Cmifi r afCa tioxlf-imumf«Worka's Compcn- DRAINS-MOOR.ROOF.AREA.GOND. STORIES TYPE CONSTRUCTION
omnia,u M Mill ton by Section 371A of We LWo Code,for the,perfonrorce U dx -
work for which dos permit is load. FIX TURES-PER TRAP
0 1 have ma!will munraio Wr te,Conpevuian Inwa .u required by Section
37M.f the Lebbr Cud,Iur de perf.ceofthe work f«which this pa.,it i,issued. GAS-FA'.SYSTEM-I INC.A OUTLETS Jic OCC.OROUP D APN
My Wrrkels Com crounion I.c eerier anal Policy number ue:
Corricc Pali,Nu.: OAS-EA.SYSTEM-0Vf0t 4(PA7
CERTIFICATE OF EKEMPIION FROM WORKERS
COMPENSATION INSURANCE GREA.SEdNDUSTRL WASTI:INTFRCT?PIOR
(This xmimi aced rot lou completed iftbe permit is for unc hundred dollen(SIM) U1CD G FEES
GRFISE TRAP
«kis.) Pl.i rH[CK IPC isp
1 aniry lou in the itry nrmarce oltM work fme which Win ithe W i.s icr'Con hall R i• r h'
nnemploy my Persian in uy manus uhumbecome w ttOthc Wmkcrs'C SEWER-SANITARY-SIORFI EA.200 FT. yUr
Z ration laws ofCdif«nia.Date bjec ompen- ENERGYEFE tH(JNU
QZ O AFlgKasu WATER HEATER WNFM/ELECIR GRAUINO FEE
y NOTICE TO APPLICANT If.alter making this Cenifcnc M Fac apioo,you should WATER SYS TM,7REATING
be.vne,mbjcet m the WmkcYs Cmar,onsumn"Titan,of We Islor CNe,you muxSOILS ME.
W forthwith comply with each Provisions«this prroo"I o leened revoked. WATER SERVICE
Q
D CONSTRUCTIO
N ENDINGAGPI.'Cr NEN'RE5IDENTIAL PINTO. SO�PI'. PAID
lherebyaff hi,ire tans isaed(See i30lmdirg egeneyfm tbepMornurce of - Date RecdpN
�� (hew«kf«which thispmdtis iuuml(Sec,J(19'I.Ci,C.)
C) F Lenders Nemo TOTAL:
LU I<rdc/,Address TOTAL
I certify Wet I have cuturd at
d this implication d se ththe abovem
mraation i. BUILDING FEE
Z) euro,.!agree m comply with all city and canty,mtimrnees ud sura laws relating to QTY. MECHANICAL PERMIT FEE ^�
V i buil,ing,cro,ucrion,mal lhaeby smhaia<represcmistier.o(bi,eiOo,cmauPm the SEISMICEEE O
shove-menummol Pr.,erty for Inepectirn p,hrp„a. PERMIT ISSUANCE
I We)&V=fit save,indemnify emnify and kap hmhmleav the City of Cupertinoagainu ELECTRIC IEE
Iiebititics.j W gnenu,emu ud expermu which my in any way acrve egdmt uld City
Noun.in cors ma of the mon,of Phi. t. ALTER OR ADD TO MECR PLUMBING FEE
APPUCANTSOURCE
UNDERSTANDS AND WILL COMPCWIP ALI.NON-POINT AIN HANDLING UNIT(TO MECHANICAL FEE
SOURCE REGULATIONS. '
AIR HANDLING UNIT(OVER IH,000CFM) CONSTRUCIIONTAK
rC�.S�fior
A,Iiea.P/Cmntracmr - D EXHAUSTHOOD(WMUCI') HOUSING MfITGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
he applicant or fatale building occupant same or handle huardw+material HEATING UNIT(TO 100.000 BTU)
the Cupertino Municipal Cade,Clupter 9.1}.and the health and Safety
2553Y(n)'t HEAGNG UNIT(OVER IOOAW BTU)
❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt♦
Will tie npplamo or in.building«cvpant six cynipmer,or dcviccs which BOILER-COMP(JHA OR I W,t1011 HTU)
Mt hareNous air antnmiwxs u dcfr«d by dee Bey Area Air Qudity M.n.gemenP out tar
nPnd BOILER-COMP(OVER I(0,IX1 BN)
❑Yes ]No
I have red the havmdeu,mmcork CTaper AIR CONDITIONER
re.Z53 in under fe95 M du;Gni- ISSUANCE DATE
formatili Health&Sano Code,Sttaioru 25505.2s 513 ad 25511.1 a ascutyth that if the NEW RESIDEbtG AL MSCI I. SQ.ET. '
hilding docs«a emrendy have a recant that it is my rtcphmibillD to ratify the attvpmY
of the rtqui.which roup herb pr'tvto iumarce of a CerifcNCof Coo,,niy. '
(hvreroauthmiad ugcnt UWc TOTAL: ISSUED BY:
OFFICE