29065 • APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - �
CITY OF CUPEWFINO ..11 BUILDING-ELECTRICAL, I r .PERMITNO.
APPLICATIONMERMIT PLUMBING-MECHANICAL. 29065 9 o 6 C
BUILDING DIVISION f G J
j I' I R1111,DING PROJECT IDENTIFICATION
HUILplt9(z AD_I)RHSS: - 'SANITARY NO. APPLICA"ION 5UBMITI'AL UATF.
OWN' 'SAMR: .1'I J CONT 'S NAOO ME: LI NO:
N/C C>NTN01.N
.16
4RCHITECI'/CNGINL'ER: - LIC NO: AD ❑
.CONT T. , . PHONE: - BUILDING PBRMITINFO
f%I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL❑UMB ECIi
J ❑ ❑
• rWZhAED CONTRACTORS DEConsof hap QTY. ELECTRIC PERMIT FEE
I hereby nffum that I.IicemeJ under provisions of Chapter r 9(commencing JOB OE$CIjIP'I'IQN.
w0Z with Stttion]OWpd Divisiun3oOhe Business and Pndusiuns Coda and my license is RESIDENTIAL: -
O- PERMIT ISSUANCE
F win full force and cffm. �'
�UV License Class Lic.4 ❑SFDWL ❑PLUMKITCBINEN REMODF.I.
I-Zw Date - Co.[."., APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGR -PIPE
F O,� ARCHITECTS DECLARATION PANELS MULTI-UNIT [I STRUCTURAL
Z p In Z I understand my plans shall be used as public records _ MODIFICATION
pZ� UPTD20GAMPS
F•,co.FIO+1 Licensed Pndessitonel _ El INTERIOR _ [I CHIMNEY REPAIR
_ 3014000AMPS IMPROVEMENT
g C� Thereby affirm hat I um o exempt forER mtheomea DECLARATION
License Law for the OVER 1000 AMPS ❑BATH REMODEURF.PAIR ❑DEMOLD'10
SLx 06 U following reason.(Section 7031.5,Business sail Professions Cute:Any city or countySIGNS ELECfRICAL ❑OTHER
u131s•F which sequins a permit to asrmwa.alter,improve,demolish,ur repair any swnme - _
0t3 prior to its issuance,also requires the applicant for such perminn file a signed statement SPECIAL CIRCUIT/MISC.' - -
�;vW!�z} that he is licensed pusauaneto the provivoms ofthe Contcacmrs License lew(Chapter 9
Cpl (commencing with Section 7000)of Division]aide Business and Profusions Cude)tor TEMP.MITER OR POLE INST. COMMERCIAL: -
e. o c' that he is exempt therefrom and the basis for the alleged exemption.Any violation of. ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Section 707(.5 by any applicant for a lenit subjects the applicant to a civil penalty of POWER DEVICES
H rt ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(SSW).
CF1 1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the strucuue is not intended or offered(orale Sec.7044,Business ❑OTHER
h and Professions Cos e:no Currencies License Law does not apply to an owner of , OUTLETS-SWITCHES-FIXTURES'
property,who builds or improves thereon,and who does such work himself or through
his own employees.provided that such improvements are not intended nrnl(ereJ for NEW RESIDENTIAL ELECfR SQ PT.
sale.ILhowever.the building or improvement is sold within ane year of rompldhnJhe SQ.FT.FLOOR AREA $/SQ.FT.
towner-builder will have the harden of proving,hut initial not build nr improve for pur- '
pose ofsale.) I I I . 1•
❑I;as owner of the property,um exclusively contracting with licensed enntmemrs to h TOTAL:
conswct the project(Seo.70,D,Bildress and Prolessitons Code:)The Colietwo 's hi-
seLawdoesnotapplymannwnernfpropenywhohuildsorimprovesthereon,and QTY, PLUMBINGPERMIT FEE
who cantmms lin such projects with n eonvunnrLs)IianwJ pursuanno rho Comrucrors
Llcene Law. - PERM ITISSUANCE "'•
. ❑lam exempt tinder see. �' ,n&ycbar mea rca,nn ,
Owner Dao ALTER-DRAIN&VENT-WATER(EA) Ryt VALUA'f10N
WORKERS COMIHNSAI ION DI.CLARATION BACK FLOW PROTECT DEVICE - 'SA
1 hereby affirm under penalty of Ivrlury o re of me following declaration
❑Ihuve undw11 main) C ,f mfC n. a IGinsure far WorkersC6mpcn .;` DRAINS-FLOOR,ROOR�ARCq,COND. IES "fVPI:CONSTNUCI'ION,
u arbor,as provided for by Section 9]001 I the I h r C de,for,Ise perinr Hance Of the - - •, yp n
work far which(his perm,isssaosd. 171XWRES-PER TRAP Y "
'7 1 have and will maintain Worker's Coinpensuuon Insurance,as required by Section IJ9s
J]W of th abor nst otic performance of the work for w ich,his noir is arta GAS-1?A.SYSt'EM-I INC.4OUTLETS eZgpU�,. p1,N
MyIirf Cn - ,eeamler and Polie 'aN]h�`L fill
Cosier. /- policy No..
r GAS-EA.SYSTEM-OV• 4(EA) NQ
CF.Rt'IFICATF.OI• EMPOON FROM WORKERS,
CTE ATIONINSUROMW GRPASEIINDUSTRL WAS . NTERCEPTOR
(This sectionnwd nor Mas ATI NI permitisfornne hundred Jnllam(E110)1 BUILDING DIVISION.PEPS
or lens) GREASE TRAP PIANCHECK FEE ••
I certify that is the perfomwmce of the work for which ibis pearl,is issued.I shall
cot employ any person in any manner so as to become subtlest e,he Wafkors'Collation. SEWS sAN TORM PA.2W FT.
O Z sonde Laws of C.1ifi mix Date ENERGY FE
WATE A WNCNT/ELCCfR
Z
NOTICE
_ GRADING FEE _
y NOTICETO APPLICANTaWork If,after coking this provision.
of of Exemption,you should WgTF.R S TEN?REATING
a ; became suomp y the Workers Comas or
provisions of the tuedl Cooke,you mus, SOILS FEC
(lJ forthwith comply with such provisions onhis permit shall he dttmcd rtvokcJ. WATER SERVICE
Q .
7Z CONSTRUCTION LFNDING AGENCY NEW RESIDENTIAL PLMB. SQ,Ff. PAID
V walk
ilm dd theaism is sued( ce.i 007.Ling agency for rhe performance of Date Rescip,N 'r
'•-, the work for which this permit is issued IScc.JfH].Civ.CJ "
Q I"' Lenders Name - - LOYAL:
L) Isnde Address T TOTAL.
11 :1 1 certify that I have read thirty and out y sm,e that rhe shove infunninis BUILDING PER
•y cuildin lagree onstruct comply with all city and counryoNiives of and ityit)entate trefining pm QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize represemutives of this city rococo,upon rhe SEISMIC ECF. -
above-mentioned property for inspection purposes. _ PERMIT ISSUANCE
(We)agrce to cove,indemnify mrd keep harmless rhe City of Cupertino against CLECfRIC HE
liabilities,judgments,costs and expenses which may in any way accrhe against said City ALTER OR ADD TO MECH.
in tunsequen the granting of this permit PLUMBING FCC
APPLICAN' 1AANDS AND WILL COMPLY WITH ALI NO POINT AIR HANDLING UNIT(TO Io,Ofl(1 CFM)
SOURCE I.iG '
I MECHANICAL FEF. ��
AIR HANDLING UNIT(OVER I0,00)CFM), CONSTRUCTION TAX
Signawre rd plmcam Oma EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicanror future huildingoccupart smrenrhundle baeunammaall tedal HEATING UNIT BII) f
as defined by the Capistrano Municipal Cale,Chapter 9.12.and the health and Safety
Code,Section 25532(u)? HEATING UNIT(OVER 100,000 BTU) -
E]ye, - ❑No
VENTILATION PAN(SINGLE REBID) PAID -
Will the applicant or future buildingate n q p a am use a ui ,nem or devices which Dare
pp Receipts,
m BOII.F.R-COMY(JHP Gil KIM BTU).
r us air nwminams e@
x deed by the Ilay Area Air Quality Management•' Ucoiisvict?ic0 co ..•fOl'AL: '
❑Vet0Nn BOILER-COMP(OVER IW,D0)BTU)
-I have read the hazmdn 1,materials red uirements under Chapter 6.95 of the Cxh- AIR CONDITIONER,
1 n ISSUANCE'DA'1'E
µl fomle Health doesn Sufmy tCom,ly have
Seniors 25$(15,is yJ and 255)4.1 to nonmed the,If rho , {
buildingJar re tl huveuteu n,,thin tee. nil, t notify th•Deco m NEW RCSIDP.NTIAL'MF.CH. � _SQ.Pf. : ..
currently y :ofa Y Y p?
• - of the rcq rc t: hich Host la mm nor t. fa(fm if r f0k upnnc"
Owner toe amhorized agent Date - TOTAL: -ISSUEDI
OFFICE