28522 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PIDMBING-MECHANICAL 28522
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7(,O 8D 4,02N/9r✓Q Y 414 Y D a36
OWNF.R' E: 02, A ) ME 1'M=N1::._V� C R �
Z 4•i ' JC rNIC CONTROL
ARCHITECf/ENGINEER: LIC NO: ADDRJ C•n �E /+ ❑
CONTACT. PHONE l7LWM J\16a,IT�ewI 6U ILDING PERMIT INFO
7400consultant Fees Paid by Applicant(Initial) BLDG ELECT Pf M MECH
7 b ❑ ❑ ❑
LICENSED put iDCONTRACrOR'Sderp DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Nut 1 am IicensW under previsions or Chapter Y(commencing 106 DESCRIPTION
WOO with Seaion7ME of Division J of the Business and Professions Curds,and my license is RESIDENTIAL:
F�-CC in full force and effect. PERMIT ISSUANCE
NUI'"6F
License Class Lie.p ❑SFDWL ❑KITCHEN RIiMOUEL V
Dem Conmacmr APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE
y 6 a
Fly ARCHITECTS DECLARATION PANELS El APPLIANCES
STRUCTURAL
Z C t2 Z 1 undersmnd my plan.shall be used republic records MODIFICATION
CZ-0 UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
I•4.F.W Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IBM AMPS ❑BATH REMODF.UREPAIR C3 DEMOLITION
C w Q 1 hereby affirm that I am exempt from the Contractors License Law for the
iq5 C 4 V following moon.(Section 7031.5,Business mad Pmhssiu is Cold:Any city or county SIGNS ELECTRICAL DTHEN
t++3=b` which m,mos;a permit m consweL other,improve,dermlish,or repmr any sometime0j Prior to its issuance,also requires the applicant for such permit to file a signed smmmant SPECIAL CIRCUIT/MISC.
u
2 j that he is licensed promano the provisions of the Contractors License Law(Chapter 9
O (commcneingwim Section7Np)of DivisionJofine Buziness Pmfessions CWc)or TEMP.METER OR POLE INST. COMMERCIAL:
6 e 0 that he is exempt therefrom unit the basis for the alleged exemption.Any violin on of [I NEW BLDG/ADDITION ❑DEMOLITION
�y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(5500),
impisuCF=Q 11,usoxmer of the Profit or my cmploycm with wages as their sole compensation, SWIMMING MOL ELECTRIC VIiMENT
2 F.0 will duthe work,and mn
esemure is not intended oreffcred for sale(Sm.]Mi.Rusioeaa ❑OTHER
THER
tail m and Professions Code:no Comment License Law does not apply to an owner of OUTLITS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees.Provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. el
sale.If.however the building nr improvement is sold within one year of completion,the SQ.FI'.FLOOR AREA S/SQ.1T.
onsiner-builder will have the burden of proving that he Jid not build or improve for put-
pose ideals.).
1,as owner of the prnpenri am exclusively contracting with licensed comm urs m TOTAL:
renown the project(Sec.7641,Business reit Professions Cade:)The Contractors Lr-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a camremr(M licensed pursuant m rhe Commemr's
License law. PERMIT ISSUANCE
❑ Imme.empmunder Sec. .B&PClormicrcrem
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S many
Si,mic.ECLARATION BACK FLOW PROTECT.DEVICE
I hereby effimm under penalty of perjury one of me following Worker ions:
❑Ibave and will foi by eCCnil irate of theConsent
Labor
Coder'umfor
erformace ofte DRAINS-FLOOR.HOOF,AREA.COND. STORIES TYPr:CONSTRUCTION
warn, r provided for by Section d. of me labor Code,for me Performance of me
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance.as required by Section
37M of the laMr Code,for the Ofthe work for which this permit is i.ssurd. GAS-EA.SYSTEM-1 INCA OUTLETS OCC.GROUP APN
My WorWll : Dgemiwmi l il and Policy n�
Caries �Y///r/Y^��CC VVY Policv No.: �7 GAS-It.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WOW-IRS' C,REASPIINUl15TR1,WASTE INTERCEPTOR COMPENSATI INSU NANCIi BUILDING DIVISION FEI-S
(Thisestion necJ not amp Joe nom.
oir isf one hunJrcd Jull (SIM) GREASETRAP
or IcssJ PLANCHECK 14TE
I certify Nm' a fir ,m ce ofm n s: ed.ls 11 SEWER-SANITARY-STORM EA.200 FT.
not em oy any a eche W, ENERGY FEG
0 z sniion 1. ...... .Dam , WATER HEATER W/VENVELECTR GRADING FEE
z 0 Applicant
C NOTIC• AP .CA mak' th' C ificatc of Excm mon,yo should WATER SYS'1'EM/rHI:ATING
a7hero ubjc, .the rker's oatin pr bions ofthe Lana Code,you must $QIL$PEE
�-.
to hhc ply woe suchp i z r em it xhallhe deemed mvkcd. t WATER SERVICE
Q
U z CONST U LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FE PAID Dam Receipt a
V 0 Ihereb affirm that turn msaronswnion lending agency for performance of
W ,r mewmkfor hlChthispwmitisiss4td(Sec,lld7,Civ.C.1
IandersN c 1 TOTAL-
OU Lcoid.1sA drew TA
>+ m is
01 xuanlrvc FEE
E^ l ceniry that 1 Howe mad trio aPNieaeun and.rete mat he infnrmaonn
Vai correct.l agree mcomply with all cityand men did...,and state laws ting to QTY. MECHANICAL PERMIT FEE
V building amsmrctinn,and hereby au a enlWivee nl Nis citym rupon the SEISMIC FEL
abmrn
ove- tioneo
ed pm,my for .set c PERMITISSUANCE
(We)agme o"ro, dem ndcph Ies- Cu,eimo against ELECTRIC ME
Iiubilini,,rd,ournts sts and hich any wa me agaimn said City ALTER OR ADDTO MECH.
I in consequence gelatin Inds se mit. PLUMBING FF.E
A PLICA ' NDERST DS 1) MP NT AIR HANDLING UNIT(TO 1L000 CFM) •�
S 'GULATI :M1(ECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCDONTAX
S' amre ofA eant/C t am EXHAUST HOOD(W/DUCD (,/a, O NG MITIGATION FEE
H AR US RIA ) LOSURE
Will me upp'ant or fmure d 'up ecru tsometo andle bore r mamrial HEATING UNIT(FO IW.OIXI RTU) /
as dcfineJ by me upenino Mm cipal apmr 9.12,and the Healm and Safety
Csdc,Scniou J2(a)7 HEATING UNIT(OVER IOO.OWBTU)
❑Ye. ❑No VENTILATION FAN(SINGLE REBID) 'AID'YU
Dom Receipts
Will the applicant or future building occupant use equipment or device,which 001LER-COMP(JHP OR 167,000 BTU)
emit hmardans air contaminants as defined by the Bay Area Air Quality Management
TIyrAL:
Uistnrtl BOILER-COMP(OVER U0.0001HU)
�Yca F1 No
AIR CONDITIONER
1 have road me hazardous tinmaterials 5,2553 ends under Chapter 695 of me Cali- ISSUANCE DATA
forma gHealthdoes&Safety tColo.ly have
Sections 25505,25533 and 255Jit 1 understand that if me NEW RESIDENTIAL MECH. SQ.FL
building aces me currency hast a¢nam,that it re my resource
of
responsibility to notify the
nfine requirements which must be met prior to isuance of n Certificate of Occupancy.
Owner or aumwized agent Date TOTAL: ISSUED BY:
OFFICE