28993 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPIACATION/PERMITPLUMBING-MECHANICAL 28993
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNG%//p . oiPTi¢/PHONE: CO kA Ok'SN MIiG O LIC NO: N/C CONTROL#
ARCIUTECDENGINEER: LIC NO: ADDRESS ❑
CONTACD PHONE: BUILDING PERMIT INFO
Q /L _`G � n ia_.) / ❑ Consultant Fees Paid by Applicant(Initial) BLD. ELLE PLUMB MECH
El
iK1/l�_R.K/ L•ICCLNSIiDC)WRAC R'SDECLARAT1oYN '� (JTY. ELECTRIC PERMIT FEE {-'J(
1 hereby aB7ne drat ant ii'smed Dader'awhimn ,I Com",9 ce.....m tins JOB DESCRIPTION
�CO XO with Section 7dh�xfo��f�yD�IVIRII 3ofthe Businessand Pnil'essinnsCode,. yliccmcis PERMITISSUANCEITIAL
I— in full foreanV� � �G rsn�m DWI. ❑KITCHEN REMODEL
aU� LiccnuAuvr:.--�.f— Lw.M APPLIANCES-RESIDENTIAL ❑ADDITION [ PLUMBING RF.-PIPE
yaw DaIEIV� ,` —Comes
ARCHITECTS DE ,I OMULTI-UNIT ❑STRUCTURAL
Z FO H Z 1 understand my Plans shall be used as public mcoNs PANELS MODIFICATION
UP TO 20D AMPS
OZ—� C3 INTERIOR ❑CHIMNEY REPAIR
F.`2~; Licensed Professional 201-I000AMPS IMPROVEMENT
OWNIiR-BUILDER DECLARATION [:)BATH REMODEUREPAIR ❑DEMOLITION
R$y�7 I hoody B'mr )air l ma f da,Contractor,I Law For the OVER IOIXIAMPS
iyyiqgO a,UF following reason St' 7031.5 B : J1f s C¢I A , 'tyn.,.my SIGNS ELECTRICAL El or
LL N¢ which eq permit 1 :t r II r J lish P y suvcate _
F"W 0 J prior tons issuance.also requires the dppl a t f h pe m i f I -gn J anlemem SPECIAL CIRCUIT/MISC.
Nut he is liccusedpunuatn nt the provisions ofthe Conirwar's License Law(Chapler9
4W3 (oammencingwith Section 700D)of Division 3oflhe Business and PmfessionsCial TEMP.METER OR POLE INST COMMERCIAL'
d 6 o M that he is exempt therefrom and be basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xml' Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
W'
not more than five hundred dollars( Ch
S500)�
Y IMPROVEMENT
C�6 ❑ Lashees of the pmpeny.onnyemntended wiNwagc osale(Se .compensmion, SWIMMING Pool.FILE
W will do the esk,and the o Cda is not License offered linos apply to 44,Business. ❑OTHER
��� and Pramaaana ode Tha crn,waar.License Law does not apply n,an owner of ouTLers-swlq'curs- xTu '
property y who builds or improves thereon,and who does such work or thnmgh
his own employees,provided that such impo,emems are oat intended or offered for NEW RESIDENTIAL ELE= T.
sok.If.hovever,die building m imp r..vemenl is wild withinone yearoerriclelim,be SO.FT.FLOOR AREA E/SQ.FT.
pwiter-builder will have the burden of proving dim he did not build we improve fur par. �• I! Tl
ae of sale,. Q Iv
0 1,ax owner of the proper,am exclusively contracting wiat licensed contractors to TOT
)L
consumer the project(See.01414.Business and Pndessions Codc:j'I he Contractors Li- APR
cense Law docs not apply it)an owner of pyeny who hui Ids or improves lhemon,and QTY. PLUMBING PERMIT FEE
o 10 1996
who commas for such projecw with u aomaccans)IIcensed purom IID the Commct( s
Imm,e Law. PERMIT ISSUANCEB 1 ass exempt under See, ,11&P C for this reason L'I I Y OF w,.c n„r,,,
ALTER-DRAIN&VEN'T-WATER IEA) VALUATION
Owner Date p
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby afftr under pemalry of pcfCon one of Ne fn mefi g duclker's C s:
(have and will maimninn Cmifcme ofConscnno sd0insurt for Worker's Cnmpen- DRAINS-RWR.HOOE AREA.COND. STORIES TYPE CONSTRUCTION
salirem as roweled fur by Section 3700 of IM Lid or Code,rot Ne performance of the
work for which this peril is issued FIXTURES-PER TRAP
I have and will onsunwin Wprkers Compensation Insurance.as required by Section
Code,I...list pr,toracdarmof he
3il isix�oe7A. GAS-BA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
MyWe,I me ro
rYolcNY
GAS-EA.SYS'1'EM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASF/INDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
(This suction need nal he camPlncd if Ne Permit is for otic hundred&If. 1100) GREASETRAP
m less)(This
FEE
I rend mad in the performance wide waskar which this Permit is issued.l shall SEWER-SANI'T'ARY-STORM EA.20D Fn
not employ any person in any manner so as to become wbject to the Workers ComPen- ENERGY FEE
,z kation haws of Coldineio.(Ate WATER HEATER W/VIiMUELECTR
GRADING FEE
Applicant
NOTICE TO APPLICANT':If,after making this Ccnilicate of Exemption, ...should WATER SYSTEMfFREATING
hecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS F0i
forthwith comply wiNsuch provisions or this petit%hull be deemed revoked. WATER SERVICE
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID Date R"eiPM
U 0 1 hereby affir that hem iso construction le i ing agency for am Pcror rance.f
O F' the work far which this .,it is issoed(Suc.3097,Ci,C.)
U Lenders Name TOTAL'
Isnd�x Addmxs TOTAL:
W 1 tend,that I have read I...application a,ad.mm that the above information is
BUILDING FEE
rH. h correct.I agree to comply within city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
U z hu ildingconslrucliminotherwhy authorize mprexcnmrives nl this city venter upon rhe SHISMICFEE
above mentioned property for inspection puryosec PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep hamdcss the City of Cupertino a,irct
Iiahililics.judgment.costs and expenses which may in anywayacerue Usinsl said City ALTER OR ADD TO MECH,
PLUMBING FEE
In canuque aDf the granting Sthis peril.
Sol[ nc UNDER STANDS AND WILL COMPLY WITH At.[.NON-POINT AIR HANDLING WHIT(TO 10,(100 CPM) MECHANICAL FEE
SOI :RF rUl s ,
AIR HANDLING UNITHOVER IO,gMI CPM) CONSTRUCTION TAX
Siy W uAppli WCnm c r Date EXHAUST 110f111(W/DUCT) HOUSING MITIGATION FEE
HAL OUS MATERIALS DISCLOSURE
Will die applicant marc building occupamstore nr handle hazardous mutedal HEATING UNIT TO 100.00D BTU7
as defined by die Cupertino MtmiOpal��uddcc.Chapter 9.12,and the Health and Safely
Cede.Section 25532(ap / HEATING UNIT(OVER 100.000 BTU)
(]Yes Nn VENTILATION FAN(SINGLE RESID) PAID Da¢ Reccip111
Will the applied" or furore hm occupant um equipment or devices which
nail hazardous air comaminamx dined by Ne Bny Arco Air Quality Management BOILER-COMP(JHP OR I W.000 BTU) 'TOTAL:
ULevicf'
❑Yes ❑No BOILER-COMP(OVER IN0,000 BTU)
i '
I have of the hiamerh us materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCN D9T�
fnmia Health&Sofcry Code.Sections 25505,25533 mal 255b1.1 maim cal that it the NEW RESIDENTIAL MECH. Sp.IT.
buildioaY lcured dy have a harem Nat it is my mxPsmibiliry nold Neo carnal
of 1 .IMO¢ primmaixku.drac' cre
rte oma . gem a TOTAL] ISSUED BY:
OFFICE