28278 O b
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
BUIPLULDING F:CBICAh
TTY OF CUPERTINO PERMIT NO.
APPLICATION/PERMIT )IN(iP1NG-,MECBpNIFICA
BUILDING DIVISION IIUILDING PROJF,(:'1'II)NN"I'IF'ICA'I'ION 28278
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
^ / UNII'a LOl'p
/
OWNERS e// / PHONE: CONTRACTORS NAME LIC NO:
�7/ kC I'tliCT/ENGIN':R: LIC NO: ADDRESS: ❑
FSectism
ACT. PIIONE. BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
/11 ` +t 3- da '�z PERMIT ISSUANCE BLDG ELECT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION pppL1ANCFS-RESIDENTIAL JOB DMCRIPI']ON
GC 21 brrcby affirm Ihnt 1 am Iicens a under provisions of Ch oalk,and
mmecense with
WCC term,)
of Division 3ofth<Busincss and Professions GoM,and my license is in PANELS
y- full force and eft nn
F'!.m License u. Lisa �k/ UP l'O 200AMPS
mjy Date�GOntr ID 2111.IOW AMPS
yOyZ ARCHTTEC1-SDEC.A ION OVER IOW AMPS SQ.IT,FLOOR AREA !I/SQ.IT.
01-0 1 understand my plans shall IN,used as Public records.
F-tnC; SIGNS ELECTRICAL
yy Z J LrcenseJ Professional
d'Q OWNER-BUILDER DIiCLARA'DON SPECIAL CIRCUIT/MISC.
KOiF 1 hereby affirm that I am csen t from the Commcmr's License Law for the
F401`¢ following reawn.(Sectinn 7031.5.Budni and Professions Cute:Any city or count' '1'IiMP.METER OR POLL INST.
mil which eryuires a person to cnrrsvucL alcor,improve,demolish,or repay any stmemre
'WY;: prior to its issuance.also requires the applicant for such Permit o file o signed statement POWER DEVICES
'W<0C Nm he is licensed pursuannn the provisions of the Contractor's License Law(Chapmr
tr'KOLL 9(commencing with Section 700)(Y)of Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
ty—V1 orthnhe is csempnhrrcfmm and the basis for thcalleged exemption.Any violation of OUTLETS-SWITCHFS-
Z Q Section 7031.5 by any applicant fur a permit subjects the applicam m.civil penalty of FIXTURES
S nm mom than five hundred dollars(16500).
KCo ❑ I,amwncndthepropeny,nrm In gas as pensmion, NEW RESIDENTIALELECIItQ S .19'
ycmp yee.swith wee theirsolecom . STORIESTYI'F.CONSTRUCTION
n. will as the work.and the structure is not immndedorofkred formle(Sce.)01,1,Business
and Professions Code:The Commemr's License Law docs not apply to an owner of
m
ppcny who builds or improves thereon.and who d«s such work himself or through his
on employees,provided that such m
improveentame not imendedor offered farmle.If, OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL:
builder wiI I have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofbcpmNe y.amexclasivelywntmningwithlicenudcmtmcmmm QTY. PLUMBING PERMIT FEF FLOOD ZONE AIN
onnma IM proje,l(See.7044,Business and Professions Coc,The Coni nenn's
License lawders not apply to an owncrufpropeny whimildsorimpeavesthncon,and PERMIT ISSUANCE
who contracts for such projects with a contracior(s)licensed pursuantm the Contractor's
License Law. ALTER-DRAUN&VENT-WATER(EA) FEE SUMMARY
❑ I am eumpt under Stt. ,tl&P C fur Ibis mason BACK FLOW PROTECT.DEVICE __0-tF7MDV FIT..,
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RIICEIITp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm that l have a certificate ofcnnsrat to self-insure,or a mnificme of _ RECEIIT p
l U(7URFS-PERTR,P- -
KorkersCompensation loan mnce ora cenibed copy thcov fGios,3500,Lab C.),which PARK FEE Y N
covers.all employ e' cr s en'I. RECEIPT#
��// `` GAS-EA.SYSTEM-1 INC.4 OVI'LE��Sc
PolicyM � � Yu d Y i BUILDING DIVISION FE1iS
Company 2 'i G! GnS Y.IE -OV ) ,. PLANCHECK FEE
[ICenificd copy is hereby fu ishcd. )) 1 I 1
[ICeniliedcupyisriledwiththecityinspectiondivisionRI GRF.ASR(INDUSTRL j=Tr3UdRCEPI'OR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRRASETR P I SOILS FEE
COMPENSATIONINSURANCE I
Olos section need not be completed Brie permit is foronrhundred dollars($100) SE NITA Y-STO .2(gs1'. ENERGY FEB
or less,) �p
I cenifythatmin, efmararre.f.he work for which this mm issurd.M9ERIE TER W/VFSlT/MECTR
nal employ any person In any mnner so is to become subjcd Workers' PAID
Cnmpcnsaion laws ul California. Dae - WATER SYSTEM/IRFATWG- %- Dae Recci,#
Z Z Applicant -
ZO NsomesTICE TOA PP LICANl,er'sIf, ucr Compensation previsions
Certificate roof Exemption,d,youmustand; NEW RESIDENTIAL PLMR.—SQ.FT. T ' L:
f^ r becomesubjecty the Waders Compensation provisionsofthrlabs Code,you must
� >
forthwith comply with such provisions nr this permit sh;Jl be Deemed revoked. BUILDING FFiIi
lL D CONSTRUCT ION LENDING AGENCY SEIS MIC FEE
•J z I hereby affirm that there is a construction lending agency for the performance of
U O Be work for which this permit is eased(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEJT
lender's Nmne
U I<ndcr's Address QTY. MECHANICAL PERMIT FEE PLUMBING 193E
I certify teat I have erred this application sad site that the above information is
cmren. I agree to comply with all city and county ordinances and stem lows relating to PERMIT ISSUANCE. MECHANICAL FEE
I--' Of, building construction,and hereby aulhoriu represenimives orchis city of enter upon the CONSTRIJCI'ION'1'A%
U Z above-mentioned activity for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to rove,indemnify and keep hmmless the City of Caperton.against
Iiabllllies,judgment,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I0,000 CPM)
I.coroe,ongofthe gram of this permit. rl
AIR HANDLING UNR(OVF,R IO.000 CFM)
Sign of AppbmnV nntracuI Due EXHAUST HOOD(WMUC)
1'AI
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITODO 100,1100 BTU) kotir Re p
Will the applicam or future building«cupam sure or handle hamrdom material
as dcfinrd by the Cupertino Municipal Cod,Chapter 9.12.and Be Health and Safety HEATING UNIT(OVER 100,00o BI U) TOTAL:
Code.Section 25532(a)^
11 Yes ❑No VENTILATION FAN(SINGLE kB.S1U)
Will the applicant or future building«cupam au equipment nrdevices which emit
BOILER-COMP(AHP OR 100,000 BTU) ISSUANCE DATE
consulates air ceremonious as defined by the Bay Area Air Quality Munigememt BOILER-COME(OVER 100,00D BTU)
DInuICI?
❑ PAID
Y. ❑No NEW RESIDENTIAL MECH.—SQ,FT.
1 have read he haaaJous materials requirements under Chapter 6.95 of the
California I Icalth&Safety Codc,Sections 25505,25533 and 25534, 1 understand that -p�e
II'the building docs not currently have atenam,that i t is my responsibil ity to notify the JY L
occupant of the requirements which man be met prior to issuance of a Cenificme of
Occupancy. CI f\. .
Owner or amhorited agent Date '1'O'I AL: ISSUED BY: VIONO
OFFICE