28465 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING..ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PRRMITPLUMBING.MECHANICAL. 28465
BUILDING PROJECT IDENTIFICATION
BUILDING AIDDR64 ESS �� ��� l SANITARYIN N'PLICAI'IONSUBMITTALDATE
19 tA`Vq
AHCN O:MNIC CONTROL,
RCINPPR
LIC NO: ADDRESS;
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CONTACT: y10NF.:� BUILDING PERMIT INFO
I j-L` �.1L,1tS' !_ C`� /9 ❑ Cunsulmm Fces Paid by Applicant(Initial) @Lt1G ELECT PLU f MECH
L`LIICDENSESCO CONT1 "RACfLOftL'STDiFC1ARw ON QTY. ELECTRIC PERMIT FEE �tlf�T,
DMZI Timothy affirmthat l oro licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Wp0 with See110u 7000)af Division 3 ofthe Business and Professions Code,and my license is PERMIT ISSUANCE / RESIDENTIAL,
Fal= in full force..d effect. ❑ pDWL ❑KITCHEN REMODEL
aeU F License Clens Lic.4
Q U APPLIANCES—RESIDENTIAL DITION ❑PLUMBING RE-PIPE
y�d Date eamraeror
ARCHITECTS DECLARATION MULTI-UNIT ❑STRUCTURAL
z0o,,z I understandmy plans shall be used as public records PANE LS n. MODIFICATION
oyNo P'T021N)AMPS
(-I INTERIOR lb pp ❑CHIMNEY REPAIR
Licensed Professional 201-10(dAMPS IMPROVEMENT W
Ca� OWNER-BUILDER DECLARATION OVER 1(NMIpMI'S BATH$4,401) �DF;MOLITION
ffyy]1 1 herehy atinn that 1:nn exempt from the Contractor's License Law for the `,401 '
la,W U following reason.(Section]1131.5,Budness and Professions Cadc:Any city or county SIGNS ELHCTRICAI, ❑0)'HI
ul W�E whicb requires a permit m con., uc6 alley.Improve,demolish,or repair any vW<Wre —V
[p[prr prior to its iswance.ul.aoregmre.uthe applicant for such pcomn to File osignedstatement SPECIAL CIRCLE 17M1SC Vj/YfIL G
that he is licensed pursunat ,,be Pravisionsofthe Contractor's Llcenu Law(Chapter 9 L
ffffYYYY�IYpO (commencingwith Section 7000 f Division 3 of the Business and Professions Code COMMERCIAL: MEaI
S cq then he is exmpt therefrom and the basis for the alleged exemption.Any violation of TEMP.MIiT1iN ON I'Ol.li INS ❑NEW BLDG/ADDITION rvDEMOLITION
NSection 0031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
not more than fisc hundred dollws(3501D. ❑TENANT ❑FOODSERVICE
R Z IMPROVEMENT
=Q ❑ Lo the work,the pmpousturmyemntendo withwagaoathei(Sm.compensation. SWIMMING POOL F.LRCfRIC
ad will do lesions anile:no
Lienee LaPo does nmle tapply.toanwner ss
of ❑OTHER
W^m and Professions CsJe:The Convectors Lions law dies not apply to an owner of )UTLLTS-SWITCHES-FIXTURES
,
a 3 propcny who builds or improve,then..,and who dos such work himself or through
his awn employees,provided that such improvements arc rot mended or oLTeml for NEW RESIDENTIAL ELECTR SQ ET.
sale.If,however,the building or improvement is sold within one year of comnvd7nthe SQ.FT.FLUOR AREA !� LSQ.FF1
ormccloilder will have the bother of proving that he did not build or improve for Wr- �10 it ej/1Jl
pose of sale.). tf/I✓
❑I,as owner of the Propert,oto e'el ivcly contracting with licensed contractors to
convect the project(Sm.7044 Hu n and Professions Code:)TM Contractor's W-
c se law Joe,not apply mon o f opery Obobtildx or improves Manor,and QTY PLUMBING PERMIT FEE
who contracts for such prof ms t tr tort%)Iiccnttdpursuanttot eCommctoes
License Iso: PERMIT ISSUANCE
❑ lam exam u ,B&PCfmthisreaun
Owner Dam
ALTER-DRAIN&VENT-WATER(EA) VALUATION
W)RKE 'y PE ION DECLARATION BACK FLOW PROTECT.DEVICE ^ ��
Iherebyn sunder perjury one of the following declarations: `
Fl I haveand will mainminu 'eniti<a¢of Consen0oselGinsure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIE. TYPE CONSTRUCTION
sation,as provided for by Scetiun 37 W of the labor Code,for the perfmmmm of the
work for which this Permit is issued. FIXTURES-PER TRAP
1 have and will noinlain Worker's Cnntpenmtion Insnrunce,as required by Section
3700ofthe Labor Cale.lin the perfornvnroofthe work for which this permit is issued. GAS-17A.SYSTEM.I INC.4 OUTLEI:S OCC.GROUP AI'N
My Worku's GmiToo,o ion hssmmncc cortico and Policy number are:
Cartier: Policy Na: GAS-EA.SYSTHM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASPIINDUS'TRI.WAti'TF INTERCEPTOR
COMPENSATION INSURANCE BUILDI G DIVISHINIT
( .sectimn need not M completed i f the Pa t is for one hundred dollars 100) GREASETRAP
rola,)IhisPLANCHHCK I•iSE
I certify that in the performance mftbe work forssuhich this permit is issued.)shall SEWER-SANITARY-Sl'ORM EA.2011 FT.
not employ any person in any ruminator ws it,in become object to the Worker'Compen- ENERGY EEE 0
z sation Lawoof Cilifomia.Dae WATER HEATER WNENT/ELECTR
Z Applicant - GRADL G ,N
= NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEs1?RHATING a
f > 501
become subject to the Workers Compensation provisions of the tabor Code.you most
forthwith comply with such provisions or this permit shall be deemed mvokod. WATER SERVICE
7 z CONSTRUCTION LENDING ngAGENCY
easy NEW RESIDENTIAL PLhiR. SQ.FL PA Dat Receipt,
V work
which his
that Here isacex!Sm.i10lending agency fonhe performancanf
the work for which this permit is issucJ(Sec.309].Civ.Cl
0 Lender's Name 'TOTAL:
V lender's Address
} 0. 1 unify the I have read this application and store that the above information is BUILDING
FW cement.i agree m comp0. ly with all cityty and county ordinances and sena loan,refiningm QTY, MECHANICAL PERMIT FEE
Ula building convection.and hereby authorize representatives of this city to enter upon the SEISMIC FE.
above mentioned property for inspection parpnus. PERMIT ISSUANCE ELECTRIC Eli
two agree to save,indemnify and keep harmine.the City of Ca nine again.,
liabilities,judgments,costs anal expenses which may in any waYa t tY ALTER OR ADD'ro MLCII. PLUMBIN FEE
in onscquence of the 6mntio,of this Permit.
APPLIC NT UNDI.RSIPANDS AND WILL COMPL) PIAL N(( T AIR HANDLING UNIT('10
SOU EREGULA'I'IONs'.
�{/�{/ MECHANI AL FEF.
AIR HANDLING UNIT(OVER IfTXX)CFM) CONSTRU HON TAX
Sigmaure of Applicant/Co:nructur etc EXHAUST[TOO[) W/DUCI) HOUSING ATION FEE
I IA%ARDOUS MAI PRINTS DISCLOSURE
as defined ll the Cupertino building ncempant,r nr handle hazardous material HEATING UN IT(TO lbs'ot[it H)
y ry Code.Chapter 9.12,and the Health and Safety
Cada Senors 2553200? ]THAT ING UNIT(OVER 100,000 If M)
❑Yes ON. VENTILATION FAN(SINGLE RE51D) PAID
Date Rech ,
will the applicunl or Tenure building occupant use equipment or devices which
emit hazardous air cones a manta as defined by the BayAma Air Quality Management BOILIiR-COMP(JHP OR I W.IXIfI BTU)
District^ 'r T
❑Yes Fl No BOILER-COMP(OVF.R 100,000BTU)
I have mail the hamdoua materials actorements under Chapter 6.95 of Ne Cali- AIR GGNDITIGNER ISSUANCE DA' E
for .Health&Safety Cssle,Sections 25505.25533 it 25534.1 andersand the if the NEW RESIDENTIAL MECH. SQ.EL
building Joos not currently have o tenan,the it is my responsibiliry,an notify an mcupant
of Ne tequiaments which must be met prior to issuance of a Cenificas of Occupancy.
Owner m am mind agent Date ISSUED BY:
OFFICE