29022 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 9•2 A02
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 2
BUILDING PROJECTIDENTIFICATION
BUILADIRESS ��� xl-,d`YYIYII SANITARY ^APPLICATION SUBMITTA
L DATE
15M
rf
ONB ICO�TWCNR$NA Ew/ C
N/C CONTROLMC %bNALIkLkW
RI '/ GINEER: G �N26,O S: 6%J 440 -b� El
-PHONE: '/l BUILDING PERMIT INFO
,
(Je 0 3 Zy ❑ Consultant Fees Paid by Applicant(Initial) BLDG ESE PLUMB MECH
o
LICENED CONTRACTOR'S DECLARATION QTY. ItLECTRIC PERMIT FEE 1`J"
wo
1 hereby.1itan tem 1.m licensed under powisons of Chapter 9(commencing JOB DESCRIPTION o with Section 700E.f Uiviston 3ofthe BusmessitProfe .0
ssion,C.dend my license is
I.DO 1 PERMINSSUANCE RESIDENTIAL:
Fly '.full force and eRat 9Z ❑$FOWL ❑KITCHEN REMODELU License ClassLit,.p -
� Date Convenor f. APPLIANCES-RFSIDCNTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Z O > ARCHITECT'S DECIA 1'ANEf4 ❑MULTI-UNIT ❑STRUCTURAL
r" I understand my plans shall be used as puhl' x ret, MODIFICATION
OZ— UP9'02MAMPS /T'�/,.'�/,RIOR ❑C11IMNEY REPAIR
Licensed Professional 201.1000AMPS IAIYROVEMF.NT
i 54^c OWN13R-BUILDER ECLARA' )N OVER IOOOAMPS ❑BATH REMODEUREPAIR [3 DEMOLITION
y33yx KK 1 hereby affirm that 1 am exetnpl m Ibe Contra tar's License Law for the
W 3 d U following reason.(Section 7031.5,Bust ss and profession. Code:Any city or county SIGNS ELECTRICAL El OTHER
1+1 LL. which requires a permit to convect, ml)improve,demnli h,or repair any structure
I:LLty priormioissuaacc.alsurcgm-,I applicanttmoo,hperm tufleusignedsnmment SPECIAL CIRCUI'F/MISC.
p. thmheislicensedpursuantmth rovisi.mofrhe Conuucm License Low(Chapter9
GO (commencing with Section 7 )Of Divtsinn3.fthe Ruxines and Professions Cale)or TEMP.METER OR POLO INST. COMMERCIAL•
M
Mica
that M is exempt theref and the basis for Ne alleged ex prion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
mt4 S.don7031.5byv ppEcemforapenoliobjedstheapp-cannnacivil penalty M POWER DEVICES
ern not mare thu unal colors($500). 110TENANT ❑FOOD SERVICE
~�O ❑ net of the praNdy,or my employees with wages a theirsnle compensation, SWIMMING POLL ELECTRIC IMPROVEMENT
$a w J.Ne work.and d¢swcturcisnotintended or oRercd for .ale(Sec.7WL Husiness OTHER
a ' d Professions Cottk:'Ihe Cmarocmrs License Inw Jas n t apply to an ownerjw
OWLETS-SWITCHES-FIXTURES -
.. P operty who builds nr improves thereon,uad who it such mk himself or throu
ht own employees,provided dints 'h i ants me vended m offered for NEW RESIDENTIAL HLECTR SQ FT.
aul ILh.execr,thebuildin impry cold within• e>'ur of armpletion,the SQ.FT.Fl.00R AREA SISQ.PT.
own -builderwillhav drab ren imgthar he did of buil orimprnve for pur-
pose t
❑L ur of the p elusively c.na limit licensed contractors to A
n,tmc heeprnjeci( trod N ns C c The at.,urs Lt-
censels does not op noac,.fpropc who builds nr improves thereon orad QTY, PLUMBING PERMIT FEE
whocont thasuchproj 't.winbaconw ods)licensed pursuant o the Cnnwcturs
License Lu PERMIT ISSUANCE
❑
Iran ex I unde,Sce. B&P C for this remant
ALTER-DRAIN&VENT-WATER HIA) VALUATION
Owner Data
Aproyfdc
KER'. OMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /yN ti„jet•
ndo unity ofperjury one of the fnlluwing declamttons: VVBCJ
❑Ihai eCertificmc.(Consent mndGinsure for Worker's Camper- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
radon, Secdom 3700 of the labor Code,for Ibe Performance of thew kfotil is tsmed. FIXTURES-PER TRAP /"
1 have and will maintain Worker's Compensation Irsumrce,as required by Sation
of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYS TEM-I INC.4 OUTLETS OCG GROUP APN
My Wor 'sC attestation 'er and Policy.
Cartier. CCCCCC?? Policy No.: GAS-EA.SYSTEM-OVER 4 TA)
CBRTI GATEE OF
FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRI.WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need mot be completed iftee ,,all I,forone hundreddnllare SUIT) GRHA$ETRAP
or less.) Lk
I amity my that.the any coati user of as to hok fawhich this to the Winkera Ct,hIse - PLANCHECK FEIi
a.,employ in any manner set as as hcrnme eub'en to the Warkcrs'Com n- SEWEN-SANITARY-STORM EA.200 FT.
J Pe ENERGY PEE
Off. ration Laws of California.Data WATER HEATER WNENTULECfR
O Applicvnt GRADING FF.F.
VJ NOTICE TO APPLICANT.IL after making this Certificate of Eaatnptm,you should WATER SYSTEM/TREATING
I"! become subject to the Worker's Compensation provisions of the Lather Cade,you must SOILS FEE
fCf�.l
forthwith comply with such provisions or this permit shall be dcemod revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAOENCY NEW RESIDENTIAL PLMfl. SQ.PT. PAID
VQ I for which thi that issued Sce.i0lending agency birds,performance of Date Receipts
y. E+ the work for which this permit is issued(Sec.309],Cie C.)
O lenders Name TOTAL:
Lenders Address 'AL:
CI certify that 1 have mad this applicmtom and into that the almoo information is BUILDING FEE
U) correct,1 agree to comply with all city and county ondinances and state laws miming to QTY. MECHANICAL PERMIT FEE
U building conmmction,and herchy uudvaiae mpresemutivw nfthia city to enter upon the SEISMICFEE
igbo e-mentioned property for inspection pte,ows' PERMIT ISSUANCE
(We)agree to save,indemnify vad keep haat the City of CaTerom against ELECTRIC FEE
' Iiubilities,judgments,costs it expenses which may many way see...gains[and City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING FEL?
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOUR ERF UTATIONS. 2I F�1 J^fes MECHANICAL FEE
sly AIR HANDLING UNIT(OVER 10,003 CFM) CONSTRUCTION TAX
Signature of Applicurt/Contmemr Date EXHAUST HOOD OYMUCf) HOUSING MITIGATION FEE
HAZARDOUS MATI'RIALS DISCLOSURE'
Willdeoppdi,sum orfunre building acupant stone.,handle haeardonsmderial HEATING UNIT(TO 103,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coale,Sechon 25532(e)1 FIRM INC,UNIT(OVER 103,000 BTU)
❑Ye. t
VI7N'11LATION PAN(SINGLERFSIU) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt N
emit hamNous air commitments is defined by the Bay Area Air Quality Management BUTLER-COMP(3HPORIW,0110 BTUI
Dlor, I :) i 11 too, TOTAL:
❑Yes BOILER-COMP(OVER 100,"BOU) �,I ,
I have read the hazardous materials AIR CONDITIONER
requirements under CTapm,6tand that
Cali. -' �ISSU uCE DATE
forma Health&Safety Ctde...lens,d 05.I,my and 23534.I urdersnnd Nat tf the NEW RESIDIEH AL MECH. SQ,PI.
buildingdoesnet swhich hove. met
iIismyresponsibilitymteofytheoocuFant
of the mquirenlKnn which muss be tun prior m isxuance of a Certificate of Occupancy.
Ownerarauthomed.gent Date TOTAL: ISSUED HY: V[IY/M
OFFICE