28677 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. ,
BUILDING PROJECT IDENTIFICATION -
B�U y.DI A )RIES S: SANITARY NO, APPLICATION SUBMITTAL DATE
pS v� 5 NG b j_r- e- h 1 Fr-
OWNER S NAMF: DNF: CONI NAMOR'I NAME: LIC NO:
_� (� VO NIU
CON'IROLk
CHITECT/ENGINEER: LICNO: ADDRIll AA v ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD L[ ` pI ` MECH
EN
LICSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑
I hereby affirm that I am licensed under provisions of chapter 9 ecommcneing JOB DESCRIPTION
�CZO with Sectinnp00(0nl'Divisima3mf the Businessnnd Professions Cad,undmylicc,twie PERMIT ISSUANCE RESIDENTIALJO
�U�ff-- fall force lass effect. ❑SPOWL yS�ITCHEN REMODEL
) Licenu Class Coate APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMB INE RE-PIPE
0. Dau TS DECLARATION
{F-
ARCHITECTS DECLARATION I'ANF,LS. ❑MULTI-UNIT _ ❑MODIFI MODIFICATION ZO- (understand any plans shall be asst us puhlle rcemrds MODIFICATION
oz—, UPT0200AMPS
F�CYI
Licensed Professional ❑INTERIOR CI CHIMNEY REPAIR
201-ItppAMYS IMPROVEMENT
Oat I am exempt R DECLARATION Contractors
OVER KWAMPS
y U 1 hereby.(Rent thin I am exempt from the e,uatnns Cush:License Law far the El BATH RIiMODEVREPAIR DEMOLITION
.following rcm.n.(Section-nation,'.
eta 5, '..1oHasmua uM Pmfea mmli la.. Any airy teror m on SIGNS BLEC'I'BICAL OTHER
41 I+• whichitst eeapermit aecue,dre ,plicimam orsudemolish,are.sig anyxwmur,
�LLm
hot
imissaunre.....11.Me thusim.O.fare Commich tteinofierns,Lnedsatemco SPECIAL CIRCUI'UMISC.
y thin M1e it licensed pursuant to the provisions of the Cnmmdotx Licenu law(Chapter9
p p0 (commencing with Section 7000)of Division 3 of the[rosiness and Professions Cmle)or TEMP.MET ER OR POLE INSI COMMERCIAL,
0. that he la exempt thercl'ro.t and the basis for the allagul exemption.Any violation of
[I NEW RLDG/ADDITION 'DEMOLITION
Section mum'ban
hundred
dollars($50nnit subjensthe upplicununa civil penally of POWER DEVICES ❑TENANT ❑FOODSERVICE
F Z� not mum than five hundred dollars IESW).
HC ❑ I,ns owner of the pmpeny.many employees wilt wages es their sole compensation, SWIMMING POOL ELECTRIC IMPROV17MENT
W will do work,and thestrueure is nor intended m offered for sale(Sec.'/044,Business ❑OTHER
E E and Professions Curb:The Commsrm's License Law does n I apply I owner.f - UTLETS-SWITCHES-FIX TURES ..
property who builds or iinpmves thereon,and who does such work himse through 24)
his own employees,provided that such improvements are not intended o ref d for NEW RESIDENTIAL ELECTR SQ RE
mle.If.hnwevcr,the building or impnwement is sold within one yearafro rl�en,the SQ.FT.FLOOR AREA LSQ,FT.
wnusbuilder will have the burden of proving that he did no ilA ter im�for Aur-
JameofsNc.). 1 '
❑ I,as owner of the property,am exclusively contnmdng wl n �$, trycmrs to '1'[ I� 4+.
wnstrum the project(Sec.]044,Business and Prbfe Ions :)The Odnllacmr's Li- '� � !
cense law does not apply to an awnerofpropenywh 'Ids i,--p sth�2rreemon.and QTY. PLUMBING PERMIT FEE ��
who contracts for such I As with a Commnd.)lice.. armanrtmh mammate y ./
License Law. PERMIT ISSUANCE
❑ l um excmpt under Scc. ,B�r this reason O
ALTER-DRAIN&VE -WATER BEA,) -s VVyk1.UA710N
Owner DVEND-- r
WORKER'S COMPEN ON ;CLARATION HACK FLOW PROTECT.DEVICE
�❑ I hereby affirm under penalty of peri m followingdeelardticum, V�,�
V `
IhuveandwlllominminitCenilianc of Consent I msurefor Worker's Cmmlte.- DIIAINS-I'I,OOR.RD014,Al1EA,COND.
sari..,as provided for by Section 3]1X1 of the Lath nr Code,for the perfmmanec.1 uhnSTORIES TYPECONSTRUCI'ION
work far which this permit is issued. FIXTURES-PER TRAP
❑ 1 have aad will mainmin Worker's Compensation Insurance,as required by Section
I'M 0111,Labor Code,lot the performance ofthe work for which this permit is!,,sued, GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP, APN
Ile Warke's Com nwti a 1 ce comer mA Policy
���'E .tf, roe )Ya9�y Q•�Q ^'
Cartice jj2FgL ' ^rVD
Policy Nra.:((Kl�ybe �J OAS-EA.SYSTP,M-OVFN4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/MDUSTRL WASgE INTERCEPTOR
(This sectionneed not lti completed ifthe permit is(armee hundreddollms($IW) BUILDING VISION PEES
or less.[ GREASE TRAP PLANCHECK I'P.E
I certify that in the performance ofthe work for which thispermit is issued,[shall SEWER-SANITARY-STORM FA.2WIT.
.at employ any person in any manner sa as t.become subject m the Workers'Cmnpen-
z sntimn lawsof Califon ia.Date ENERGY FEE
O Applicant WATER HEATER WfVENTMLECTR GRADING FF.P
f^. NOTICE 10 APPLICANT.If,after nmking this Certificate of Exemption,you should
a r 101
becmnesnhject to the Worker's Compensation provisions of the labor Cnde,you must WATER SYSIHNIITREATING
� forthwithmns
forthwith comply with such pvisinor this permit shall Na deems[revoked. WATER SERVICE 'SOILS FEF.
� z
Z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMH. SQ.FT PAID
DIhetebyaffirmthurthere is a construction lendingagency for thcpermormara,of _ __7_
the work for which this permit is issued(Sac.3ME',Civ.C.) .
0 Lender's Name TOTAL:
Lcndu's Address
Iy 1 ccnify tbm 1 have read this application and cote that the above information is ` BUILDING FEE Is
IZ) correct.l agree to comply wifir.11 t,and cnumy uNinances and ante lows relining to QTY MIiCIIANICAL PIrRMIT PEE
V 7- huildingconstruatma,and herebyauthmirc represemmivesafmis ohytoarecr upon tiro - SBISMICFEL,
above-memimnre to
inspectionpurposes.
IWc)a rte t.tetra,indemnify p yin � g PERMIT ISSUANCE
g yes whit boundless any w Cit of nstsi.inn ELECTRIC FEE
a Imincla meoftm,cmetsa.d expenses tris. may in tray way accuse against said Cly ALTER OR ADD TO MUCH,
in core<quence of the gmming of this permit PLUMBING FEE
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT. AIR HANDLING UNIT(TO ltl,pgB CPM)
Sl L N5. MECHANICAL RE
AIR HANDLING UNIT(OVERIO.000CPM) CONSTRDCTIO TAX
Stg u of ApPl CmWCamrocmr b Date EXHAUST HOOD(W/DUCT)
HAZAROOUHOUSING MI'I'IGATIO EI:
. 1ATF.RIALS DISCLOSURE
Will the applicant or future building occupiumsfmre or handle hazardous material HENT ING UNI T(TO Ell BTI))
as defined by Ne Cupertino Municipal Cade,Chapter 0.12,and the Health and Safety
Coda Section 25532m)'I HEATING UNIT(OVER I00,000 BTU)
❑Yes C]No
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building.ccupam use equipment or devices which Doe Receipt
emit huraMous air canmminants as defined by Ne Bay Area Air Quality Management BOILER-COMPLIHPOR 100,000 BTU))
District? TO L:
❑Yu F1 No I [[.F.R-COMP(OVER 100,000 BTU)
I have read the herarduus materials requirements under Chapter 6.95 of the Cali- AIRCONDI'T'IONER _ ISSUANCE DATE
fomia g althdoes&Safety Cale,Sections 25505,is my and 25534,1 undersand thin if the NEW RESIDENTIAL MECH. SQ.FT.
building does nemuwhich have.,rant,that o is sea responsibility tete o fy the occupant
of the rcquimmems which must be mm prior m issuance of o Cenifcam of Occupwcy.
Owner nr uuthnnzed agent Dam 'TOTAL: I550CD BY: � a�` �'�xa
OFFICE