28937 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-'USE BALLPOINT PEN ONLY
CIT)IPF CUPERTINO' y , BUILDING-ELECTRICAL PERMITNO. � w
BUILDING DIVISI(1N APPLICATION/PERMIT! - PLUMBING-MF.CIIANICAL _Y 'LJ {JJ
BUILDING I'ROJ ECP IDENI IFICAIJON'
37
BUILDINGADDNSAN By NO. APPLICATION SUBMITTALDATE
3 S n� -
OWNAME: fli[NE:. CONTE CTpR:S NAMIE: BIC NO
�f �� N/C CONTROL#
ARCHITECDENCINEER: LIC NU: ✓L J 3 pp )v � S - �V! // ❑
CONTACT. PHONE: )n. /C'- BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BILI.
LDDG ELECT - PLUMB MECI
- 1,10ENSEDCON7RA=R:SOLCLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of chapter 9(commencing -JOB DESCRIPTION
I %Z
X05 wan secdon](romorui:dsimttonne Buaine.e and Pmrex.iand code,rift,ter Eernae is
00 in full force and effect. - - PERMIT ISSUANCE - ,FOWL ❑KITCHEN REMODELU U License Class - Lic.k
�W Date - Contractor - APPLIANCLS-RESIDEM'IAI. ❑ADDITION ❑PLUM13ING RETIPE
F 7 m ARCHITECTS DECLARATION OMULTI ONE ❑STRUCTURAL '
I'ANEIS
)Zl undersand my plans shill he used as public records MODIFICATION
OtQ - UI'T021NIAMPS - ❑INTERIOR ❑CHIMNEY REPAIR
1-•SFW Lensed I-mfivsslonul - 2111-IWOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER i(NXIAMPS ❑13ATH REMODEURF,PAIR El DEMOLITION
y1 a I hereby affirm that 1 am exempt from the Contractor's License Law for the
X 3 d U following reason.(Section 7031.5,Business•and Profession..Code:Any city m nmmY SIGNSELECTRICAL ❑OTHER
YY1I LL. whmM1 req pcom t to construct,alter,improve;a fish per day swnurc
F':•O`3
prunto its issuance, I requires thea Is tf r such 3 pp pans t to Ile a siginal statement SPECIAL CIRCUIT/MISC.
yhot he t licensed pr. am uthe prov sono f the C Ia.t 'License Law(Chnta9
00 (const cog writ Section BNXp ofD vioon3 ul the Bustneas rid Pr dessions Crbe)or 1'EMP METIER OR I'OLEINS'F. - COMMERCIAL: l
C.ay c�, that he is exempt therefrom and me basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION- ❑DEMOLITION
[p S<etion Wlll.S by any applieunt far.permitoddect,lhe.pplicanlm actual penahyof POWER DEVICES
❑TIENANT El FOOD SERVICE -
t mea than Five hundred dollars($5110). - IMPROVEMENT
SD ❑1,as owner of me progeny,or my employe<s with wnge.a nsmeir stile compensation, SWIMMING POOL ELECTRIC +
will do the work,and the structure is not nneed or offered Corsale(Sec.]D14,Business ❑OTHER
,and Prol'<..mrs Crile:The Contractor,Llcensc Law dors nob ll ly to ua owner of OUTLETS-SWITCHES-FIX'I'URIES '
C pmpenY who builds or improves Nercnn,and who does such work himself nr Ihmugh -
his own employees,provided that such improvements are not amended or offered for NEW RESIDENTIAL EL17MR SQ PT. '
sale.If,however,the building or improvement is sold within one ye.r ofeemplefion,rhe - SQ.IT.FLOOR AREA - E/SQ.PT.
owner-hudder will have the burden of pawing that he did not build nr improve for puN -
Pou of s.1,T
❑1,us owner of the pmpcny,donexclusively contracting with licensed contractors to TOTAI.:
construct the p deet(Sec.]W4,Business anit]'mI sloes Cndc:)Thr cumano ri Li. - vv
c IawdoesnotaM,Iyto nownernf Pmpen b Builds orimproves thereon,end Q7'Y, PLUMBING PERMIT FEE '
whocommnsforldehprnje mwithacormu pike dpursuenuome Comrdemes
hicensc law, PHI<MITISSUANCIi /,;(�`_• `,i
1 am exempt under! B&P C I'anhi.reason i J
ATTER-DRAIN&VENT-WATER(EA) ,VALUATION.
Owner Dam
WORKIiN'S MI'IENSA''ION DECI. ATION BACK FLOW PRO'I EC'K DEVICE.
' - -
iM1ercbyaffirmadd rally ofperjuryomcofinef lawin'dechartions. .27 -500
>171) f
d will main - vCenifcaerfConsennoself-in relic Workers Cron pen- DRAINS-MOOR,ROOF,AREA,CONO +
ded f Section 9]t10 of the IaMm Gelc,f Sha ST(RIES TYPE CONSTRUCTION
vi y, perram,ana nrme ich permit is issued. FIXTURES-PER TRAP, - �- -
illmainein m�S neatioa havulu ce ¢quired by Section _abor Ced (nnhu onnance oDhe wo (n ich this pennh is issued, OAS-EA.SYSTP.M-I INC.40lTH.E'fS OCQGROUP APN
Can,,,, of carrier and umberareaP cy ac GAS-IIA.SYSTIEM OVER 4(EA)
: T IE OF ESE 10 BOM WORKERS' =: - -
COMPENSON INSURANCE ' ORF.ASRdNOUSTRL WASTE INTERCEPTOR
( t neednolbeco eam ifine permit is forma,hrmdmedolllos E100) BUILDING DIVISION FEI3.S -
lessJ - GREASE TRAP 1 PLANCHECK FEE
Icenif t ninmeper mi ofine work for which this permit is issued,Ishall
not ploy aq ymannersoasmhecnme subject to the Workers'Comprn- SEWER-SANITARY-STORM EA.100 IT ENERGY FL'13
,'� sada aws of Celifon!n.Dam
- WATER HEATER W/VENT/ELECfR - s -
O O Applic. I GRADING FEE
tiNOTIC In AI"dCAN l)11',after tnalso,This Cedifiewc of Esc uptinn,yon should WATER SYSTEM/I'REATING
a, become s j o the Workers Cmmpensminn provisions of the labor Cale,you most SOILS FEE
foMwimc ply with such provisions nr this palinal shall rte decmalre 1okeJ. WATER SERVICE
-CONSTRUCT ION LENDING AGENCY + 'NEW RESIDLNTIALPI.MB, SQ.rL PAID
U 0 I hereby affirm that mere is a construction lending agency for the performance of Date Roberta#
G4 the work for which this permit is issued(Sec.3I91,Civ.C.) .TOTAL: -
O U Lender'.Name ,
Lentil Address - ' t
I certify that 1 have read this split cation and state that the aMtve Infnmtarion is BUILDING FIRM 00
(0./y corral.I ante,,mmtply with all city and,Bunt dmunece mW nwtc lows rdutin to ��r y02 building 'r s QTY. MECIIANICAI,PERM ,e'gamsuudiroend h<mny amnonzercprcuntaliv<s ofteas dly teeneruponlite sHISMIC PL'L 0
perty to,inspection pm,se".
(We)agrw m save,indemnify and keep hvrmless the CityuCCupenina against I'LNMI'1'ISSUANCE - ELECTRIlahilaics,juegmemceostxund expenses which nry in anywyaccrue against fluid CityALTER OR ADD TO MEGII,in conseence nflhe grantingofthis pemm. PLUMRI :1EAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALE NON-POINT 'AIR HANDLING UNIT t701B,(NIO CFMECH NI nDPC•F. A11wSOUR('iREGU1.AT.1n0�Ns. P s l " suUt"I/// /O_� AIR HANDLING UNIT(OVI3R IO,000CONSTRUCTION TA%'
Signature of Applicam/Co n or Doe E%HAUS'I'HOOD(WMUCT) ' HOUSING MITIGATION PEES
HA pUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haordous material HEATING UNIT CrO I coNal B'RJ) 00
as defined by the Cupertino Municipal Code,Chapter 9.12,wd the Health and Safely
" Gde.Scnion 23532(.)] HEATING UNIT(OVER 00,000BTU) - -
(]Yes r Nn VENTII.ATION PAN ISINGLERESID) PAID��-�-� y4
Will mae m fuea
r Dam Rctip,t g
emthadondo.,
ri,timamrtomsasdefinbdbyhe Bay ArcoAir Quality Mvnugement BOILER COMP CHP OR REE)TNE B ru), i
District? TO
TAL, �rRO C]Vice HOILER-COMP(OVER IN),00)BTU)
XNo
I have dend me has and mate 1 AIII CONDI I'IONPR
q m m order Chapter 695 Ime fahISSUANCE DATE
ramie H Ids&Sa(cry Cade Sections25505 23511 ami 8511 1 understand that Yf the
NF.W RESIDENTIAL MECII. SQ.FT.
r blit lJl J I r Oy h' m t'that t aCedfil tfyd capons - '
nfm is xht a dp totssw ce nfa Ccnlfcsl
Owcror:mthor¢ed agent Date 1, IDEAL: - (7 r
, IssuF.O By:� � ,/9 f�^77Aw.rrl '
OFFICE