28971 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITYOFCUPERTINO f BUILDING.F:LRcrRICAL MRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /X 9 I 1
BUILDING PROJECT IDENTIFICATION `V V
BUILDINGADDRESS: SANITARY NO - APPLI TION SUBMITTAL DATE
�D Q L .50/ 2
WInNER'S NAME: PHONE. ACfOV S NAME LIC O,
O01� _ s.eZI N/C C( N
AR IT: OHNGINEEK: LIC NO: IiSS. - ❑
CONTACE PHONE: EDILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
e"�r' L r CIU) ❑ ❑ ❑
LICENSED CONTRACTORS S DECLARATION QTY. ELECTRIC PERMIT FEE
m N
1 hereby amrat I oro licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z win Semion]O(XI)of Divi,i0n]eOhe Business end Professions Cale dmylicenx is RESIDENTIAL:
W00 in full force and of PER MIT ISSUANCE
�U~UU ❑ADITI ❑KITCHEN REMODEL
U Licens Ess Lic.p APPLIANCES—RESIUENI'IAL []ADDITION ❑PLUMBING R&PIPE
Cummcun
ARCHITECT'S DECLARATION / El MULTI-UNIT ❑STRUCTURAL
L.7 to ( PANELS
s2Orr�2 IunJemend my plans shall Mused as public records MODIFICATION
OZ—p UP T0200 AMPS El INTERIOR ❑CHIMNEY REPAIR
Licensed Professional Elbe DECLARATION
201.11100AMPS IMPROVEMENT
syq" LLas1 Oat I ho eUILDERDECe Contractors
ON OVIiR I000AMPS BATH REMODEUREPAIR
yy 1 botchy affirm Erse 1:un exempt iron 's License Law lin the ❑DEMOLITION
)d 3 L FU. following reumn.(Sorin.01131.5.Business and Profession,Calc:Any'city a county SIGNS ELECTRICAL THER
((++11 u,y which requires a Permit m con tmn,.111,improve,demolish,in repair say slrucwre
F�0 pAorm its issuance•also requires the applicant far such permino file o signed stmemem SPECIAL CIRCUIT/MISC.
G� Nat he ie liceawdpuisuanuothe pmvisions of the Cnmracme,License Low(Chapter 9
O (commencing with Section 7000)of Division Iof the Business and Professions Code)or I EMP.METER OR POLE INST. COMMERCIAL,
that he i,cxwnpt therefrom and he basis for n,a alleged excmplinn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^w Section 9031.5 by cry appllennt for a formol oil,..1,rte oppl!enm to a civil penalty of POWER DEVICES - ❑TENANT '❑FOOD SERVICE
f?Cat msec than five hundred dollars(SSW).
C]1,as owner of the progeny,or my employees win wage,in their sole compensation, SWIMMING POOL ELECTRIC IMPROV13MEW
will do the work,and the amounts is not unwanted orof chat for sale(Sec.IIW4,Business ❑OTHER
S ti and Professions Cede:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES— XTURES
property who build,or Imprcve,thereon,met who does such work himself or through
his own ch ployces,provided that such haphi sono a arennI inlnnJed or offered for NEW RESIDENT 1, ECTR SQ EL
sale.lf,however n<building nr innihomemnw,dwininonc yetrn(cnmplei at SQ.Ff.FLOOR AREA 5/$Q.ET.
owner-huilder will have the burden ofpmving that he did not build or imprnve for put-
pose of sale.).
❑I.as owner of rte property,am exclusively contracting win licensed contractors to 'AU
onsnuct the project(See.7044,Busioese and Pmm,,ior&Cude:)'Duc Contractor's Li- FEB O1' 199
cans Low it not Fit Io un owner of properly who builds or improves thereon,and QTT. PLIJMHI FEE FI
who a.nIinr rut sac deet,winacontrunnrts)licenced garter mine Conwamrs
License Low. PERMIT ISSUANCE Cl(Y Ur
IJVU
❑Ism<iemp Sec. ,B&P C tact this mason ka Ut`CrI I
El r D:nc ALTER—DRAIN&VENT—WATER(EA) VVrALURf1ON
ty RKER:S COM :NSA'1'1(IFOGCLARATION
I hertb�ftam under h f BACK FLOW PRfJ'1'ELT.DEVICIi
Penalty perjury one of the following declarations:
Cl Ihave and will maintain a Certificate of Consent to self-insum for Workers Comper- DRAINS—FLOOR,ROOP ARFA,GOND. STORIES TYPECONSTRUCTION
cation,m provided for by Section 3]00 of the Lehrer Cale,for rte permmancc of the
work far which this permit is issued. FIXTURES—PER TRAP
❑1 have mA coil air r in Worker's Contpensrion Insurance,as required by Scion
3]OO of the Loh for the perf.......fl a wprk for whichthic permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS
CE OCC GROUP AI'N
m
My Wrakers Ii i urn r cy
Cartier a GAS—FA.SYSTF.M.OVER4(F.A)
Clint E F EMI'fl N FROM WO •RS' GREASF/INDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(ThLiseetior need nm completediftheprmilisl'or ono r! oln (S10B GREASETRAP
m lens.) PLANCHECK FEE
I certify Dat in 1'onnencenf the work for which this permit is issued,Ishall SIiWER—SANITANY—STORM EA.200 IT.not employ ony piers any mann so as m baa hoed m the Workers'Lumpier- ENERGY FEE
Z cation Laws ire.Date WATER HEATER WNENT/ELECTRLWZ7
O Applicant GRADING FI!E
V1 NOTICR' APPLIC otter making t t s crtifmate Escrom on,you should WATER SYSTEMi BEATING SOILS FER
F" become suhjei,m n Are,Compemmbm pri v cions of the Lnlwr Cade you nmol
forthwith comply with such Provisions or this permit&hail be dem.ed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ.FT, PAID
U Q khereby or
thi that there isoissued
construction30 lending agency for the Performance of Data ReceiptM
W s�
the work lire whim this pennh is issuW(Sec.3llq],Civ.CJ
p t"s Leader's Name TOTAL:
LJ l<ndcls Address TOTAL:
1 certify that 1 have read this application and state that the above information is BUILDING ME
(n correct.I agree tacomply with all city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives ofthi.x city to entertoorme SEISMIC FEE
above-mentioned pmpeny for inspection puq'oses' PERMIT ISSUANCI!
I We)agree to s e,indd niiii and kttT harmless rte City of Cupeninn uguimt ELECTRIC FEE
luddlities,judgmery its and expenses which may in my way accrue against said City ALTER OR ADD'In MECH.
in consequence of gmntingefniapetmil. PLUMBING FEE
APPLICANT RSTAND$AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0(10 CFM) MECHANICAL PF.E
SOURCE TIONS.
2ZA AIR HANDLING UNIT(OVER IQOIXIC M) CONSTRUMIONTAX
Signamrenf App'•n ommoon oro EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURIi
Will the applicant or future building rcmined store or handle Insecurities mmedal BEATING UNIT(TO I OLYXI BTI/)
his defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)I HEATING UNIT(OVER I(ah"BTU)
F-1 ye, MN. PAID
VR I ILATION RAN(SINGLE RESID) Date Receiptp
WII the applicant ur fuwrc building wcupant use equipment or devices which
emit haaWous air cmmmumn,as defined by the Bay Area Air Quality Management BOILER—COME GHP OR 100,000 BTU)
OTAL
Olitnd?
❑Yee [:j No BOILER—COME(OVER 100,000 BTU)
I have re hazerdnu,materials AIR CONDITIONER
re.8533 Dai under Chapter of be Coli. ISSUANCE DATE
feria Hwlt ale,Sections 8505.25577 and 8534.1 understand nm if the NEW RESIDENTIAL MECH. SQ.FT.
building Icurrtmly hov armor that it is y responsibility to madly the occupant
smentswhich theme ssyy nifcate of p
Owner arreem / - ate TOTAL:
u J ISSUED BY:
OFFICE