28750 CITY OF CUPF.RTINO ^••V••..rrrrr..••`y`•••` - BUILDING•ELECTRICAL. PERM IF NO. �Y�—g50
BUILDING DIVISION APPWLCATIONIPERMIT PLUMBING-MECHANICAL I
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPIACATION SUBMIIITAL DATT.
C T [n'L'2 qK
WNIiR'S AME: PHONE: UNTRACIf)RS NAME: LIC NO:
CNHl CONTROLx Eo GIN O T 2 S �c Tv ✓E C�%o 533
ICIiITECT/ENGINEER: LIC NO: DRESS
7S IJ, c- C Irl n7o M V.
CONTACT: P11ONIi: 'BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) BLDG ELECT PLUMB MEOI
LICENSED CONTRACTOR S DECLARATION QTY 'ELECTRIC PERMIT ?';�'�r� ,''„PEBr;.;�' ❑ � ❑
I herrhy nffimm mm I Am erod
licensed e,prmkaiar,a nr coupe,9(ri mncing JOB DESCRIPTION
�az with Section 70WOfDivision 3aftM BusiressanJ PmfemionaCsale,AM.,y liranae I, RFS:IDEuTuL.
00 PERMIT ISSUANCE
m full force end etre / S'�S 3 3 ❑SFDWL ClT C
KIHEN REMODEL
�V�j Li nee Cie u - Lich G _ APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
��41 ale ARCIIII'ECT'S ContDECLARATION PANELS [I ❑MULITUNIT STRUCTURAL
LL
IundentanJ my plans shall he used as public words MODIFICATION
)z'3 Oil TO 2100 AMPS ❑INTERIOR [I CHIMNEY REPAIR
LLcenael Pnde.m..l 201.1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER I(XgTAMI'.5 El RATE RF.MODEIJILGPAIR CMULII'10
1 herehy AM,,.that I em exempt(roses the Cmnrnaor's License Low far me
)j O V following rcwm,(Section]0313.11udresa and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER _
a 3 LL which requires o permit to construct.aper,improve,demolish,or repair any mmotirc F 16
w boy prim to Its issuance,also requires the applicant far such permit Me a signed statement SPECIAL CIRCUIT/M ISC.
�. that M is licensed pursuant me provisions of the Comracmrs License Law(Chapter 9
CC (commencing with Section 7000)o(Division3 of Oa Besinesamal Prafesakar GuApor HEMP.ME11iR OR POLE INST. COMMERCIAL• a
that he Ts exempt merermm end the basis for the alleged csandumn.Any violation of ❑NEW BIRO/ADDITION ❑DEMOLITION
X LL Section]031.5 by any applicant fm ap0nnit mdjec0 the applannt to a civil penalty of POWER DEVICES OTENANT ❑FOODSERVICE
WZZnot me than five hundred dollars(INTO).
rs`r+06 �1.as owner of the popery,or my employees with wages as their Acle compensation, SWI MMI NO POOL ELECT RIC IMPROVEMENT
well do the wok, oil he emom,is not mminded of offered fir.]a(Sec 7W4,Rmaty COTHER
seal Profession Corle:'Me Contractor's License law dreg not apply In an owner of OUTLETS-SWITCHES-FIXTURES 00
63 property who builds or imprnvea thereon,and who does such work himself or through
his own employees,provided that such imPmventents are not intended in offered for NEW RESIDENTIAL ELEcTR kQir
ells.If,Mweve,,the buildingor improvement isauld widsmnne yrmifcompktion.11he SQ,ff.FLOOR AREA S/SQ,14.
owechnilder will have the hoiden of Arming that he did not build or improve fbrpur-
From crania.).
❑1,as owner of he pmpedy.am escludvdy convecting with licensed contractors In TDTAJO
construct,he prnject(Sec.70,14,Business and I'ndessioni Code)The Canmacmr'a Li-
cease law docs not apply to An owner of property who builds or Improves mereon.And QTY, KUMBINOPERMIT'• '
who contracts for such projens with a mntrnemr(al licensed pursuant to 1110 Contractors
License law. PERMIT ISSUANCE /T
❑I am exempt under Sec. ,B&P C for this reason {x
Owner Data ALTER-DRAIN&VENT-WATER FHA) 1. VALUATION
WORKERS COMPENSADON DF.CLARA'TION BACK FLOW PROTECT.DEVICE ''c;,- 1990
I hereby elite under pemaltyof perjury one of the following declarations: J
3 lhaveand will maintain a Certificate of Consent to selr-invuro for Workers Cmnpen- DRAINS-FLOOR.ROOT(AREA,COND. S RIES TYI'B C(1NS1RUCfION
,anon.as prmided En by Section 31(1(1 of the Lelaer Code,rte the performance ol'the ,ytV
work for of ieh,his permit is issued. FIXTURES-PER TRAP
❑1 helve and will maintain Workera Compra.edinn Insurance,as required by Section
3100 of the Ubir Cone,far the performance af,he work for which this permit is i.asued. GAS-EA.SYSTEM-I INC.40UTLETfS OCC,GROUP APN
My Work Co pen tie Insn�reapp carie end Policy roan arc:
Caniee , egjK "Ce Policy Nn.: I•+�.�/ 7 �/ GAS-EA.SYSTEM.OVF.R4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRI!ASE/INDUST RL WASTE INTERCEPTOR + ” BUILDINO DIVISION FEES•+
Ghisscetinn need ural he en,plemdiftM permit is fm one hunolrtd Jnllam lS l(XI) GREASETRAP
m less.) FLANCIIIiCK FEE
(certify mat in the perfonnen«af the wok furwhich iia Aha Wodasual.I•hall SEWER-SANITARY-STORM EA.2011 rL
nm employ any person in any manner an as m bcenme suhjerna the Workers Crm,pem ENERGY FEE
Z enion law.aof Cnlifmnlo.Dam WATER HEATER WNEN1fFLECI'R
O AppBcan, GRADING ITT:
NODCRIQ APPLICANT:IL alter ranking this Ccate of)exemption,you should WAI 17R SYSTEMOREA'I'ING
a become subject In the Worker's Conformation Provisions of the Talbot Cole,you must SOILS FEE
W Rmhwith comply with such provisiomsorthia permit shall he deemed revoked. WAFER SERVICE
CONSTRUCTION LENDING AGENCY NEWRESIDENTIN.fLMR. SQ.I.T. PAID
V E IMrebynffmnnnmuc
Ohem k.roAmrtinn leadingagency for melerfmmmweof Dote ReceiA,x
LL 1-t the work for which lhislemui,is issued(See3191.Civ.C.)
Q C[1' Leaflet's Name MI AL:
W Lender's Address ( ��
y I codify that I have mod this Application and sate that the abion mhemmion is BUILDING FEE
h cored.legs lncnmply with all city and roomy nnlinancea 9nA store lows relmin hs i At..a �;` r'S
R QTY. MECHANICAL:pERMIT I, 0.h,OEM,"
V building construction,and hereby authorize mpesrnmtives of this city to enter upon the SEISMIC ITE
aMve-memirsetl p.Perty for insp0dian pugmsea. P[RMI T ISSUANCE(We)agree m nave.iadenmim
fy and keep WmJeas e City of CuAedimn.,aero ELECfR IC FEE
Rabililirajudgtnents,core and ezpenas which may in any way accme againstsxid City ALTER OR ADD to MECII. PLUMBING RE
in consequence of the granting of this permit.
APPLICANT UNDrRS LANDS AND WILL COMPLY WITH ALL NOI'�POINT ANDLING UNIT ITO IBrgTO CFM) MECHANICAL THE
SOUR FJ1Er(tOhn��C� IO (meg
—s—�JGI r/]/-/ (AIR UNIT 10.000 CFM) CONSTRUCTION TAX
Sign placantt:ormactor Um w EXHAUST HOOD Own)UCq
HOUSING MITIGATION PER
c AZARIX)US MATERIALS
uxupo DISCLOSURE
Will the Applicant m furore building rccupam Wore nr handle luazAldmllus materiel III?ATINO UNIT fD3 I00.110 R1 U)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Surety
Cods,Section 25532(G? HEATING II NIT(OVER IIX6()(Al BTU) alt
Fl Yes C1 No VENTILATION FAN(SINGLE RESIM PAID
Dale Receipt x
Will areni applicant or AFF a Milding ecupanl use .Air enl or devices wheat BOILER-COMP 13BP OR 100,OGT BIT)
nit MznrJnw air contaminants as dcMed by the Boy Arco Air Quality Management TOTAL'
Jialridl
❑Yen E]No BOILER-COMP(OVER I(X),(XgI BTU)
I have mal me hmanlrnn mmerimu requiremen,a under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
(main health&Safety Gale,Sections 25505,25533 and 25534.1 unaknwN that if the NEW RP_SIDENI'IAI.MECII. SQ,tn'. t
Wilding does no curomly have o mnant,that it isany responsibility to elify the occur.m
ofik"uimuremswhichn„ntkme,primmi.asuancenfacedmcmeofrxcupaoy. 1 \
Owner or ao,harimd agent Dam 'I f ISSUED BY:
OFFICE