28938 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY -
CITYOPCUPERTINO - RUII.DING.ELECTRICAL PERMITNO.
BUILDING DIVISION APPI.ICATION/IaRRMIT• PLUNIRING-NIEC[ CAI' 28938
... _ - BUILDING PROJECT IDIiN'1'IFICATION -
1jU1LDINGADDRESS:- - ., SANITARYNO. APPLICATIONSUBMITTALDA'D
aii
E.—NAME: PHOMNACIUR'SNA E: LIC NO: - O
Ij /I NIC r� CONTROL
AH HITF.CF/IFNG EER: A. LIC NO:; - RIFSS: - ❑
Corg --111946 lLD1�'L51ow W
IC NT Cr yl - -/ � 't . . r BUILDINC'PERMIT INFO -
❑ Consultant Fees Paid by,Applicanl(Initial) + tLE PLO
LICENSED CONTRACTORS DECLARATION QTY .ELECTRIC PERMIT PI E
Ih h,offmthtl am licensedunJ p 'If Chapter 90, nose mg , JOB DESCRIPTION
507, Is IiSection' 7000) fD 3 fd Bad drrf-s m.Code,and t yrm .� - , .. RESIDENTIAL: ..
air ifull n and effect 'PI?RMIf ISSUANCI? ❑SFDWL R j1❑KITCHEN RF.MODEI.
QUV License Cl s Lich APPLIANCES-RESIDENTIAL [, []ADDITION U `❑PLUMBING RE-PIPE
�G�] Date
Count.., - - 'n
ARCHITECFSD C ARATION - ❑MULLI�NII}. ❑STRUCTURAL
ZOIZ d Imv Il be ue sp li foJ a y' _ PANELS. VENA 2� '/ MODEFECATION,,
OZ UI'T0200 AMPS s ❑INTERIOR+ 1�s�HIMNHYREPAIR
L P� aY 101d0011AMP$ IMPROVEMENT
s >
Is V •'
ea R. OWNER I3UII DLR LAkAIION OVER IMIAMPS - ❑BATH REMODEURFPAIR [-]DEMOLITION
• O U I hereby affirm that 1 am exempt from the Contractors License Law far the ._,s I fiyo
W 3LLt following reamn."--'an7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ' _ ❑OTHER
�
yQ which requires o permit m construct,alien improve,demolish,tar repair any anw ure
� NJ .dor to its estuarine,alstostmres,heappliant for such pennitm fileasigmal,micmem SPECIAL CIRCUIT/AMSC.
G� that he is licensed pa G the provisions oftheC t t r' L L (Chapter 9 COMMERCIAL: "
QQ (conmen nb with S.ti 701X) fD' i fth B . dP f:: .0 dc)nr I EMP MLFER OR POLE INST'
d c a math ' xe opt thercfr 1 Ih b:s f m II L d exe pi- to y v nl:nioa of • )h' f ❑NEW BLDG/ADDITION ❑DEMOLITION
k•^ Section70115 by any applicant for a perms object,me applicant ail penalty of POWER DEVS ICEr/i _ .. NANT ❑FOOD SERVICEF_Z_i• not more than live hundred dollars($50(f. u
< ❑l.theworofinepropeny,structure npnemntended withwved for tale(Sele 044.8 sines. SWIMMING POOL ELECfIUC IMPROVEMENT
�_owilldmthew'nrk,sorbsheContractors
License Law does and
elply 70f4, wner of •OOTIIER " 5
and Prof n Code:The o t t 1 L d t work
Graf OUTLETS-SWITCHES "FIXTURESr s
Properly I bed. tap .II and i d -- h e M1 al 11 ih m gh
h,s'own etnployccv provided that such m. cots are ria itmnde<I or nffured for NI:W RBSIDBN'1'IAh LLhCTR SQ Irl'..
sale.If,however,the building or improvement is sold within one year ofcomplenoqthe - SQ.FT.FLOOR AREA $/SQ.FT
owner-builder will have One burden of proving that he did not build or improve for pur-
• posea sale.).
4,as owner of the progeny,am exclusively Prole,contracting with licensed contractors mnL `
rnnsw8 the project lSec.1044,Business.rid Pmfessiont Co...,I,.,0-11. Conaannr's Li- - _
me Law docs'nm applYman owner of pmpenywnabuilds arimpmves thereon,and QTY. PLUMBING PERMIT FEE .
-' who coetrune far suchen leen wllhuwnmemr(s)Rensed jsu: a n the C....occoars -
License Loss. PERMIT ISSUANCE
P s
❑ Lem exempt under Sec., ,H&P C front,reason, ' -
ACTS R-DRAIN&VENT-WATER(BAT �
Date VALUATION
Own r -
WORKERSCOMPLNSATPONDICLARATION 13ACK FLOW PROTECT DEVICE 11 S� ` ` ;W1 Ih by fl d penalty t. IUY of the f ll gd I f L v` t -J_
❑ Ih I 'll t Crtl" i dC 11 IIme far W k "C pn DNAINS-FLOOR,ROOF,AREA,CON 1)"'
scition as provided 1 by 5 li PIXI-f the Labor C d,fn the pe f ante of the STORIES' 'TYPIF CON S'I'RUCTION
h' htha
. mt - FIXTURES PER'fHAP s"
El Ih ^
❑ h ttu
and ill=if n W e k I Coon Incur required hyo.
3700 of th Isb Cale,( m in nuance tmfor,f ve do,permit i a k GAS [A SYSTEM.]INC.4OUTLETS
OCC GROUP APN
My Worker's Contains. Iriscounce ca and at rare
Curti - - P I y GAS EA.SY591FM OVER4(EA)
CI R'fll'ICATC OF I?Xf:MPT10 WGRKEHS e - -
COMPCNSATION ANCI /, GHFASE/INDUS INh WASTE LNTERCLI40R ,. BUILDING DIVISION FEES
frn s¢cuon neeJ not beta twit permit kfu conch elors(SIW) GRtASETRAP -
orlcs_) / - PLANCHI,'CK FEE'
I cer'fy that theperfo a of kf ITII1�I t xucd.l hall- SEWER SANITARY STORM EA. PI'.
p - snhjecltdth Worker,'Competr - - .ENERGY FEE `
note I y yp navy mannermact uSL Lb
,Z sallon Laws of Cul forma Date {
zO Applicant - 'v WATER HF.ATI?R W/VF.NT/ELECTR GRADING FEE ,
tq NOTICE TO APPLICANT:I1 after making this Cert 1 ca¢of Exemption,you.should WATER SYSTEMIFREATING a
become subject m the Workers Cotnperuncor provisions ofine Labor Code,you most SOILS PER
ToMwina comply with such piovismin'ta this permit shall be deemed revaked.
WATER SERVICE
0. Q
UO ,. r CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. . SQ.FT. PAID
�+ Ihaebyaffirm that mere is n=1raction lending agency,forthe performance of Date 'ReceiptM
Phework f hith this. i' . ed'(Sec.3097,Civ,C.) R
Ixnde Name •s - - TOTAL:
Lenders Address s TOTAL:
�" y '1 cenify that I have read this application and normal the above infom,ation is BUILDING FEE
y correct,I agree to comply with all city and county ordinal and state laws relating to QTY. Y MECHANICAL PERMIT FEE
building construction,and hereby aimariu representatives of this city to enter upon the s SEISMIC PEE
above-mentioned Property for inspection purposes.
' 'id keep hannlexs the City of Cup;dmn.guinat PERMITISSUANCE' `�
(We)ugu m nuv - ELECTRIC FEE ^
liabilities,judgrtems cos andeapenses may many way va.riiamad, id City ALT17RORADDTOMECH, 00' PLUMBING FEES '
incnnsequcn ottheg permit.
. NT tNDERSTAn DSA D WILL MPLYVITH' LL NO. POT f AIR BARRELING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE k'�L k IONS. qu.`/N. -
tl •� `K AIR HANDLING UNIT(OVER 10'"CFM) CONS]RUCTION TAX •'
.go. of of Applicant/ aorta for <: Dom' EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FIFE
HAZARDOUS MA&RIALS DISCLOSURE s.
Willthe...he.,or future building occupant store or handle hazmdoas metcn.1 11 EATING UNIT TO 100,000 BTU) o _•.
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety -
Code,Section 25532(0)?. 14FATING UNIT(OVER 100twO BTED
Ycs
D ❑+o I VENTILATION PAN EST NGLE RESID) PAID -'
t - Dere Rcttitu#
+'
Will theit c t or future d firing y the B y ea Air d hent 1 - !
emit hazardous sir contaminants as dehocJ hY the Bay Area Air Quality Management BOILER'-COMP I31iF OR I WA00 B'1'U7 - -
Umn L I{OILER-COMI'B)VER IW,IXq BTU) TOTAL:
❑Yes 0 N ., -
IhmeaaJ the hazardous matedala requiremems uedcr Chapmr fi.95 of me Cali AIR CONDITIONER ISSUANCE DATE
foram Health&Safely Code,Sections 25505 25531 and25534.1 undeAund thin tithe _ NEW RESIDENTIAL MECH' SQ.Pf.
idtheo does irerm a which h be t I im tat Y P :hftyt county ........ •�
ojthe rcquremct ome which a,,be airl. on ._aryon, luCcef am ofOswpuncy '
Ownermaumoriredaged Date T1 ISSUED BY:
.,OFFICE