28742 L
PLICANT TO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
TY OF CUPERTINO `BUILDING.ELECTRICAL t, - PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. .28742
-
BUILDING PROJECIADENTIF'ICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
NER'S AMB: r... .v,h PHONE C CI=R'S NAME- LICNOI/4"7
V - N/� CO OLN
CHITLCf/ENGI EER:, LIC NO DDItESS: . "
C p'1 a '„(_N / _ „' BUILDING PERMIT INFO -
i0. ^ ❑ Consultant Fees Paid by AppHcani(Initial) ,BLDG IiLEcr PLUMB MUCH
❑ o ❑
LICENSED dand Iran
her edCTORSDECLAN I[ONrcimp QTY ELECTRIC PERMIT FFF
I h by ff .h t l d under p t n. fCopmr 9(mmmenc g s JOB DESCRIPTION
with t ]Ip8) f0. 3 Oho BusinessdProfession,C.Je and my Ever.
is
00 - PERMIT ISSUANCE, + - PRESIDENTIAL: r
loaf and eRec..
%UU�PJ 1rel. as Iia# D - - ❑SFDwl ",�KITCHEN BE
MODEL
gvv Dec. Convncto AI'111ANCFS-RESlD[!N]'[Al: ❑ADDITION ❑PLUMBING REPIPE
ARCHITECTS DECL RATION aliiEl MULTI
UNIT ❑ AL
STRUCTUR , `
Z q nn I understand my plans shall he used a public recoNs - I'ANl'eL5 .,
OZ- - UP TO 200 AMPS:' MODIFICATION
[=roF1� Licensed Professional El INTERIOR ❑CHIMNEY REPAIR
�y�,p { OWNER.BUILDER DECLARATION ' OVER
INXAS IMPROVEMENT - s
M<W Q 'I hereby affirm that 1 oro exempt from the Contractor's License Law for me OVUR IDE AMP$ ❑BATH REMODEVREPAIR Q DEMOLITION
iqqi5$ 4 U following lemon.(Section]831.5,Bminess and Profemiom Cexnc:.A.,city m c.uniy SIGNS ELECTRICAL. [].OTHER
u+�4� which requires a dami(m construct,alter,improve,demolish,or repair any structure
prur I al ic4 Ih PPI t for such perantIsigned...men' MPCCIAI.CIRCUIT/MISC
LyyLyy� Thad n Jp i II th P fth c .. ICbde)or
5p0 Icon enc ng with Seed m](NIII),I Div isio 3.fthe Duaness JI fess ons Code)or ILMP.MCTLR OR POLCINST.
Ihm he is exempt merefrnm unJ the basis for the alleged exemption.Any valumn of - - ,❑ 'W BLDMADDDION ❑DEMOLITION
1_ M
Section 703 IS by any vpplicanl for a permit subjects the applicant o a civil penalty of POWER DEVICES -
'>. not more than five hundred dollars($500).
ANT El FOOD SERVICEFSa I.its owner ofthe property, employees wise woes as their wile compensation. SWIMMING POOL ELECTRIC OVEMENT' _
❑ thesc ,ade YemP Y B pen.
p4�F' ddvithrd...Codec no Com iscar s Ludesded.Law does
netlalply EH4,Business ❑OTHER
LLl and rywhob Code:Throve,thew' License Lawdoesnalapply toOUTLETSOU'LULTS-SWITCHES-FIXTURF_5
.:4'3.. his own who builh or impvsvth thsuch i and who does such work himself or through ° C
' his own emPloYees,proviJed that such improvements ore not invaded or offered for NEW RLSIDENTIAL ELECI'R 'SQ FT�
sale,If,however the building nr improvenuant is sold within one yeurof c'nr clion.lhe - SQ.FI'.FLOORAREEA SISQ.IT
viwn r-builder will have the Aunlen of proving That he did not build nr intpmve for par
fora of salol. a - +f
❑ 1.as owner of the property,atm exclusivelyceniartm,with licensed conlmcmrs to TOTAL:' - +
consumer the project(Sec.A10.L]last....and Pinfdote.CAc:)no Caron 's Li-
' cense Law does...epfly man owner of property who builds or impruvcar re end On'. PLUMBING PERMIT' FEE
whoamtmns f.rsuch pmjecu with ac.mme.ru(s)licensed pursuam mtheC .mese,
License Law. PERMIT ISSUANCE
(DI am exempt under Sec. h P ar U s
Owner
HR-DRAIN&VENT-WATER(EA) VALUATION
' " Uam '
anion,eaprovided
erebyda WORKER'S COMPENSATION UECLA I( 1 .K FLOW PROTECT DEVICE
ffrin under pelml.y.f,c,j vice.1 lheI I mg declaration.`
/ Ihavc and will'maintain.ClitiOcam.f CB mm • rcfur Workcr'sC mI)yI- BRAINS-FLOOR,ROOF,AREA,COND. : r STORMS 'TYPE CONSTHIJCTION
provi ed for by Section 3700 of the s ale, r the fart of e .
work for which this parau is traded. . FIXTURES-PER]RAP
❑1 have and will maintain W.rker's Co., sa ranee,or rarySection
3]00ofthelasm-Crde.fnree pofman...no ewo r whichda,pee t i,i,s.cd. - GAS-HA.SYSTEM-IINC.000TLITS OCC.GROUT' AI'N
My W.rkets Compensation Insurance carrier and Polic mMn are. ,
Cxrricc Policy N..: - GAS-EA.SYSTEM OVER 4(EA) `4.
CERTIFICATE OF EXEMPTION FROM WOR KF,IRS' "' s
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
or lesx,) GREASETRAPI
This sect.n neat nal be aintpldesl if the permit is for one hlmdreJ rLilars(SIM) fl GILDING DIVISION FEES
- - -
11
'� PfANCHECK PER
I certify that in.he) 1 of the kl'-- Lich ltd P ueJ.Lsball SEWER-SANITARY-STORM F.A.21X1 FL
not employ any person t y i a9I be u '• tire
W k :'Compen- ENERGY PEE
O z sal on Llws njjjjp��p��JJJJIIIId , I WATER HEATER WNENT/ELEC R - GRADING FEE
z Ap UCH
[A NOTICE IC NT:If,after making this Certificate
Exemption,you should WATER SYSTEM/TREATING SOILS FEE
become mbjec t. Workers Compensation provisions of the Labra Cale,you must
W forthwith comply vshsuch previsions or this permit shall be deemed revoked. WATER SERVICE „
Q w
;Dz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB SQ.FT PAID
V,Q T hereby affirm that there is a construction lendagagency lin the performance of 'Date Receipt#
4A N the work for which.his permit le inoacd(Scc.3097,CI,C.)
O v LcoJcrs Name TOTAL:
4i1 Lender's Address TOTAL: '
_ 6. 1 certify that I have read this application and nate that.he above information is BUILDING FEE
E5moh conect.I agree..comply with IT city and county mcbrouce,ioul,ale lawsrelaing to QTY. MECHANICAL PERMIT FEE
z building conswcdwmmd hercby,uumorize rtprexnta.ives.f this citym enterulwn the I SEISMIC FEE -
.hove-mentioned property for inspection PuHnscs.
(We)ones to save.indemnify and keep harmless the Cityof Cupertino agvist PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,cons and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
"con
the gralni f this fermis PLUMBING FEE
APPLIC 1 .DER AN 5 AND WILL COMPLY WI RI ALL NON-POINT 'AIR HANDLING UNIT(TO 10,000 CPM) "r
MECHANICAL.PEE
' SOD e11 LA INS
AIR HAND IIANDLING UNIT(DVER 10.1X10 CFM) °' CONSTRHCfION TAX '
�asde
a Contractor Dam EXHAUST HOLD OVIDUCT)c 1AZAR000S MATL'RIALS DISCLOSURE HOUSING MITIGATION FEE
Thee licam nr fummbuilding.ecopam store or handle hexuNous material HEATING UNIT(TO I st"BTU) _
'iincd by t upcnin.Municipal Code,Chapter 9.12,and the flml.h and Safety
Cadet,Second 5324)? HEATING UNIT(OVER 100,000 13 30 1995.
I]
. Yes ❑No 2 VENTILATION FAN IS INGLE RES ID)• . ,, PA f
g01 the applicant i,or Lane IJ ngoccupam use cyl fn nl, r J vices which ^ Date R pt#
01 i( ab vrc.nwm nCnti wAd neJ by.he Bny Area MrQrlly Managemem tl(TILC.R-COMP(3HPOR IfX1,01p IiTU) (PI vF U_f CII1 Try
Div .,,
HOILBR-COMP(OVBR IW,11011 BTU)
S.. ❑Yes' .E)No
7.
I have read The haas.Jou,nearmis reyuirevards under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
hand.Health&Saf dY Code,Satiom 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MF,CII. SQ.FT.
buildingdoes not currently have a tenant.That it is my responsibility to fruity the.ccupam
of.he requireme.0 which mon M sen prior to issuance of a Certifeam of Occupancy.
Owner mtuthndsed.,a, Date { TOTAL:11 ISSUED BY:
+', OFFICE it