28850 assn r w r - raw- r 1.11 Vncr••
CITY OF CUPERTINO n m r5ere yr r r rare nry a ur wnrr BUILDING-ELECTRICAL PERMIT NO. 28850^ ^ ^0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING•MECHANICAL 218 18455
i 'Ydr1Rr+*hH?BUILDING ROJBCTI HNTIFICATION/ti+�o�•wrz'v
BUILDINGADDRFSS: S, SANITARY NO. APPLICATION SUBMITTTAA`L,DATI
00 R'S N'AAMAME /VVPHONE: CpNTRACIUR'S NAM' LIC NO:
5qAg306(__ Au WC CONYROLX
'"GER MNOI rER: LIC NO: ADDRESS: ❑
I Yg
ACT: \ PHON:: ? sirL'h"",S•�;•5"BUILDINO PERMITINFO
If u L +aASe�l <W 6 � 4"M q ❑ Consultant Fees Paid by Applleanl(Initial) pG HCI
LICENSED CONTRACTOR'S DECLARATION Otl 'p '4 kj' s nt�gn_,e[y ¢:y;Ut(�:,{i '+ + Ni
1 hereby affirm that 1 mn licensed under Ions of Chapter 9(commencing
ELECTRIC PBRMIT^n �grt•',c r tl' » I
y Provisions p g ;' JOB DESCRIPTION
qqq RgZ with Secmmr,fmrp of Di ,.m3ofth flusinessend Pro"mmono tR,l dm licenm is
W O y PERMIT ISSUANCE RESIDENTIAL
V
in Cie and ettm. ❑SFDWL ❑KITCHEN REMODEL
fF..Z License Clm LIc.X too APPLIANCESCo. -RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE
h! Bem ARCHITECTS DECLA ION ❑MULTI-UNIT ❑STRUCTURAL
F+ PANEL 4
IpOs 1 undemead my plum shall M1e used a pub' records .— MODIFICATION
pZ qq 1'TU 200 AMPS
El INTERIOR [I CHIMNEY REPAIR
Licensed Professional IMPROVEMENT
101-IOW AMPS
OWNER-RU RDECLAR ION OVER IIXO AMPS ❑BATH REMODF.UREPAIR ❑DEMOLITION
1 herthy s empt fro e C Co :An or t
O U F.Hwhich mown. «Bon c.rmI ..Imr.r Code:Any SIGNS ELECTRICAL ❑OTHER
which requite a 'I m mmwcL eller.imp a mulish.or a Ic u m
yyg pilon to lu hsueme, wrtquirtsshe appll< ( hprnne I Law mcnt SPECIAL CIRCUR/h1ISC.
00 p. dn"Wh licenud pu nnpnl pros Cmdom a Law apter9 /_'.OMMPRCIA .
mconaencing with Sm m701X1 f in Jof the s as W. Dfofees "Coda)oI TEMP.METER OR POLE INST. �:
C that W is eumpt there m ds for Nee u e pilon. vinlmmA of ❑ EW BLDG/ADDITION ❑DEMOLITION
Semen 7031.5 by any Bcwlfor (subjects a Il antro civllpenellyof POWER DEVICES ANT ❑FOODSERVICE
Am rises then If bund dollen(S
C ❑LAsownerof Nepro y,many employees with wegu.... Hole compeneelinn. SWIMMING MJOI.ELECTRIC efIMPROVEMENT
will do the work,.nd thee) chiral...tnmndedoruttertd for e1Sec.TN4,Buelne.s —M Lao
❑OTHER
1 end Profenlom Code:11sm ontrwtm'r License law d rat Apply to w nwmr ofIT OUTLITTS-SWITCHES-FIXTURES
.. property who builds or Impm Merton,wel who J« ch work himself m through
Me own empinyen,pmvided t wch impmveme am. ,
rtnm Intended or oaemd for NEW RESIDENTIAL ELECTS SQ Pf.
WA If,however.the building or l veancnti,v wlthinoneyenrafcompl,do,the ^/SQ^FT.FFLLOOORAREA
\ $/SQ IR.
owner Wilder will have Ne burden o m he did not build or improve for pure I ` G�
ale
kA jtfe�
m the 1.11,am eaclmlvely rtmoscting with licensed contra n to TA
,40 construct the project(Sec 1044,Business and Professions Code)The Convectors U .1
cess ea not apply to a owner of property who builds or Improves themnn and FIY t n PLUM9BJO PEITv
RMi � kPEB ;4.'
eosin«u rwe
In I.with aumtrvmm(el licensed punuuttn Ne Cnntnctory Off`' `x" yin ' '
wcense5 PERMITISSUANCE r •' n
xe .«. ,Bk PCfur this reAso
O ITER-DRA IN A VENT-WATER(BA)IC; re VALUATION
ea
�
WORKE11017MMSA N D[CLARATIQN BACK FLOW PROTECT.DEVICE O e�
I herthy.Erol under penalty of perjury ne of th following ded.mtinn.:
I haveand will maintain.Carlo....of Consenuoself-Inure for Worker's Compen- DRAINS-FLOOR,RIDGE,AREA,COND.
cation,u provided for by Sation 37M of the Labor CMe,far the Performance of are STORIES I TYPE CONSTRUCTION
.,it for which this permit is Issued. FIXTURES-PER TRAP
❑1 have sed will maintain Worker's Compensation Insurance .,acquired by Section
37M of lire Lehr Code,fm the performance of the work for which this permit is issued. L GAS-EA.SYST[iM-I INC.40l1TLETS I OCC GROUP APN
My Workef.Compensation Insurance carrier and Policy number am:
Cardec Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUS OIL WASTE INTERCEPTOR
(Tbin section need rothcompleted ifthe pcooll le for me hundred dollen(SIM) Yea"!?S'Y 57w ,bmo DIVISI
or leu.) OREASE TRAP
PIANCHECK FF.P.
1 Hoy any Person
in the Any mmvnce ero(the work etbecom which this permitislrs'Cronan-ed.I shall SEWER-SANITARY-STORM EA.IM FT.
not employ any pesos ny Imnnet w u m became subject the Worker'Cnmpen- ENERGY PEE
Z It..".Aof Calif.!..isDent
Q WATER HEATER WNENTIELECfR
Applicwl GILGRADING ITP.
NOTICE TO APPLICANT:If.efTer ma king this CcrtiRnte of Emmption,you should WATER SYSTEMRREATING
become aubjm m the Woker'n Compensation Pmvieimu of the lahnr Cmle,you mmt SOILS FEE.
foMwith comply with web provisions at this Permit man h deemed revoked. WAI Elt SERVICE
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ FT. i PAID
l U Ihemhy.floon thenhert ivemnnmetinn lending agency Bu the Performance nr Dom Rnoi X ,
Us the work for which this Permit iv lssued(S«.3197.C1v.C.)
Leader.Name
ILL
Wilding
Adelms
1 cenify that 1 have red thin application end slue thm the alive infmmminm is
As , z BUILDING IEE
VI
correct, egm to comply with all city and county ordinances and stem levee minBng to ��y,µ{ +.(,+;.�MECHAIvl�A1Y PERMCf"cC"f „�ti' PEE� S§"v
G77 building construction,and hereby whorre reprsentnivn of this city m enter upon the •.?y`�'i. -...raw ur..'.:ul+'l,A+ ,+ SEISMIC FEE
above-mentioned properly fo inspection Purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC ME cy
"s,judgments,cuts and expense.which may In any way accrue agaiut sail City LTER OR LTJ MP.CII. �"
In n e granting of this permit. PLUMBING FTE �a
T U .RSTANDS AND WILL COMPLY WITH ALL NON-POINTR DANDLING UNIT(TO IO.pO CFM) �j
S LATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IB,oBOCIM)
CONSTRUCTION TAX
n of ApplicwUC.Amector Data EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant atom or handle hrardous materiel HEATING UNIT(TO 100,000 BTU)---V,
u defined by the Capsular,Municipal CMe,Chapter 9.12, no the Hedlh end Safety
CMe,Section 155330)7 1 HEATING UNIT(OVER 100,0011 BTU) -
❑Yee (3 No VENTILATION PAN(SINGLE RESID) PAID
Will Ove.hr cmnntofuture budding mcupby
ase equipment Quordenimswhich BOILER-COMP OR IfX)AW BTU)
aril heiWnu eir canmminenu u deRned by the Be,flArte Air Quality Management i
l ..+ Dutncl0 Yea FI BOILER-COMP(OVER IW,UWBru) rtli(Ih'O
I have reed the haaudone materials requirements under Chapter 6.95 of the Can- AIR CONDITION ER ISSUANCE DATE
found.Health A Safety Code.Sections 2.55M,15537 and S.S.W.l understand Nal If the NEW RESIDENTIAL MECH. SQ.FT.
building does Are currently have•temnt.that it is my responsibility m notify the nectipun
of de requirements which mum h net prim to issuance oh Cawflcam of(kxupwasy,
Owner orwhorired agent Date ISSUED BP�J
OFFICE