28567 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I . _BUILDING•ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING•MECHANICAL O
BUILDING PROJECT II .NTIFICATION o 5[` 7
J o I
BUILDING nr ADDRESS: -// / 1 SANITARY NO. APPLICATION SUBMITTAL 1) IT
O,
OWNIiI' XAMI:: PHONE: &<OR'S AM is LIC NO:
f p/� N/C CON'I'ROLM
IRCHITECr/ENGINEER: LIC NO: DI]RF�SS: ( vAC/ AGM O (
/ Y[.r
CONTACT`. PHONE: a( - BUILDING PERMIT INFO
Mj1&)44 «a) 6-t'oatj ❑ Consultant Fees Paid By Applicant(initial) 0LE LUM ME
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I sun licensed under proviaiona of Chapter 9 tco amencing JOB DES RIPTIO
Q 09Z with Section?000)ofDivision 3.F the Busiaeasaad Prefcesions Crate,and my license is RESIDENTIAL:
OO PERMITISSUANCE
�F in full force and effect ❑SFDWL ❑KITCHEN REMODEL
HU❑ Lteeam Class Can APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPIT
Lr 7'-a Date !TS DEmr
p,Om ARCHITECTS DECLARATIONPANELS - ❑MULT4UNIT ❑S'TRUCT'URAL
Z O m 7z 1 understand my plans shall be used as public records MODIFICATION
OZ4 M - UPTU 200 AM ❑INTERIOR ❑CHIMNEY REPAIR
1=�21'W Licensed Professional 201-Iqp AMPS. IMPROVEMENT
y S�? OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH RF"MODEUREPAIR L1 DEMOLITION
1 hereby affirm thol 1 am exempt rram the Ci ,.act.,',License Law far the
se at/ bdlowingremon.ISection?a out. far,sand ,darnm Code:Any city or county SIGNS ELECTRICAL [I OTHER /
uuf7 3 O which rclk issi n permit to cnnawq,alae improve,demolish.or repair any swcmm /`�SjJLgy�
prionoits issuance,also requires rhe applicant for such permirin rile asigneJ smtemem sp
ECIAI.CIRCLJITWISC,
that he is licensed pursoa I to the provisions ofthe Contractor's License Law(Chapter 9
y�OC (commencing with Section]O(q)ofDivisionl of the Business and l'rvfessiom Cale)or TEMP.METER OR POLE ST '
a n m
not he is exempt therefrom and the basis for the allegrd esemptiom Any violation of ❑ EW BL /ADDITION ❑DCMOLITION
4` Sectian0031.5 hyany applicant Earn permit suhjecuthe applicant ovcivll waaltyol' POWER DEVICES
I-Z Y not more than five hundred dollars($500). TENANT FOOD SERVICE
Fl SWIMMING asowner of the property,or my cmployaswith wagesaztheirsnle campensadon, SWIMMING POOL ELECTRIC MPROVEMENT
will do lbs work,and the suucmre is nal lnlendeJ arefferW for sale(Sa.9044,Business _ F1 OTHER'
and Profcsslons Code:The Comment, License Law does not apply to an owner o )UTLL'I'S-SWITCHES-FIXTURES
6 3^ property who builds or improves thereon,and who docs such work himself or through
his own employees,prvvidxd that such improvements are not intended or offered for NEW,RESIDENTIAL ELEC R SQ FT. R $TE
sale.If.however,lbs loading.,improvement ix sold within no yearof"an earn.
SQ.IT.FUOORAkEA E/SQ.FT.
..c,build,will have the burden of proving that he did not build ter improve for par-
pose of sale.).
❑1,m owner of the propwny,ant enclusivdy eantmefr,with ct Iiccmsed contractors m T L' NOV 2 O 1995
nstrythe project(Sec.'BW,Business and Professions Cost,.ow ContmorIb
ds
come Use does not apply to an owner of pmperty who builds or improves thereon,and QTY. PLUMBING PERMIT FEE "� .vOW
who contracts for such projects with s camrectugs)Lamed pursuant to the Contractor's rII/sµ.,1. t Lr l^rnrh1
License law. PERMITISSUANCE I ,LK& L
❑I am exempt under Sec. ,B&P C for this reason _ ...iii
Owner - - Dmc ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE l �
1 hereby affrin under penalty of perjury one of the following declarations:
61.IInocund will maintain.CenificxmofComent to aelbi....c lin Worker's Campem DRAINS-FLOOR,ROORAREA,COND. STORIES TYPE CONSTRUCTION
vation,as provided for by Section 37001oLthe Lehr Gds,for the perfonn.nce of the
walk for which this permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insumnce,as required by Section
370d.f1he labor Cade,fortis perfnrmanceaf the work l'orwhich this perp is issued GAS-PA.SYSTEM
-1 INC.4 OUTOCC.GROUP -' APN
M Wori Com tion ps cec 'er end Policyn r:!�,1-! .
�1�/nPnlicy Nn.: VWI GAS-EA.SYSTIiMOVER4(EA) A
CI:V EPIC g.OF EXCMI"I'ION FNOMW RKERS' �1
COMPENSATION INSURANCE GREASWINDUSTRI.WASE INTERCEPTOR
(This section need not be completed ifthe permit is forone hundred dollars($100) _PVI)51'6 DIVISION FEES
nr
rem.) GREASIiTRAI' PLANC
I certify that in are performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.2W FT
not employ any person in any manner so as m become subject to the Workers'Campers- ENER E
z submit lows of California,Date
WATER HEATER WNENT/ELECTR
Z Applicant' G FF.-
y NOTICE TO APPLICANT.If,afierntakim,this CeniOcme of Exemption,you should WATER SYSTEM,"REATING
f~ hxome subject to the Workers Compensation provisions of the Labor Cale,you must SOILS FEE
Wforthwith comply with such provisions or thi s permit shall be deemed revnkeJ., WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RFSIDEM'IAL PLM B. SQ.FL PAID
Z I hereby affirm thatthem is o canstmmion lending agency for the performance of Dam Raei it
the work for which this permit is issued(Sm.3094,Civ.C.)
0 U Lenders Name TOTAL:
(11 Leader's Address
fy 1 certify 111.11 have lead this application and scute that the adore halk rmatinn is BUILDING FE r�
.w W) coni l agree 1.comply with all cityund county inch...ccspnd nate lawa relningm QTY. MECHANICAL PERMIT FEC
U 7 building construction,and hereby authorize representatives ofthis city m enter upon the SF.ISMICFE
above-nentioned property for inspection purposes. PERMITISSUANCE t ��
(we)agree to save•indemnify and keep harmlersthe City of Cupertino against 1t1.EC'1'kIL ✓
liabilities,judgments,cents and expenses which many in any way accrue against said City ALT-ER OR ADD TO MECH.
maen2 f
in cocgce of the granting of this fermis PLUMBING PEE
APPLICAN DERSTANDS AND WIL _OMPLY WTH ALL NOW NT AIR HANDLING UNIT(TO IBM)CFM)
SOURCE '0-ATIONS. MECH IL :E
AIR HANDLING UNIT(OVER I0J010 CFM) CONSTR'Sdl&TA
Signvm of ApPlic a— lac EXHAUST HOOD(W/DUCT) ROUSING MITIGATI(NFEI?
I 9AR OUS MATERIALS DISCLOSURE'
Will the Applicant 61 lumre building.ccnpantsmre mhandle hazardous material HEATING UNIT ILO 1000,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safety
Ctsle,Section 25532(4? HEATING UNIT(OVER PI0,00011TU)
❑Yes No PAID
VENTILATION FAN(SINGLE.RESIU) Date RaeiptN
Will the applicant in front,re building by the Bt use ea Air Qu or Mara which BOILER-
thazardnusuircontaminantsmdefinedhythceayArcaAirQualityManagement CGMP(31iPGR I00.p00 BTU)
TOT L: LA
ti
rima❑Yu ❑No BOILER-COMP(OVER 10LON)BTU) 1 ��/��
I havHealth
read the h ode,S s fires 505.2 533 an urder 25534,1 and rstand the Gdl- AIR CONDITIONER ISSUA e '
Eomia Health&Safety Code,Sections t,and i,5533 esJ 25534.I to m understand thw if the NEW RESIDENTIAL MECH. SQ.FT. 1r/
building doges noaurtently have a,'nett,that o is ua ce of aaCenifito notify the occupant
of the reyuiremenls which muss be incl prior m issuance of a Certificate of Occupvucy.
Owner or authomcd agent Data _ ISSUED BY:
OFFICE
a