28547 :APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY • t
Ir
CITY OF CUPERTINO r BUILDING-ELECTRICAL PERMITNO,
BUILDINGDIVISION APPLICATION/IsERMIT PLUMBING-MECHANICAL , 285,47
BI ILDING PROJECT'IDIPWIFICATION V
UUILDINGADDRESS: - SANITARY NO. - APPLICATION SUBMTPIAL'DAII
�y111 007—O VEgFc•G'rT Fr[ Swee K 'STU6T_
P1CON
' A�OME
7s e 'V� �5_(94s/. oigaF^ k, C O .
NIC - CON I'ROLN 1
ARCHIMCF/ENGINEER: LIC NO: ADDRESS
:, ❑
370 Arm. 4 L-ro'
CONTACT: t, .PHONE: - BUILDING PERMIT INFO
,F ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB SUCH
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEEtal -
i hereby alTrm flad I sum fitZmwed mole,pro,no.tvsof chapter 9(commerc ng - JOB DESCRIPTION
yo]0 will,S r 7001)r(Dl i of he Buri dP f ions Code and mylcense s RESIDENTIAL,
OC infullfr, nde d. PERMIT ISSUANCE .'1.! ❑SFDW ❑KITCI IEN REMODEL
<U j Licens Clew Y
NFF.^,satelj Dam CCmur cm7r'nUleqHOLg
APPLIANCES-RESIDEN'i'[A]. CADDITION PLUMBING RE-PIPE
ANCHITELT*SDECLARATION
' PANELS ' 0MUI:I'1-UNIT ❑MODIFISTRUCTUAAL'
MODIFICATION
Iunderstnnd my plans shall 6e useJ as puNic records ". � . MODIFICATION
,p oUP TD 200 AMPS
' • INTERIOR CCHIMNEY REPAIRFg�1pp"tp�
Licensed Professional 2111-11100 AMPS + IMPROVEMENT'
3 wmrsc •OWNER BUILDER DECLARATION OVER 1000 AMPS _ C BATH RE'MQDELIREPAIR QDEMOLI'f10N
iNqK'U r I hereby Finalist rhut 1 1. exempt f m th Contractor',ns. License Co.(or the L�L�� r�
i5 'C (0110- g .(S-ran 7011 S,Business and P fe- n:Cute Any city aunty - 'SIGNS ELECTRICAL * '•r 1�A'O-+THC•R
I++ OIn which requires apermit to construct alter. 1 v J f h, pat any structure cture ulrL ill '7 5-rd
prior( is t:atne also no,moesdern,plicamnf hpc a fl g da dement SPECIAL CIkCU1T/MISC
Ips.sW� [bar he Ic dpursuant m the,ronsions of the Connector L I lCh pier9
a0p (c&mnenmg WithSction 901(1afUvoao 3ofthe Butimes,adP @.x !C Ir)m. TEMPMhTERORPOLFINST COMMERCIAL,
that he is exempt therefrom and the basis Carlini 11 get tonermailm.A y vmlaunn of ❑NEW BLDG/ADDITION ❑DEMOLITION
a� Y• S...too
'"LS by any applicant for a Perrot bl t the x1ru tt it penalty of POWER DEVICES
tel m'� - El TENANT 'r El FOOD SCkVIC&
z no more,more than Eve hundred dollo..($51Np. ,h t„ a 1, IMPROVEMENT
C1,ns owner of the prnpeny.or my employees with wage es their sole mmPenmtion, SWIMMING POOL ELECTRIC -
ptg( will do the work,and the structure is not intended oroffered for sale(See 7044,Business DOTTER
913 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FI%TllR S
Q' property who builds or improves thereon,and who does such work himself or through - ,
his own employees,provided that such improventenu are not intended or offered for NEW RESIDENTIAL ELEC SQ fT.
sale.It.aiwave,the building or improvunent is soldwiminore world nnnplution;(ho SQ.P.FLOOR AREA S/SQ.FP.
o rvbuiWer will have the burden n(proving thud hedidnothuildmimprour-veforp + •
poaesofs.1a). ,; - ,
[-1 h as owner of the property,am enelunively wnwctin,with licensed cmadonirs m' TOTAL:a "
comma the ponlct(See.7044,Business and Professions Code)The Contmcmr'si.i- P A'
centt law does not apply to an owner of Prolany who hiilds or improves mereon,and QTY, PLUMBING PE MIT [ZEE
who commilts tar such projects M th a conn.alons)licensed pmsuam to the Conmt, is 'aTQ 1'
License Co.. PERMIT ISSUANCE 10,
04
❑l am exempt under Sec. .B&P C far this reason
Al-Hik-.DRAIN&V
VENT-WATIiR(iA) VALUATION
Owner Data -
WORKERSCOMPENSATIONDI'CLARAIION BACK FLOW PNUTILT DRVLCIi Y ter LVrCfll lly
Ihereby oflvm under pendtyof pry epaone of the followingd la r ns V
C lhav<andwll ma mina Cemfcvte of Cnnscmmself nsu fo Wo trr-Compen- DRAINS_FLOON.HOOP AREA.GOND. STORIG'S 'TYPO?C0N5'TNUCTION
setion,as provided for by Secuon 377 of the Labor Code,forthepe 1 e of the C ,
work mr which this permit is issued. POSTURES-PER TRAP d
❑I have and will maintain Worker's Compensation Insurance,as required by Section t - ,
3700 of the Labor Code,for the pcommence of the work for which this Permit is issuul: r GAS-EA,SYSTEM.I INC.4 OUTLETS OCC.GROUP 'APN
My Worl6� sC'mp nemion p iter ce artier unit Policy,yaphy qrc.
Currier�P �m�L Policy No.: N 800274-1 ' GAS'EA:SYSTEM.OVER 4(EA)
CLs FICATE OF EXEMPTION FROM WORKERS'
COMPHNSXGON INSURANCH GREASHANDUSTRI.WASTE INTERCEPTOR
SION PEES
(This section need not be completed mi
ifthe Pert is for one hundred dollars(S 100) BUILDING DIVI
or less) - GRI'ASE TRAP PLANCHF.CK FEF. - n
Icenify(hm in t heperformanceafthoW Is far which this permit is ismed,Ishall SEWER-SANITARY-STORM PA.200 PT.
nut employ any person in any m uran,ser asr,,became subject m the Wmkers'Compcn- ENERGY FEE
O z anion Laws.17 Cali(oarm.Data WATER BEATER W/VENT/GLECTIR
Applicant - - - GRADING PER
r%y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTREA'ITNG
F ; Become subject m dhc Warkcr's Compensation provisions of the Lanur Code,you must ` ' SOILS FEE
IJJ forthwith comply with such provisions or this permit n],all ltd Jeemad revoked. WATER SERVICE .
0
CONSTRUCTION LENDINGAGIiNCYNEW RESIDENTIAL.PLMB. SQ.Pi', PAID
V O lhcrehyeflirnt(hanhere is it urtm
consrtion lending agency foe perforance of Date Illc6in#
the wmk for which this pepnit is issued(See 3097,Civ.C.)
W -
U m
Lenders Nuc 's ' TOTAL:
- Lenders Address - TOTAL:
1 certify that 1 haw read this application and state Nat due above infommdon is BUILDING FE
it h7 corzcu.l agree to comply with all city and county eminences lord state laws relating m L.
QTY. MECHANICAPERMIT FEC
ViihuilJingconewcdon,ImA hereby umhoriae representatives efthiscitymemerup�n Ne SEISMICFEE
ve
abo -mentioned pmpeny for inspection purposes. + PERMIT ISSUANCE;
(We)agree to save,indemnify and keep harml,.the City of Cupcnino agnirel ELECTRIC FEE
liubi lilies;juJgromis,cos(,and expanses whichntny in any way a,,.sagnma,aid City ALTER OR ADD TO MECH. -
innmseyuenceo(thegnanting this pcnnME it. - PLUMBING FEE
ALFEE
YPIANTU
DERSTANI AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 16moliCSH
CONSTNICTIONTE REG .ATIONS.' -
OAIR HANDLING UNIT(OVER 10,(g10 CPM) CONSTRUCTIONTAX.
Sd4DAm of ApplicanVContranor Date EXHAUSTHOOD(WMUCG HOUSING MITIGATION FEE
I HAZARDOUS MATERIALS DISCLOSURE.
_ Will theapniculd orfuture building accupam stem.,handle hamodim,material s H RATING UNIT N 0100,000 BT U) '
as defined by the Cupertino Municipal Cafe,Chuptcr 9.12,and the Health and Safety '
Code,Section 25532(n)? HIrATING UNIT(OVER IBII'cou Bt U) -
0Yes `I No -c !' PND -
.. VENTILATION PAN(SINGLE kCSID) Date Rcccipd a
Will the applicant or future building occupant use equipment or devices wwhich BOILCRCOMP(3HP OR 100,000 BTU)
emit hadous air contaminants 4s definal by the Bay Area AirQual Ity Manngemem - TOTAL:
3� I]istric(? 1 -
Dyes XNa BOILER-COMP(OVIiR I00,000 BTU)
AIRCONDITIONER Y'
I have mml the btoodurs materials requirements under Chapter6.95 of the Cali. ISSUANCE DATE -
fomia Health&Safety Cmc,Sections 25505,M533 and 25534.I understand that if the ANEW RESIDENTIAL MECH. SQ.IT.
' huilJing dcesnot currently havehmnsm,thio it is my mspnruiM1iliry to notify the tecupant
offla,.ohnnents which lssuancea(a CenlficamaTOccuponc, x a 1
n„I Ownerarauthoneedagent Data TLIq ISSUED BY:
OFFICE .