28827 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 28827
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDENTIYICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
x-0337 Ili a ,moo -
OW R'S NNpML( PHOGNE C N' R'S NAME: LIC NO,/ aI'F/On r OHJ RS /J/OO S 6 CQJ N O L l-.nr/� NIC CONTROLp
7"U"
C CT/ENGINEER: - LIC NO: ADDRESS: N
CONTACT PHONE: - BUILDING PERMIT INFO
e e �oo er r�/9�s=6o 6� 0 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
7
LICENSED CONTRACT'OR'S UIiCLARATION QTY ELECTRIC PERMIT FEC
1 hereby affimt that I am licensor under provisions of Chapter 9(commencing JOB DESCRIPTION
1�BTrnZ with Section 70010)of Division 3 of the Business unit Protestant Code.arm my license is
FSBin full force and effect PERMITISSUANCE ❑KITCHEN REMODEL
�FU�j
License Class 1.iag API'LIANCF.S-RFSIDFMIAL ❑ADDITION [I PLUMBING R&PIPE.
N S Date Contmemr
ARCHOTCTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
OZF.z I understand my Alam,mall be used as public records PANELS MODIFICATION
4-0 OTTO AIB AMPS ❑INTERIOR El CHIMNEY REPAIR
Pmtw Licensed Profneionml 201-1000AMPS IMPROVEMENT
�Ys�� OWNER.BUILDLHDECLARATION OVER1000AMPS ❑BATHREMODELIUMAIR [I DEMOLITION
IX W 6 I hereby off rte that I R-exempt Horatio,DECLARATION
License law far the
d U following reason.(Section 4031.5,Business mud Pmfemmiot Code:Any city or county SIGNS ELECTRICAL. []OTHER
F F which requires o permit m nms0uet alter,improve,demolish,or repair any structure -
priormitsissuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MIST.
p5 6f that he is licensed posuanun
the provisions of the Contractor's License Law(Chapter 9
'^ q (eommencing with Section TBW)ofD,ci,lcH 3ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a o W that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
n Section T(131.5 by any applicant for aperm,subjects the applicant to a civil penalty of POWER DEVICES
H ❑TIiNANT ❑FOOD SERVICE
��y not more than live hundred dollars($500).
6 01,towner ol'Nu property,or my employees with wages us Neir ante compensation, SWIMMING POOL ELIiLTRIC OTHER IMPROVEMENT
will do Nestim.aotle: heCare imfin's teicense ita,dJBtsalepplytoanownerof ❑OTHER
end Profession Code:The ores thereon.
License Luo dms nm apply s if owner of OUTLETS-sWITCHES-FIXTURES
properly who builds or imprmn thereon,send who don such work himself or through
his own employees.building that such improvements are mm intended or offered for NEW RESIDENTIAL ELECT SQ FT.
onmeLhoweveallhaffia ve she bng urden(if
issoldhe aid non build or improve
the $Q.PT.FLOOR AREA f/SQ.FT.
owner-builder will have Nc burden of proving that be tliJ not build or improve for put, ✓) R
pose of sale.). a Or `� -7
❑I, i owner of the pmpeny,can exchanalyand
comructiog with licensed contractors i. TOTAL:
oie La the es not apply
to an Business and Professions ds ori The Catnmcm:. Li- ?pr �
cense Luwdncsnmapplyman with
acofpmpeny whosedprrlmpmves thereon.and QTY PLUMBING PERMIT FEE
who contracts for such projects wirdacnmractor(s)liansul pursuant it) Contractors
Licenu exempt
PERMIT ISSUANCE
❑I vat exempt under Sm. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
owner Date nJ -,(> 7
WORKF.R'SCOMPENSATION UIiCe folio ing BACK FLOW PROTECT'.DEVICE O( 7 � O
I hertby aRem under Penalty of perjury one of the following Jalarmions:
IhaveandwiilmaimainaCenificamofConsentmulGinsumfor Workers Cnmpen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES 9'YPE CONSTRUCTION'
sation,as providW for by Santia.3900 of the labor Code,for the performance of the
work for which this Permit is issuN. ITXTURE3-PERTRAP
1 have and will meinmin Workers Compensation Inmmon.t require)by Section it Gl V 11
37M of Ne Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS ' OCC.GROUP APN
'Carrim
it,wr sCCERTIFTCATE OFB(F.MPTPolk, a�Af ION FROM WORKERS' �� GAS-EA.SYSTEM-OVERJ(EA) 1p
JH 191196
COMPENSATION INSURANCE GREASFRNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not he crammed if Ne Permit is forone hundred dollars(SIM) GREAS - ^•-- [� /�y�
or less) SEWER TRAP PLANCHECK FEE V i VV
Toy any that in the any manner o ineas
work for which this the W rkenf Compel] SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner an as to become subject to the Workers'Compen- � ENERGY FEE
z sm Laws of C.1ifnmia.Date WATER HEATER WNENT/ELECI'R
O OualApplicant GRADING FEE
to NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSMg4r'REATING
Imomembjcetto Ne Workers Compensmirn pmvisians of the labor Code,you must SOILS ME
forthwith comply wiNsuch pmvkwnsor this permit shall he deemed revoked. WATER SERVICE
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O Thereby offrm Nauberc is acatwainn lending agency for the performance of Date Receipt
W o--n New.rk for which Nb Daunt is"saw(sec.30D,Civ.C)
O t~ lender's Nome TOTAL:
WLenders Address TOTAL:
1 certify that 1 have read Nis application and mem that the have information is BUILDING FEE
r0./) correct l agree to comply wide all city and county ordinances and state laws telating to QTY, MECHANICAL PERMIT FEE
V btildingconalrntion. it herchy amhurize represenmtivex of Nie city menta,upon the SEISMIC DEE
above-mentioned pmpcny for inspection purposes, PERMIT ISSUANCE 1�
(We).9.to save,indemnify and keep hamdess the City of Cupeninr against ELECTRIC FEE , Q
liabilities,judgments,costs and expenses which may in tiny way aceme against said City ALTER OR ADD TO MECH. bt ?O
in consequence of the Starting of this Permit. PLUMBING FEE V eCN
APPLICANT,UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,03 CFM) seer /�•q�OO
SOURCER ULATIONSS MECHANICAL FEE
iC%_ _ p 1-71" AIR HANDLING UNIT(OVER IO,000CPM) CONSTRUCTIONTAX -36$
Sigul3ure ofApplicanJContactor Dm EXHAUST HOLD(WMUCF) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant slum or handle hazmdros material HEATING UNIT(TO 101,000 BTU)
as defined by the Culimina Municipal Code,Chapter 9.12,send the Health and Surety
Code,Section 25532(a)P HEATING UNIT(OVER 100.0W BTU)
[D Yes ❑Nn VENTILATION PAN(SINGLE RESID) PAID
Will thea applicant or future building occupant use t or devices which
Data Receipt p
pp g p ea Air n BOILER-COMP(3HPOR 100,00013TU) p
mit hvuNous air contaminants as definW by the Day Area Air Quality Management TOTAL: O oa�5
Tsmu7 BOILER-COMP(OVER 100.000 BTU)
1F,1 Yes �No
I have re ad the hazalloux materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE E
former Health& cry Code,Seaisms 25505.25533 and]5534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingdocs carom ly he tenantthmitismyresponsibiliry to no'fy the occupant
of the requi eats whit met PH",ft,iunce ora Cenifpt tone cy.
Ow or authorized agent Dare TOTAL: ISSUED BY:
OFFICE
--- - ad--
-