28825 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIAYICAI, n O O C
BUILDING'PROJECT IDENTIFICATION G v O J
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
zo 36 - sA rn '
FIG.0 z-�l i- a ,a
OWNJ SN ME, 'yI - PHO CO ACTOR'S NAME: p-LII,CysNO:
l.. a �a /Q"✓/ //�»es h' 98s- 6oa0 VfllYlelw S O7U CIQIf NIC CONTROLN
RCHIIEC (ENGINEER: IAC NT ADDRESS: Q
CONTACT PHONE: BUILDING PERMIT INFO
er 9 98S 60 6 / Consultant Fees Paid by Applirent(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby afford not I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O p'Z with Section 7")ofDivision 30fthe Businesxund Professions Code,and my license is
00RNTI
we PERMIT ISSUANCE -
W U F m full fame and effect. DWL Ll KITCHEN REMODEL
aVV Licenee Class Lic.p APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
bi<a, Date Connector
ARCHITECTS DECLARATION ❑MULTI-UNIT- ❑STRUCTURAL
Ypy'� lundersmnd my placation]the used as public recoNPANELS s MODIFICATION
OZ4O UP TO 200 AMPS. El INTERIOR ❑CHIMNEY REPAIR
t:Ed Licensed Professional - 201-MAIAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
6 I hereby affirm that 1 am exempt from the Contrucmr's License Law for the OVER]"AMPS El BATH REMODEL/REPAIR DEMOLITION
?�pp'55�c O M U following reason.(Section 7031.5.Business and Professions Cale:Any City or county SIGNS ELECTRICAL ❑OTHER
which requires a pennil to construct.alma improve,demolixh,or repair any suucmrc
LLO prior to its issuance,also inquims the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
�} that he is licensed pursuant it)the provisions of the Contractor's License Law(Chapter 9
e500a (commencing wish Section 7")of Division 3 of the and Busineax Professions Code)to TEMP METER OR POLE INST. COMMERCIAL:
d e LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Y•e
Section 7031.5 by any applicant for o permit subjects the applicant to a civil penalty of POWER DEVICES rn ❑TENANT ❑FOOD SERVICE
'aQnot more than five ft hundred props dollars y em y PROVF.MENT
OLas owner of the propertyor. with wages as for sale
compensation,Busies SWIMMING P(IfIL ELECTRIC r, OC
will Bothe work,and the The oprianctintended,Lmv does et apply 1.i m,Business OTHER
rod Professions GNC:The Con thereo LLcensc Lew does not apply s if owner of OUTLETS-SWITCHES-IgXTUIiES
6 3 property who builds or improves t thereon,and who does such tinte himself or through o
his own however,
the building that such improvements s are not intended or offered for NEW RESII3ENTIAL ELELTR SQ FT
owner-builder
will hveth human
it at he did non build or f prove for the SQ.FT.FLOOR AREA S/SQ.FT.
neo-builder will have the buNen of proving that he did not build or improve for bur- tQ //�
pose of sale.).
❑1,as Owner of the Sec.7property,am exclusively Pomading with licensed droaddcmm i- TOTAL:
came Law
the es not(Sec.o an Business rope property
who
Code:)The Contractor's Li-
whoconwdcesnutapPly MpavLxwithaommandywhesedpnorlmprovexCommosand QTY. PLUMBING PERMIT FEE [j
who c0mrams for such pmjxu wird a contrunorta)licensed pursuant m the Comracmr's !
License Law. PERMIT ISSUANCE
Cl Iamexerdptunder Sco. ,B&PCfmlhixbwvw
Owner Data ALTER-GRAINA,VENT-WATER EA) VALUATION Sys
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penally of perjury one of be fallowing deductions:
�I]I have and will maintain eCenifcate of Consent to self-insure for Wurkets Cowper- DRAINS-FLOOR,ROOF.AREA,GOND.
STORIES TYPE CONSTRUCTION
scion,as provided for by Section 37W of the labor Code,far he performance of the -
work for which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Wn Performance
of
w histiorkfor hi h required by Section
3011 of the Labor Cede.fomhe peoformaxe of the workftoWr,uwhichbe tLNis permit is issued. GAS-EA.SYSTEM-1 INC.40UTLE1'S OCC GROUP APN
My Wor 'xFntpBenxai%o%Igsufunce�ante Policy No.:
f��lomlQR 0-1 GAS-EA.SYSTEM-OVER 4 HEA)
Carrier: k i G.TN
CERTIFICATE OT EXEMPTION FROM WORKERS' n
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
'BUILDING DIVISION FEES
(Thissectlnn need not be completed iDhe pumltls for one hundred dollars($100) GRBASETRAP ^
or last PLpNCH13C EE M D�
(cenify thin imhe berfoomvnce ofthewurk for which this permit isissu ad I,hall
C.., - SEWER-SANITARY-STORM BA.200 FT.
not employ any person in any tnmtam an as to become subjecfm the Workers'COmpen- f SPI FEE /o^
,� Notion Laws of Culifomiu.Data WATER HEATER WNPNT/ELECfR
Applicant GRADING FET^
ti NOTICE TO APPLICANT:If,efix,making this Cenificout of Exemption,you Should WATER SYSTEM/IREADNG
a became Subject m me Workef's Cmrpensution provixions of the Labor Code,you most SOILS FEE
forthwith comply with such provisions m this permit Shall he deemed invoked. WATER SERVICE
0. 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FC PAID Date Receipt p
U O IM1ereby affirm thanherc ieuconeWetinn lending agency lm the performance of
ON the work for which this permit is issued(Sec.3097,Co,C.)
U Lender's Name TOTAL:
lender's Addict, TOTAL:
0. 1 certify that 1 have read this application and state that the above information is BUILDING FEE !/6
[A discreet l agree to comply withali city and county ordinanas and Nam laws mlmingm QTY. MECHANICAL PERMIT FEE p
U building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE r T•�
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to cave,indemnify and keep hmmlcss the City of Colon..against ELECTRIC FEE J 7
liabilities,judgments.coots mad expenses which may in any way accoeagainn said City ALTER OR ADDTO MECH. PLUMBING FEE �3
in nsequcnce ufthe granting wild,permit.
APPLICANT,UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT LTO 10,000 CFM) MECHANICAL E
NCE al
SOU /IATIGL_4.0-4 At / J.Y/9G PM
� Tg'f7 AIR HANDLING UNIT(OVER 10,000C ) CONSTRUCTIONTAX
Siylidiumof Applicamu Conua� � EXI
�� v— IAUS'I'HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOS RE
Will dotipplicant or future building crewpwo,mre or handle homrdmodaterial HEATING UNIT(TO 100.000 BTU)
as defined by the Canadian Municipal Code.Chapter 9.it.and the Health and Safety
Code,Section 25532(0)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑N0 VENTILATION PAN(SINGLE RESID) PAID
Dine RmciptN
Will the applicant in fuwm building occupant use Area
Air Qu or devices which BOILER-COMPOHPOR 100,000 BTU)
emit hazardous air contaminants as defined by the Buy Arca Au Quality Management
TOTAL:
District BOILER-COMP(OVER 100,0011 BTU) J
(]Yes F1 No
I have read the hazandous materials requirements under Chapter 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATE
facia Health&Safety Cale.Sections 25505,25531 and 25534.I undersand that if the - NEW RESIDENTIAL MECH. SQ.PT.
build gone tcuncntly h0veu¢nam,that it is my mspamibility to notify the occupant �(,,L//
of the rye' a w/h/�'u/must be ren prior to issuance of a Cenif¢a up y /k
Ow oramhmizedagc� m TOTAL: ISSUEDBY�"a'• '
OFFICE {