28823 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.MECHANICAL 3
BUILDING PROJECT IDRN'1'IFICATION
BUILDING ADDRC$S: SANITARY NO. APPLICATION SUBMI'ITAL DAT[
6
'Fl dS orrenfi Ran 3- G .� a0_'
OW Iili'S NAM?: I'I{ONL': COMItAC'TUk'S NAME: LIC NO:
Ten � r_166W e/s G/ NIC CONTROL#
ARCHITECLIENGINEER: .CNO: C ADDRESS: ❑
CONTACT. PHONE: - BUILDING PERMIT INFO
❑ ConSBRant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
'K t
uCEN. DCOMRACTOR'$D ct.ARA'naN QTY. ELECTRIC PERMIT FEE
DMZ 1 hereby a11Um mat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section 700(8 of Division 3 of the Business vnd Professions Code,and my license is
OO in full force and effect. PERMIT ISSUANCE
y alb WL ❑KITCHEN REMODEL
aUU License Class Lia# APPLIANIES-RES IDEM'IAL ADDITION ❑PLUMBING RE-PIPE
�• R Dole Contmmor
ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL.
y p n co ❑I understand my Plans Shall be used as public records MODIFICATION
OZ—, UPTO 200 AMPS ❑INTERIOR:' /,;� �s ❑CHIMNEY REPAIR
Fr,RJ f" Licensed Professlomtl 2UI-HBOAMPS IMPROVEMENT. P ty
9gm� OWNER-BUILDEReaa.,tun DECLARATION Rmmenc OVER 1000AMPS E)BATH EMODEUREPAIR [I DEMOLITION
C Q 1 hereby.Seats that I am exempt from the Conaacters License Law for the �r{}}}���IJQ
it
W O6VF which ingmason.permit
]o31.5,Busile land Professions Cade:Any city osometwy SIGNS ELECTRICAL oO""'^
YI a LL Fyy which reyuima v permit m cnnvmn,alter,improve,demolish,or repair any swctum 0 loo,
(?7y¢ priormiw issuance,also requirev the uppliwmlbr sucM1 permino RleaSigneJ statement SPIzCIALCIRCUIT/MISC. L(/Yf o.
vWvW��} than he is licensed pursuant to the provisions ofthe Contractor's License Law(Chipter9
6'�Q kommettcing wim Section 7000µd Division3nf me Business and Rmfessiana Cad<)or TEMP.METER OR POLE INST. COMMERCIAG:Cjf//
IL y�y e C mat he is exempt thando and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 1 V�DEMOLITION
m
Tem Section 10315 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES
4411 m ❑TENANT ❑FOOD SERVICE
t ZZ p not snore than five hnndrd dollen(E500).
❑ I,us owner of the properly.or my employees wim wages as Meir sole compemation, SWIMMING POOL ELECTRIC IMPROVEMENT
❑OTHER
will do the work and me structure is not inuc dei oroffered for sale ISce.]044,Business
3 and Professions Code:The Contractors License Law dose not apply to im owner of OUTLETS-SWITCHES- rwvs
property who builds or improves thereon,trod who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL EL" T SQ IT.
MR.IL however.the building or improvemem is sold within one year of completion.the SQ.FT.FLOOR AREA $/SQ.PT.
owner-builder will have the burden of proving that he did not build or improve for par
pane of sale^)e 04w
❑s ns o w c of the property,,B sines and umtmming with:)The
contmatoss i. TO (� O'A/
can=La the es jet(Sec,o nn,Business and Professions ds or
The Contractors n J
who co w tsfors chplytoan with
ofpraperly who builds or improvee thereon.and QW. PLUMBING PIiRMIT $ ��
whonse Lace for such projects with a commna(s)licensed pursuam a.me Contractors
License Law. ' pCRMITISSUANCE -
❑l um exempt under Sec. ,tl&P C for this reason
Owner Da¢ ALTAR-DRAINA,VENT-WATER IRA) VALUATION �./�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE nO �G'r� GJ^
I hereby affirm under penalty ofperjury one of the following declamiions: a O
I have and will maintain a Cenilicate of Consem to self-insure for Worker's Compel, DRAINS ,ROOF,ARL'A,COND.
Much,as providevl for by Section 370E of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. MIXTURES-PER TRAP
I have aad will maintain Wmker's Compensation Insurance,ao required by Section
3700of the LworrtCoddSe,,forthe performance oohs work for�whiich otthis permit is issued.. GAS-EA.SYSTEM.I INC.n OUTLE"S - OCC.GROUT' APN
My Cartier:rkC�L.�G'ttSYNLcpve-cT�a�r—icrPolky No.y n^'a7o(924'407 GAS-EA.SYSTEM-OVER 4 IEA)
CERTIFICATE OF I:](EMPf10N FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEESIThls section need not he completed ifthe permit is forune hundreddollam($lot))
GREASETRAP �g oeOO
or kasJ PLANCHCCK FEE OC
.Ieciify that in the performance mate work ferwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner w ax m become subjcel m the Workers'Camper ENERGY FEE
,Z ration Luws of Culifem m Dam WALLER HEADER WNENT/ELECTR
707 O Applicant GRADING FEE
rte. y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYS'TEM/fREATING
bom
ece abject m me Workers Compensation provisions of the labor Code,you must SOBS FEE
L4 a fonhwith comply with such provisions or this permit shell he deemed revoked.
WATER SERVICE
Q
�^ CONSTRUCTION LENDING AGENCY NEW kESIDENI'IAL PLMB. SQ.PT, PAID
V 0 I thereby whit fithi that them isaronstrve.3097.ding agency mobs Performance of sips#
OF mework for which this permit is issued(Serve.3097.Cr,CJ
U Lender's Name - TOTAL:
Lenders Address TOTAL:
a1 certify that 1 have read this upplication Sad seta that the above information is BUILDING FEE *:ill
Vl corset.l agree to comply with all city and caunry ordinances andstete laws rtlming to QTY. MECHANICAL PERMIT FEE
U building construction,end hereby authorize representatives alibis city to enter upon me SEISM IC FEE , OO
above-mentioned properly,for inspection purposes. ` PERM IT ISSUANCEf We)agree m•save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way oars against said City ALTER OR ADD TO MECH
in consequence of the growing of this permit. PLUMBING FE 8 OD
APPLICANT}INDERSTANDS AND WILL COMPLY WITHAL NON-POINT AIR HANDLING UNIT TO I(I,q)fI CFM) paa7l
SOU/RC/HJ��/`'ULATIO, MECHANICA E Ji s30
Z.e_ t� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCT( NTAX
Si um of Applicant/Con tort Date EXHAUST FOOD OVMUC17
HAZARDOUS MATERIALS DISCLOSURE HOUSING MIT ATION FEE
Will the applicant or future building occupant stare or handle hamrduue material 1117NI'ING UNIT(ITL 100,00s)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,nod the Health and Safety
Code.Section 25532(e)? HEATING UNIT(OVER 100,000,PTU)
E]Yes on
" VGNI'11,ATION PAN(SINGLE RCSID) PAID
Will the applicant or future building occupant use equipment of devices which are ReM t#
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COM('OHP OR IW,mO BTU) TAL:
DieWn?
C]Yea BOILER-COM P(OVER 10,00 BTU)
�j'n
I have read the huuJous materials requirements under Chapter 6.95 of the Cali. AIRCONDII'IONER ISSUANC E
brain Health Safety Code,Sections 25505,25533 and 25534,1 undmend mut if the NEW RESIDENTIAL MECH. SQ,FT.
buildingil 1 tenant,that it is my mspomihility ramify the osc m
of theJ rents out be met priarm issuance Ccnifjl o' c.
✓� O(/
O c rani thon� Date TOTAL: ISSUED BY:
OFFICE