28943 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. w
BUILDING DIVISION APPI.ICATIONIPERMIT PLUMBING-MECHANICAL' �{l
BUILDING PROJECT IDENTIFICATION
117
A4 16 SSANITARY NO. APPLICATION SUBM.f�IIVIAAL
DATE
1�oo 46 1 nic
ow �i4O{7yByIt- T' NTRAT § 6i: ,nCl/ LIC�� SIC CONTROL pSfMTO7 ` 6`- J
ARCNI'1'ECI'/IiNGINEGR: LIC NO: M mSS:,n �_ Lg'1JY/VAI/�. / /�O �� 1 ❑
CONTACT. PHONE: !�- N BUILDING PERMIT INFO
❑ Consultant Fns Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH -
LICENSED CONTRACTOR.DECLARATION TY HLECTRICPHRMIT FEE
1 hem-by affirm that I um licensed undo provisions of Chapter 9(commencing JOB DESCRIPTION
,Q„�Z with Seainn]IKK) fDivision3ofthe B.1m1,x;1 r.. s.' s C�armylicvmu1.' RESIDENTIAL:
QQ in full force and t PERMIT ISSUANCE
til 0SFDWL O KITCHEN REMODEL
<rJF Li, ise[ O Lic.p APpL1ANCES-RESIDENTIAL ❑ADDITION 0 PLUMBING R&PIPE
Contreaor _
7y A CIIITECI-S DECL ATION 0MULTI UNIT ❑STRUCTURAL
y p '� 1 undcrsmnJ my plans shall M1e uied as pubic tucoNs PANEfS - MODIFICATION
QZ-
(: , UP70200AMPS ❑INTERIOR" GCHIMNEY REPAIR
Licensed Professional
y� E OWNER-BUILDER DECLARATION 301.1(x0 AMPS IMPROVEMENT
y I hereby affirm that 1 am exempt from the Cm armwex License I.esv(.,,be OVER 10(10 AMPS 0 BATH REMODEUREPMR 0 DEMOLITION
iC Q 6 V following mason,(Section 7031.5.Business and Professions Coda:Any city hcount, SIGNS ELECTRICAL OOTHER
W C which renames a permit to construct,alter,improve,demolish,or repair any structure
priim to its issuance,also requires the applicant for such Permit o lilt a signed stmeme.t SPECIAh CIRCUIT/MISC. �—
�y�ynn�Iy that he is lice ad mountain to provisions mile Contractor'.License Law(Chapter 9 COMMERCIAU
Cep (commencing with 3ehian7(0(Ipd Division 3.(the Harare.and Professions Code)st TE-MP.METER OR POLL INST.
a�e C that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
Vii Section 10715 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
.nom TE NT ❑FOOD SERVICE,
z not more Nan five hundred dollars(5500). I OVEMENT
O Ol,as owncndthe property,or my employees with wages as their sole enmpensalinn, SWIMMING POOL ELECTRIC
will do the work mal the swchma is not intended nr offered fnrs.le(Sec.7094,Business ER
W and Pronfin jam Care:The Character's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
�' pmpeny who builds or improves therton,end who Jrxs melt work himself ar duough
his own employees,provided that such improvements arc not intended or offered For NEW RESIDENTIAL ELECTR SQ FI'.
RZ
sale.If.however,the building or improvement is sold within one year ofcnmpletion,the SQ.FT.FLOOR AREA 3/SQ.1a,.
owner-builder will have the burden of proving that he did not build or improve for our.
pose M sale.). s
El 1,as ownern(rhe property,.m erclueively contracting with licensed comments to TOTAL: J
corcurrat the project(Sec.7044,Business and Professions Cale:)The Contractor's Li-
and.Law
i-and. aw does not apply man owner ofpmpedy who builds orimprove.rhetmn,and QTY, PLUMBING PERMIT FEE
who convects for such projects with a conuecmgs)licensed prruantIn the Commences w 1
License Law, 0 19
0 l mrcxcmpt under Sec. ,B&1'C for this rens,. PERMIT ISSUANCE 98
Owner Data
'ALTER-DRAIN&VENT-WATER FA) "s'!-�,r r VAI,UAI'ION
x .
WORKER'S COMPENSA'T'ION DECLARATION BACK FLOW PROTECT.DEVICE �'V
I hereby affirm under penalty of pepury one of the following decimations:
O lhaveand will maichim.Certificate of Comentloself-insure for Workers Compen- DRAINS-FLOOR.ROOF,AREA.CORD.
since,as provided for by Section 37M of the Labor Crate,for the performance of the STORIES TYPE CONSTRUCTION
work Tuve ch this pamii is issued. FIXTURES-PER TRAP
and old mmmal.Wnrka'a Compensation Insurance,ns uacm rd by Sestio.
3700o°ftthe LdNrmm Cm1a,,ficutlhhe�p�eerrtficrpsmcannccee(apC tthcwnrk frrAhhiicshtthii�s permit is issue d. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
MyW ` �r 4L-�tcyblr%: C=/ GAS-LA,SYSTEM OVER 4(FA)
Crtc
CERTIFICATEOFEXEMPI'ION FROM WORUI'RS'
COMPENSATION INSURANCE GRFASE/INDUSTRL WASTE INTERCEPTOR
('this seaJon meed not he amat laedf
iNe lwnnlfort is u.ehundred dallms($100) BUILDING DIVISION PEES
GREAS
or less.) E.TRAP
PLANCHECK FEE
I eerily that innhe perfansmnceofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person to any manner re as to become subject w Ne Worker'Compcn- ENERGY ITS
Z sal on laws of California.Date WATER HEATER WNENT/ELECTR
Z Applicant GRADING FEE
NOTICEID APPLICANT:If.Mir nuking his Ccnificate of Exemption,you should WATER SYS'1'C:M/TREATING -
[+ become subject to the Warker's Compensation pravaunne of the labor Gale.you must SOILS FEF,
forthwith comply with such provisions or his permit a hall be deemed revoked. WATER SERVICE
Q
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMSQ,FT. PAID
V n O.I hereby affirm that is a conswenion lending agency for the performance of Dine RcceiptM
{L lF:-yt the works which this permit is issued(Sea 3097.Civ.C.)
Q U lender's Nmnc TOTAL:
Lenders Address ,TOTAL:
y1 candy that 1 have mail this application ministate stmt the above information is s BUILDING FEE
ZI chose.I agree to comply with ell airy and countyouli...ces and state laws relatingro QTY. MECHANICAL PERMIT FEE
building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(W.)agree move,indenand,and keep trunks,the Ciryof Catania.against PERMIT ISSUANCE ELECTRIC FEE
Iinbilities,judgments.costs and expenses which may inunywayaceturagaireasald City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence suence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO 10,00)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signntureof ApplicanUCommaaf Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant or future building wcipantnore orhandle hamNous trmmrial HEATING UNIT(TO 100,000 HTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320)? HFATING UNIT•(OVER 100,000 BTU)
❑Yes ON.
VENTILATION PAN(SINGLE RESID) PAID
WIII the applicant or future building occupant use equipment nr devices which Dole Reuip H
•emit hrrommus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 110,(00 BTU)
DistricC TOTAL:
�I 0Yes 0No BOILER-COMP(OVER I00,00l)BTU)
AIR CONDITIONER
I have rend the herallousmnterialrm irements under Chapter 695 of the C.li- ISSUANCE DATE.
torn;.H Ith Sudety Curb.Sections 2550 25533 trod 25534..1 understand that if the NEW RESIDEM'IAL MP.CH. SQ.PT.
hu' dr rot cure is huveutvnum h it.vny re w' ilirym tify the occupant
t th n' eat 't (Occupancy.
an
II s mbnrizcJ 6cnt Drs¢ _ TOTAL: ISSUED BY:
OFFICE