28880 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. n O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRF.SS. p - - 'SANITARY NO. APPLICATION SUBMITTAL DATE
C CT-. Cjft-crNt) (4 a I (6-16 fly,.
IF OWNER'SN Ly!,`1 PHONE: / CONT CORDS NAME LIC NO
1[7 �OhFd2S'� R&iC (,i/••�'2r1O NYC CONTROLq
RCHffll- /ENGINEER: LIC NO: ADDR):SS�_ jO �WV�s J^ SAO ❑
' IWC-/ D SAO
/ CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) ' BLDG ELECT PLUMP MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby affirm m
that Iain li red under provisions of Chapter 9( mm
eae�aing JOB DESCRIPTION
' a9Z with Section]000)af DivisionJofthe Businessmtd Professions Code,and my license ie RESIDENTIAL
O PERMIT ISSUANCE
F0.-Iy r• in full fake and affect. (,•1. '3 O ❑SFDWL ❑KITCHEN REMODEL
FU tj�� License Clays Li,#
yQ0. Dete C.inmcmr APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
Dm ARCHITECTS DECLARATION .[]MULTI-UNIT ❑STRUCTURAL
Z O rad r' 1 understand my plans shall he used as Public records PANELS MODIFICATION
'OZ— - UPTO2WAMPS ❑INTERIOR C1 CHIMNEY REPAIR
Licensed Prossimnal- - 20I-EXIOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
py�d,W 1 hereby affirm that I am exempt from the Contractors License Law for the OVER 1000AMPS ❑BATH REMODEUREPA ❑DEMOLITION.
Y706U fallowing reason.(Section 7031.5,Business and Professions Cade:Any city ear county SIGNS ELECfRICAL (]OTHERY]LL O which mat ims o permit to conswm,aline improve,demolish,or repair any swcture
priors its issuance,a iso rtpmear Ncapplicmt far such permitto Elea signed statement SPECIAL CIRCUIT/MISC. a
ythat he is licensed purnmal1.the provirkmam In Connectors License Law(Clarinet 9
p QO (commencing with Section?1100)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: '
a yy c C no he is exempt therefrnin and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
he w Section 7031.5 by any applicant fora permit subjects the applicam too civil penalry of POWER DEVICES []TENANT 0 FOOD SERVICE
a ZY hat mora thanfivchundredclollars(E500). I IMPROVEMENT
< 0 Losinvem.fthepropeny,army emplvyecs with wages as their sole compensation, SWIMMING POOL ELECTRIC
O will do the work,end thestmcmre is not intended oroffcad for side(Sec.]B44,Business []OTHER
3� and Professions Cade:The Connector's License law does hat apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who bonds or improves thereon,and he does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the buildintim improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur. B- A 6
EI pose of sale J. .
1,ns owner of the pmpenY•inn exalusivelY nsmmcting with littnae cnnwctors m
construct the project(SIL.]014,Business and Professions Code:)The Commonrs Li. 6 Q •1f 95
cense Law does ect apply to an owner of p ny who It Ids or improves thereom en l TY, PLUMBING PERMIT FEE OCT1 {/ I v7 v7
whoconunets forsuch project with Ismatm. r(s)licensed pursuant to the Committers /s
License law. - PERMIT ISSUANCE
m thi
- yI�-x,l l Ur Vul'tNIINO
O l aexempt antler Sec. ,B&1'C for s mason
Owner AUTER-DRAIN&VENT-WATER(EA) VALUATION ,
MS RICTION BACK FLOW PROTECT.DEVICE
I he. undmpc(a 'f r ry neDofthe ollowingdeelarudans:
flaveardwillm ' mna Cc'rf�. f m selBFLOOR ROOF,for Worker's Cotillion. DRAINS-FLOOROOF,AREA,COND. STORIES TYPECONSTRUCf1ON
scion.as Provided fa y Section]] of the IaMsr Code,for the performance of the -
work for which this permit is issue FIXTURES-PER TRAP
I have and will maintain Workers Compensation bica roma,as required by Section -
31W 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
My Work_e((a.C,o_mppeey t -ion Insurance carver and Policy
Cartier.
Al— M141((Ar�Wqr���rNPolicy No.:AMM ( - GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF[INCAUTION FROM WORKERS'
COMPENSATION INSURANCE GRLASF/INDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FIiFS
(This section need not M1e nsmpleted if the permit is forme hundred dollars($100)
con'..) - GREASETRAP PLANCHECK TEF.
I certify that in the performance ofthe work for which this permit is issues.)shall SEWER-SANITARY-STORM EA.2W FT.
not employ any Person in any manner air as to became subject to the Workers'Compen- ENERGY FEE
OZ. satin,Laws of Celi(omia.Data WATER HEATER WNENTIELECTR '
z 0 Applicant GRADING PEE
W NOTICE TO APPLICANT.If,after making this Cenificme til Exemption,you should WATER SYSTEMOREATING
abecome sub)ect nature Worker's Compensation Provisions of the Labor Code,you must SOILS FEE
4iI forthwith comply with such provisions or this permit shall her clamed revoked. WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPCMB. SQ.pr. PAID Date ReceitK
4.Q hereby which
Rrm thetmere istural(mction leading agency for the performance of P
0 mewars for which this permit is issaW(Sm.3N7.Ci¢CJ -
F" Landers theme TOTAL:
{U21 Lorders Address - TOTAL:
I minify that I have read this application and start thin the above information is BUILDING FEE
Ncorrect.l agree to comply with all city and county ordinances out state lows relating to QTY. MECHANICAL PERMIT PEE
. C.14 building construction,and hereby vuthodze reprtuntativesof thiscity or enter upirdin SEISMIC PEE
above-memioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree to save
.indemnify and keep harmless the City of Cupertino against ELECTRIC HE
(We) costs unit expenses which may in any way accrue against mid City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT:UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE PpGULATI(RJS.
\CQE DVJ\X 1t�. `I .CS AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCfIONTAX
I�- V O`I
Signal. o ppliaam/Connactar - Dao EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building acupam store or handle hazardous material HEATING UNIT ITO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
'Code,Section 25532bo? HEATING UNIT(OVER I M000 BTU)
❑Yrs �No VENTILATION FAN(SINGLE RESID) PAID
Data Receipt M
>\ Will the applicantor future building occupant use equipment or devices which
hazmJous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMPOHPOR Oft"BTU)
)swat? BOILER-COMP(OVER 100.000 BTU)
C]Yet �No
AIR CONDITIONER
1 have reed the havrdous materials requirement under Chapter o95 of the Cali- - ISSUANCE DAT
fomia HeWm&Safety Coda Sec tion.25505,25531 and 25534.1 understand mu it me NEW RESIDENTIAL MECH. SQ.PT.
boiling Jots nm turen0yhavea iters I,that it is my rc.ponsi514.1 to notify me mrmpdm
of the rruirements which man his met prior to isemme of o Contra.of Occupancy.
Owner or authorized agent Data - ISSUED BY:
OFFICE