28884 (2) APPLICANTTO FILL IN INFORMATION WITHIN FEED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ ate
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L l8 }V(
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
63 n Post 8 S5
OW'tR'SN PHONii: CONTR CI'OR'$NAMIi: (ems LIC NO'.
N X57- 25 �er S Il NIC CONTROL[
sit
ARCHITEC7VENGINBER: LIC NO: ADDR12SS I ❑
COMPACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPL MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alum that 1 nm licensed B.ander paWsbmt of,Crxh. 9(commencingsis JOB DESCRIPTIO
WO, with Seclinn 700(hof llivicionlof lheBminess unJ Profession,ECJ),nnJ my license is RESIDENTIAL:
F in full tome and effect. PERMIT ISSUANCE ❑K TCHIiN REMODEL
a�kFi Licen.veG,ect L;),» 6 WO 1? 1 0SFDWL.
F z Dale Conll o• 4 r VS APPLIANCES-RESIDENTIAL []ADDITION IMF
REPIPE
F,Dm ARCHIE DCPS DECLARATION YY ❑MULTI-UNIT ❑STRU TURAL
z p n Z I understand my plans shpublic be used as records PANELS
MODIFICATION
Oz—Q UP TO 2IXIAM1'S ❑INTERIOR ❑CHIMNEY REPAIR
M1- .4 Licensed Palcssiamel 201-1100AMPS IMPROVEMENT
.4 atIr,OWNER-BUILDER DECLARATION OVER 1000 AMPS D BATH REMODEI/REPAIR DEMOLITION
C� �
Q 1 hereby off roc that 1 em exempt from the Contractors License Law for me
Sd a L F following reason.(Section 70315,Ilusinass and I'rnfoxeinne C dc:Any cily ar county SIGNS ELECTRICAL 0OTH17R
YI LL.y which requires a permit or come,qN ellen improve,demolish,or repair any almmurc
in.,heslcensed pursuant
toils,theapplm, f,hawchperminoicensa gne(wnamem SI'ECIAI.CIRCUIT/MISE.
EC2�V(} (commencing wit pursuant loth)of visions of the a Brontors Licaneehw(s Code)or
(commencing with Section of Division of he Bucin)ssand Professions CnJe)nr TGhfl'.MF,'I 17R OIL POLE INST. OMMER IA
d d that he is exempt therefrom and me basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
K^_to Section 703 L5 by any applicant for a parrit subjects the applicant)a civil Penalty of POW17R DEVICES
ot - ❑TENANT ❑FOOD SERVICE
pN, nmom dean five hundred dollar,
F�Q I.as owner of the n IMPROVEMENT
E ❑ [rope y,remyamntended with for sale
Business
SWIMMING POOL ELECTRIC
Cie will Jolhewons node:The maranmmmnense Law roffieresi
not apply toamouner os ❑OTHER
L 3 erd Professions Gdc:The )so, ors and who
law Jac.not apply R,an owner of OUTP,ITS-SWITCHES-FIXTDRE$
his own who builds ar sided th thereon,and vem does such work tied o f or Through
his.If. employees,pmvidW that such improvements are ern intended or offered for NEW RESIDENTIAL ELELTR SQ IT.
sole.If.uilderhowevill have
human
an ofpumcnt is at h within ora build
or i nnovs,drourn, he
par, SQ.Pf.FLOOR AREA 9SQ.PI'.
0 sofbuilder will have rhe buNen of[raving the he did not build or imprm'e for par,
1 cl rale.),
1,as...or of the Saopimperty..B cxdus unit enntmcting with licensed)I hCconuonors i- TOTAL:
ttmtlmcl N)pntjal($co.7(H4.Business and Pndectinm CaJCJ'PM1c Cnnrnn7or's Li-
cause Law does not apply to an owner ofpn)Nny who builds or impmves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contracwr(s)licensed pursuant o the Contrnnor's
License Law, PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for reason.
Owner Data
ALTER-DRAIN F,VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby./firm under penally of perjury no of the following Jedardlans:
❑ I have and will maintain a Certificate olcoment to scllimsurc for Worker's Comper. DRAINS-FLOOR.ROOF,AREA,GOND.
section,os provided for b Section 3710 of the Labor Cede,for the STORIES TYPE CONSTRUCTION
y. perfonnancc of the
work for which Chit panniis orker PI%TURES-PERTRAP
❑1 have and ...Code fo,Workers Compensation ccolthw rk in,,which
h his and by Section
J My
Lubin Cane fi the perforntance of the work forwhich elite permit is issued CAS-1iA.SYSTIiM-I INC.40U'TLETS OCC.GROUP APN
My Worker Com1p'�$nwtin rand Policy nu Is, q
@men— GTr Igccartrd'olicy 0:711 {Sgc7�%S GAS-lit.SYSTEM-OVER 4(H,A)
CERTIFICATE OFF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASrANDUSTRl,WASTE INTERCF,PIY)k BUILDIN VISION FF:F_S
(This section nicd not be completed if the permit is for one hundred dollars($100)
or leas.) - GREASETRAP
1 cenify that in the Performance of the work for wEach this[)emit is issued.)shall I'LANCHEK FEE
nm em In any lrecam in an SEWER-SANITARY-STORM EA.200 FT
p Y e ,kciecnn the Wnrkcis Contpctt- P.NERO PEE
r� salon Laws of C]. ' w
z O Applfcam [J ` WATER HEATER WNENT/ELF,Crk CRYING FEE
(A NOTICE TO C NI.IL aper making this G fate of Exemption,you should WATER SYSTEMO-REATING
a � become subject to the Workers Compen.auun provisions of the labor Code,you muse 1L5 FEL?
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
Pati- z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U t herebychfla t prom,
is.
sued(Seo.30 len Jing agency for performanreof ae
� f' the work for which this pennfl is issued(Sec.JU9].Civ.C.) '
0 U L<Wer's Name TOTq
Landon Address U I
yI archly that 1 have read this application and.tam that the above information is BU P,N I' .
0 aenecn.I agree to cmnply with all city and county ordinance.antistatic law,relating to QTY. MECHANICAL PERMIT FEE
C.) Z building contraction,and herehyaudeone,representatives ofthisclty loenterupnn the
shove-mentioned prapeny for inpCctinn purparcc.
(We)agreeaesave,indemnify and keep harmless the City of C.,mirm against P17RMIT ISSUANCE EL CTRPC
Iiabilities.juJgmems,costs and expanses which may loony way acme agalntl.said City AL'IERORADDTOMF,CH.
consequencein of the granting of this permit. PULP INC,FEE
q CFM)APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,gFM) h1ECHAN AL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10t00CFM) CONSTkT o', AX
Sfgnaluaof ApplicanVConttnctor Date EXHAUST HOOD(W/DUCP) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
ac defined by the Cupenino Municipal Csde,Chapter 9.12,and the Health and Safely
Code.Station 25532(a)' HEATING UNIT(OVER 110,100 BTU) CT ��,
[3 Yes E]No
VENTILATION FAN(SINGLE RESIDE � PAID
Will the applicant or future building t use equipment Data Rll pt»J
pp gbymen qui nen)lity Management
/sf-r„
emit hazaNnuz air contaminants es depned by Nc Ray Arca Air Quality Management BOILER-COMP(3NP OR 100,000 RTU) - ) V(-
District? BOILER-COMP(OVER 1010,000 BTU) VUf*gtrA ,
❑Yes ON.
I have read the hmmomv mammalsAIR CONDITIONER
rcyviremcnm under Chapter 6.95 of Cali- ISSUANCED TF;
formaHealth& y Cn I,.Sections 25505,25513 and25534.1 understand then It the NEW RESIDENTIAL MECH. SQ.PP.buildidyhavoItbiella Man,r'y otmaneC ora eenir)ara /ll( r ng n / ,II:d, TOTAL: ISSUED BY:
' OFFICE