28580 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.. CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT ND. 285
C H O
BUILDING DIVISION APPLICATIONfIERMIT PLUMBING-MECHANICAL
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BUILDING PROJECT IDFA'TIFICATION'
BUILDING ADDRESS: SANITARY NO. APPLICA/TON SUBMITTAL DATE
CU40 e7
OW ER'S� E: PHONE: COQ 'S A e�/� IC NO
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ARCHITECIIENGIN17ER: LIC NO: ADD 55: ❑
CONTACT:" PHONF,: - F BUILDING PERMIT INFO
-�uv� ❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLU 1B MECH
ID ❑ ❑
LICPNSED COMRAC'[OR:S DECLARATION QTY. ELECTRIC PERMIT' FEE
1 harsh, from that I Am haamed under providom of Chapter 0(commencing JOB DESCRIPTION
wotth Section A100)of Division 3 ofthe Business and professions Cade.mid my license it RF- ID NTI
F,1O in force and cf t. PER MI'f ISSUANCE
AA�
% F ❑SFDWL - [:1 KITCHEN REMODEL
FQF--U U Liccme a Lic,x -
rn6a Dam Cnnlractnr APPLIANCES-RIiS1UENTIAL C1 ADDITION O PLUMBING RE-PIPE
F.�w ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O Z 1 innervated my plane shell be used as Public reemrds PANELS
MODIFICATION
O7.-'M - UP'f021y1 AMPS
F-4F'LLI Licensed Professional C1 INTERIOR [I CHIMNEY REPAIR
101E IMI000 AM IMPROVEMENT
E 0 W< OWNER-BUILDER DECe Contractors
ON OVER I(qO AMPS C1 BATH RF,MODBI/REPAIR O DEMOLITION
Q L hereby a/firm that 1 am exempt from IM1e Conv.aor's Licenxc taw fnr the
K 31 O following rwxan.(Section 7031 5,Beol eve and Professions Code Any cily lir maoty SIGNS ELECTRICAL ❑OTHER
W LL O h which requires u permit to construct,alter,improve,demolish,or repair Any structure /J
Fs Q prormi.ixmance,Alan rcyuimnhcopflient for such permitto file.signed statement SPECIAL CIRCUIT/MISC.
6F that he is licensed pareuenno the provixionsofdo Contractors License law(Cnapler9
'ho (cmmerneng with Section 700(ol 1),vision 3ofthe Bmio.olnd Profexsions Code)or TFAtI'.METER tIR POLE INS3', OMM .R IA '
a ly c C that he ix exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
M_o" Section 3031.3 by any Applicant fm a Permit subject de Applicant)a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
dol more than five hundred dollm(S5W). IMPROVEMENT
56 01,as owner of the property,or moploym,with wages as their role compensation. SWIMMING PO(eI.ELEC'T'RIC
1-2 will do the work.and the nmence I%not imcndcd or offeml for safe(Sm.70,14,Business ❑OTHER
3 m and Professions Cade:The Contactors License Law does not apply to.n owner of OUTLETS-SWITCHES-IIXT ES
po lcrty who builds orImprovesthemon,and who does such work himself or through
hie own.niployees,provided that such improvement arc dol Intendel in offered far NEW RESIDENTIAL ELEC'IR SQ FT.
sale.If,however,IM1e buildingurimprovement ix sold within one year ofcompletion,Ib< SQ.IT.FLOOR AREA SISQ.FT.
owner,builder will have the burden of proving that he did not build or improve for put-
prose ofsala).
0 1,as owner of the properly,ten eaclesivcly cool ofeling with licensed contracture to IOTA
colonel the pmjcel(Sec.31M4,Business and Professions Code:)The Contractor's Li- � ' ^
ccn=law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT L/
who contmeu for such project with a comma ods)licensed pursuant to Inc Contmmr's
License Law. PERMIT ISSUANCE E'p 12
[:1Tem exempt under S ,P&PC Bn th
ea is rescan
ALTER-DRAIN R VENT-WATER(EA)
Owner Date ALTER ,A&LUATI
WORKER'S Co MI'17NSAFION DECLARATION BACK FLOW PRO]ECT DEVICE �.�1'�/�H��NU
1 hereby affirm under Penalty of pequry one of the following declaturnmV V
❑I have and will maintain a CedificateofConcent to self-insure for Workers Compcn- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTION'
cation,as provided for by Section 3710 of the Labor Cokc,for the performance of the
work Iia which This permit is issued. FIXTURES-PER TRAP
0 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700idNelaMr Code,(snhr�s cumene a,an
for I Irwwfnhqiiccrh this permit is iisuWl.. GAS-FA.SYSTEM-1 INC.i OUTLETS pCC.GROU1` APN
CarncoM,Wh on nu(P' is... Palley N,JbLCL '�F1 eI/�A `41 GAS-EA.SYSTEM-OVER C(CA) '
CEI. PIC ITE OF PXEMPf1ON FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
GREASE TRAP
or co.)(This section need not be completed if the permit is for one hundred dollars(311X1) BUILDING DIVISION FEES
I
PLANCHECK FEE
Toy anyshadeNe permanneenf the work for which this pared is irs Conch- SEWER-SANITARY-STORM EA. FT.
not employ any paten in any manner m as to become subject m the Workers'ComPcn- ENERGY FIiE
,0 Alton Lawn of California.Dae
z 0 Ap,lician
WATER 1113ATER N'/VF.N'T/EI,IiCI'R ori
GRADING FEE
zp NOTICE TObj APPLLCANP:LI;Compensation
this Certificate ofExemption,Laborode.y u must WATER SYSTEM/TREATING
a ; become subject to the Wwkcrrvini s his provisions ban of the labor Coke,you teas SOILS FEE
� forthwith mmiPly with such pmvirionr lir this permit xhAll M1e AamW revoked, t WATER S13RVICf?
7z CONSTRUCTION LPNI3INGng agony NEW RESIDENTIALPLFIB. SQ,FT. PAID
V k frw which
the them issce (Sea 0lending agency for the performancmf Data ReceiPtX
W ,tet. the work for which this permit is issued(Sec.311,7,Civ.C.)
Q [-t Tanner's Name TOTAL:
L) L rated Addtees TOTAL:
Fy I certify that 1 have read this application and nae that the above information is BUILDING FEE
to airmn.l agreemrnmply wlm all dry and ninety ordinancce and stere lows rnmting u' QTY. MECFIANICAL PERMIT FEE
V Z building constmetioo,and hereby authorize representatives ofthis city mentor upon the ~IC FEE
abevementioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We).,.a to save,mdemnify And keep h r mlcss the City of Cupemno Against - IC FEE
iebin „ilim,judgmctns,crostxend expenses which may in anyway ucerucagainst said City „U N
AI:1'ER OR ADD"f0 MECH.
nseyuence of the griming of this Pcrmn, PLUMBING FEE
APPLICANT U ' ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14003 CFM)
SOURC RE TIFE
O' MECHANICAL E
(fes AIR HANDLING UNIT(OVER 10.0CPM)
WCONSTRUCTION TAX
Signature of AP tceHAZARDOUS
AZA for I'/ 'Fins EXHAUST HOOD(W/DULT) HOUSING MITIGATION FEE
HAZAR W e building MATERIALS DISCLOSURE
Willy the Clpentnr futureiploe,cupantstemar huddle Health
nand Safety
HEATING UNIT('IY)IOO,WOBTU)
as ddincdio the Capcnina Municipal Cede,Chapter 9.12,and the Health and Salbty
Coda Section 35312(e)? HEATING UNIT(OVER 100,000 BTU)
{]Yes ONo VENTI IATION PAN(SINGLE.RES ID) PAID
Urate ReceiptA
Widths air coammfuture building ed bycupantuse equipment AirQuor Management
BOILER-COMP(3HPOR1W."BTU)
:mit haaatdoux air contaminants as def lied by the Pay Area Air Quality Management
Distract f TOTAL:
El Yes C]No BOILER-COMP(OVER 100,000 BTU)
I have read the h ae-Thms marards AIR CONDITIONER
r5.2553 And
mad fi95of the Celi- ISSUANC E
(milia Idth R Safety Cider Sections 23505.8333 and 2333J.1 u o...dynd that if the NEW RIiSIDIiNTIAI,MECH. SQ.FT. sa
Lending chem not a which hove A imam,thm it is ua reNif.Certificate
m ramifyoc aaeay.
of The rtgaimmenu comae niers he mm Adm m nirvana lir a certumme of(kcapancyy.
Owner m aummiaed agcm Dare TOTAL: ISSUED BY:
OFFICE