28554 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ass ten ^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L}l!7 rVs lJ�L
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL
,_77x3 un+( J e Z n• ' q^
OWN�iR"NAME: PHONE ry C NTRACfOel NAME ,L }.IC NO:
YQ n .15 3— ?9It D pi `o:�s?i-, NIC CONTROL N
ARCHITECT/F:NGINEEW LIC NO: ADDRESS: S3-� W IC 1 ❑
�a QIY131'w� - `
CONTACr: Q —PHONE: BUILDING PERMIT INFO
�I fir `�2115 3 / (•� b s'� ❑ Consullant Fees Paid by Applicant(Initial) .2LIJQ ELECT PLUMB MECH
❑ ❑ El
EE
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT F
I hereby affirm that I am licensed under provisions of Chaper 9(commencing JOB DESCRIPTION
�0p with Section 700n IT Division Sof the Business and Professions CodganJmylicenseis PERMIT ISSUANCE RESIDENTIAL
CWF in oil tom,and effect .63')J�
U License Clasq�� Lia.p ❑SFDWL ❑KITCHEN REMODI
HQL Date 7 Contrac�CoAs +C .Ila APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIP
p.Dm ARCHITECrSPYCLARATION PANELS ❑MULTI-UNIT QSTRUCfURAL
Z p Z I un ccs nA Inns shall m s ublic records MODIFICATION
024- UPT0 2M AMPS
ul LmrnuJP a oast ❑INTERIOR ❑CHIMNEY REPAIR
201-I WOAMPS
OWNER-BUILDER DECLARATION PROVEMENT
C 5556 I hereby ffimt that I um exem t from the ConvactnYs License Law for the OVER IOW AMPS TH REMODEL(REPAIR
y u p ❑DEMOLITION
K3 CU.U following mason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER,
YI V.y which mquircx a permit to consumer,alter,improve,demolish,nr repair any swears
prior to its issuance,also requires the applicant for such permit to File a signed statement
SPECIAL CIRCUIT/MISC.
W Gthat he is licensed pursuant to the pow isiunamor
s of the Co rr 'x License Law(ChapIm9
WapO (commencingwish Section9(NXB of UivisionJol the Business suit Professions Code)or TEMP METER OR POLE(NST. COMM .R IA
d ca that he is exempt therefrom and the Foods for the alleged exemption.Any violation of
I� Section?031.56 ❑NEW BLDG/ADDITION ❑DEMOLITION
y any applicant for n permit subjects the applicant m a civil penalty of POWER DEVICES
} not mare than five hundred dollars($500d. ❑TENANT ❑FOOD SERVICE
E=C ❑],,is owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F- will delta work,mothc.amcmreisnm imenledoroffcredforoale(Sec.90L1.Business ❑OTHER
Wa 3 m and Professions Cale:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or impmves thereon,and who does such work himself or through
his own employees,provided that such improvements ace not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.IL however.the building or improvement is sold within one yearofeompletion.the SQ,FT.FLOOR AREA $/SQ.Pr.
owner-builder will have the huNen of proving that he did not build or improve for pur-
"se of ole.).
❑ 1,as owner of the Front am exclusively Contracting with licensed mmtmcrors to TOTAL:
amnrier the Project(SCC.9040,Business and Professions Cade)The Contractor's Li. A
Cease Law does not apply loan owner ofpmNny who builds orimproves thereon,andQTY. PLUMBINGPERMIT FEE 4who Contracts for such projects with a conuactons)licensed pursuant to the Comraeona ��� �®
License Law. YERFIIT ISSUANCE,
I am exempt under Sec. ,B&P C fonhk reason f/
ALTER-DRAIN&VENT-WATER(EA) i
Owner Dom "/Vh VALU{Yj�]N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
u 1 beach,affirm under pcnahy of perjury one mine following dcclamtions
�L7 l havemad will didetain.Cenificale villa...at rose!(-insure for Worker's CmnpCa- DRAINS-FLOOR,RODE AREA.COND. ,STORIES //ti /TYPE CONSTRUCT(
s onion,as provided for by Section 3700 of the Labor QMc,for the Performance of the
wor for which this permit is issued. FIXTURIS-PER TRAP
I have and will maimam Workers Compensation Insurance,us reyuiretl by._on
?00tafthelrWr CudgfmthepeAornanctof Iclork for is permit ie issued. GAS-EA.SYSTEM-I INC.O OUTLETS
My Wmkacr�Cpm tionI mru + and Pnlic 1• OCC.GROUP APN
Onrricr: /"fYI C Iti uvJ�e Polic I �9� GAS-EA.SYSTEM OVER O(DO
CERTIFFCATEOFEXEMPrI FROMWORKERS'
COMPENSATI INSURANCE GREASE/INIIUSTRL WASTE INTERCEPTOR
phlssection neMnmbewmpl iftly,a,mitisforoachundrcd Jo artOIW) BUILDING DIVISION FEES
ar
loss.) GREASE TRAP
I troll that in the PLANCHECK FEE
y pe aneeofthe work for which thispennit is iss ed, SEWER-SANITARY-STORM EA.204 IT
not employ anypeao m rymannerso asmbec�me subject Workers nmpen- ENERGY FF.E
2 capon laws of Caif otos Dam
r Q Applicant
WATER HEATF,R W/VENT/ELECIR GRADING FEE
Vj
NOTICETO
CAWeWorkcf.afmr making this Certifieme of Exemption.yt should WATER SYSTEM/TREATING
a become ambjat m e Workers Compensmimn pro 'cions of the I,atom Cale, a mon SOILS FEE
{IJ 1'onhwith comply ith such proviseTtit Tperm chat!be Jeeme�J.
Q WATER SERVICE
CO STR IL A Y ^ NEW RESIDENTIAL PLMB. SQ.FT PAID
7 Z (hereby Mn 0 t n ender �ya!(^�]�. Ilvth K✓ ve of
the work for w nth th s eJ(Sec B g 1y - Dam Receipt M
Lenders Nam
U Lerde/s Add C, ts_ ij TOTAL:
ip�,� 0 1 sen y(hot 1 have oil this application and noemcee the above informant,is L. BUILDING ME
h c."I a to comply with all city and county o and sum laws relating m QTY. MECHANICAL PERMIT FEE
z
building Co nrumion,and hereby amhorize retains olives of this city to enter upon the SEISMIC FEF,
above-me cooed pr.Peny for Inspection or a PERMIT'ISSUANCE
(W )agmr to.save,indemnify and cp htrnlesa the City of Cupertino against - ELECTRIC FEE
liabilities,udgments,costs unit experts hick ntay in any way accme against said City gL'1'ER OR AUD'rO MECH.
in toner,enmof the germing oft permit PLUMBING FEE
APPLIC VT UNTIERSTAN D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO IO.fKKI CFM)
EGULATION MECHANICAL FEE
/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCIONTAX
S' oat ofAppliceHAZARemr ate EXHAUST HOOD(WMUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant orfuwrc building mcupant nom or handle hazardous matttial HEATINGUNIT(TO IOO,WO BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Section 25532(.)9 EHEAINGUNR,UNIT(OVER 1 W.OW BTU)
F1 Yen ONu
FAN(SINGLE RESID) PAID
Will the applicant or furore building occupant use equipment or devices which Date Receipt M
emit huwrdan,air comeminams ass defined by the Bay Arta Air Quality Management P(3HPOR 1x,000 BTU)Diarst❑Yes ❑No NE(OVER I W,0o0 BTU) TALONERI nave mad the Cels, uc m rs,255 requirement ander .1 and res of the Cwi. ISSUANCE DATE
tarots g althdoes&ScurryCak,e a tens 8505.8AJ and 25530.I to notsundthatifthe TIAL MECH SQ.Er.
buildingdocsmits currently have.tenant,that it ismyce of.ibil0ymnotifyare cc'ant,occupant
of the rryuircment which must bo ma prim m issuance of a Certificate of(kcuponcy,
Owner or authonzed.gem Dam TOTAL: ISSUEDBY:
OFFICE