28932 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. L^ 8 9�S 2
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL VA JK
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'
7723 4,jaA-r .d c L.h (b^
OW E '. NAME: PRONE: CO ACTOR'SN L': LIC NO. NIC CONTROL4
W Z.5 & _T 1 �M M rvJio b3'110
ARCHITECIUENGINEER: LIC NO: ADDRIESS: ❑
Sha D i'ls i on Sfi-
CONTACT: PHONE: BUILDING PERMIT INFO
S m
Qens
Complainant Fecg Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED COMIRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE El
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
O0p with Sit 7")of])is Won 3ofba Bust«ss and Professions Code,undmy livens,is
in bit rate ante m PEKMIT ISSUANCE RESIDENTIAL
QUV Liccnu Cis b Licplik ❑SFDWL [I KITCHEN REMODEL
vFiQL Dam t Conmmtar APPLIANCES-RESIDENTIAI. 11 ADDITION ❑PLUMBING BITPIPE
A CTS DELL TIO:Q3µ COLI PANELS ❑MULTI-UNIT [I STRUCTURAL
ZOy� unJ my pl h sSdDECbli<rcconls MODIFICATION
OyFO .�/�1rN- UP rO 200 AMPS - El INTERIOR ❑MODIFI ATIONR
lessional IMPROVEMENT
201-I000AMPS
OWNER-BUILDER DECLARATION El BATH REMODEf/REPAIR DEMOLITION
d' 1 hereby affirm that I am exmnpt foto the Connectads Licume I.aw far the OVER IOW AMPS
MO0.U following reason.(Section]131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER 11-11,
3 LL F which requires a Penna m"all.t,nlmq improve,demolish,or repair Tiny structure
0� prior to issuance,also"aims the applicant for such permit Ole a signed statement SPECIAL CI RCUIT/4fISC.
z' a� that he is licensed pumuanno be pmvissons of the Commemes License Law(Chapter 9
I+I 00 (commencing with Section 7000)of Division 3 aftha Business and PmfessionsCodu)or TEM&MI3'TER(IR POLE INST. COMMERCIAL:
G C.c that he is exempt Therefrom told be bash for the alleged exemption.Any violation of El DEMOLITION
N Section 7031.5 by an applicant fore ❑NEW BLDG/ADDITION
FZP "'n more thin live hundred dollars(SSIXbnn subjects the applicator Penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE.
1.azowner of Nc property,or myji .
yecswiN agesas theirrvle compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
�,p.� wJ]do The work,and the structure is nado red Tarsale(Sec]0 ❑OTHER
nd Professions Cod :The Coibrowce se Jcea out apply he an owner of OUTLETS-SWITCHES-FIXTURES
Too who bills t a J s such work himself or through
his own earplo es, c( F pmvcosentx are not inpnled or offered for NEW RESIDENTIAL ELECfR SQ PI'.
sale.IL however, iv not pnwenmnt is said withn3��! (completion.rhe SQ.F..FLOOR AREA S/SQ.FT
,buildcr will has a bvnfen f s g e did dd r improve for pur-
posa of salc.), '
❑ 1,as owner of rhe p r my,am� sevely m ring wM hceosed summetors ro TOTAL:
imam Thcymject(Sce.7W.Bus Tint mfessions Code:)Ile Contested.l..
cense Law does not apply roan owner of property who builds or mprovesmcrem,and Q'TY. PLUMBING PERMIT FEE v
who contracts for such projects with a conrmemr(s)licensed pursuant to the Contractors Oct��
❑LicemrePERMIT ISSUANCE use law. , 95
]eexempt unJerSec. ,B&PCfor this ason s, �` (Jr 9
Owner Date ALTER-DRAIN h VENT_WATER(EA) `"4-r J/IVO VALUATIONS
WORKEk:S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE C
1 hereby affirm under penalty of perjury one of be following declarations:
❑ [have and will maintain a Cenifcale of Consentao self-insure for Workers Coriolis, DRAINS-FLOOR,ROOF AREA,COND.
tion,as provided for by Section 37W of the Labs Code,for the performa«e of the 1 STORIES TYPE CONSTRUCTIOI
work or which his permit is issued, FIXTURES-PER TRAP
Ja'I have and will maintan Worker's Compensation Imomntt,as equireJ by Section
37M of be labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS CCC GROUP
APN
My Workers Carylrtnsetion]nsumnm carrier and Policy�Wlp pyo
Cartier. �j F_ Policy No.: `L 11jY-9f GAS-EA.SYSTEM-OVF,R4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This.mcrion need not be completed ifrhe permit is fornne hundred dollars(SIDO) BUILDING DIVISION FEES
or less.) - GREASEIRAP
I certify Nat in the perl'onnanca oft he work for which y this t is issued,Iaholl PLANCHECK FEE?
not employan Penni SEWER-SANITARY-STORM EA.2W FT
parson in any manner so as to Meatus subject ro be Workers'Compete ENERGY FEE
ZArmon Laws of Cali[Umia.Dam
z O Applicant WATER HLATF,k WNENI'/ELECTR
GRADING FEF.
.Nr NOTICE TO APPLICANT.Worker
rs after Compensation
this Certificate of Exemption,you y ushouldmast WATER SYSTEM/1REATING
a 1 hecnmc subject to the Wnhpro Cons or This provisions of e thetabu Code,you must SOILS FEE
W [ forthwith comply with such provisions or This permit shall be deemed revoked. WATER SERVICE
aQ
5z CONST RUCTION LENDING AGENCY NEW RES]DENTIAL PLM B. SQ.FT, PAID
JO l hereby affirm that there is a construction lending agency for the performance of Dam
ry P be.,k for which this Permit is issued(St 3097,Civ C.)
O U Ledla',None
Lender's Address AL:
} y 1 family that I have read this application and state that the above information is
(~ BUILDING FE
Z) correct.1 agree c comply with till city and county nrdiwtcea and site laws relating a QTY. MECHANICAL PERMIT FEE
U z iflawingconsnucriou and hcrtby auNome¢prtsematires Units city neater upon the SEISMIC
oMve.mceionW pro save far inspection keep cs.
(We)agrees,save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRI
Iia consequence
costs and of thi,expenses which bay in any way azcrvc against slid City ALTER OR ADD TO MECH.
inam.myuNT Uf thegranting of thisD WILL
PLUMBING FE'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT CFO[0,000 CFM)
SUU EGULATIONS. \^I 1AI MECHANICAL FEE '
IA� /( /-x- AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION nX
Sig w fApplicaaVContmoor � rr r Drift /l EXHAUST HOOD(W/DUCT
HAZARDOUS MATERIALS DISCLOSURE HOUSINGMITI ATION FEE
Will Ne applicant or fumm building«cupam store or handle hanallous materiel HEATING UNIT(TO I10),000 BTU)
as defined by the Cuponina Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)? HEATING UNIT(OVER 100.000 BTU) _
❑Yes '<No
VENT ELATION FAN(SINGLE RESIDj PAID
Will be applicant or future building occupant use equipment or devices which Dam ceipr p
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU)
Disnin'!
0 Yes BOILER-COMP(OVER IM."BTU)
]have mud the havudous mamrials mquimmems under Chapter 6S5 of the Cali- AIR CONDITIONER
forma Heab&Safety Cale.S«tions 25505,25533 am125534.1 undersudi Thu if Ne ISSUANCE TE
"gdiesnatriorm yh t at.Ihu it is myrespnnsihility to nniify rhe occupant NEW NESIDGNTIAI.MECti. SQ.FT
The uiremcntswbicIt t priortoisuance if
Certificate( Core ant
0 I
(I net authoriaW tgcm Dare TOTAL:
UED BY:
OFFICE