28469 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY' -
CITY OF CUPERTINO BUILDING-ELECTRICAL. - - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. " 28469
] O /14 v C�,
BUILDING PROJECT IDENTIFICATION G o
1 LDINGAUDRESS: -. SANITARY NO. APPLICATION SUBMITTAL DATE
O ER'S NMF.: f PHONE: ygRACI'OR'SN LIC NO:
C IfM1Y x NIC CONTROL Is
a
ARC IIECIANGINEER: .IC NO: pDRE
CONTACT: PHONE: BUILDING PERMIT INFO
Q,Consultant Fees Paid by Applicant(Initial) BLDG ELECT B/�E.UMR$ MECH
LICENSED CONTRACTORS UICIARAI ION O • ❑
1 h rte thereby all that 1 licensed d provisions of Ch lc )( cna n QTY ELIE(TRIC PERMIT'. FEE ..�
r s JOB DESCRIPTION
WiYx with llfro ndN)ofDivision a fihe Business unitP foss a sCtsde uJm license is
O � y PERMIT ISSUANCE+ �• '� RESIDENTIAL: '
in Tense am CRecI' ❑SITYM. El KITCHEN REMODEL
'NV License Clam Conn APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Dote - Connector
E, ARCHITECTS DECLARATION PANELS - ❑MULTIUNIT ❑STRUCTURAL
Z O a Z I undemand my plans shall be used as public records MODIFICATION
OZ UPT02W AMPS El INTERIOR '❑CHIMNEY REPAIR
.��,I".,W Licensed Professional 201.100DAMPS - IMPROVEMENT
Aw2dOWNER-BUILDER DECLARATION ,
yy ce 6 1 hereby affirm that I am exempt from the Comm"or'a License Law far the OVER 1 WDAMPS C1BATH REMODEUREPAIR C1 DEMOLITION
b<0 W V'following mum.(Section 7031.5,Business and Pmmunce,Code:Any city or county 'SIGNS ELECfRICAI. ❑OTHER
Ya11 LLE which requires a permit ro consttuc6 alma improve,demolish,or repair any structure
E..I�O prior to its issuance,also requires the applicant for such permit o rile asigned statement SPECIAL CIRCUIT/MISC.
fa. } that he is licensed pursuant to die provision of the Con.emr'a License Law(Chapter 9
W GAO (commencing with Section 7000oof Di vision J of the Business and Professions Coda)a, TEMP.METER OR POLE INST. COMMERCIAL:
el' a thoI he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
SeTinn 70315 by any applicantf apermt subjects thet it pc ll,of POWER DEVICES
m ❑'TENANT ❑FOODSERVICE
EFFF.... nuI itsara
f dreJJ Tor my5W)
O 0 1 Int n rte employeeslh . -ss IMPROVEMENT
P re Y Yg at their l c Ion SWIMMING PUUL CI.LCI RIC
II Jt thek into the wet m:not t d d B does
s apply
octan Business - ODTHI:R
dad anileProfessionsl Jc ie, o t t r L' to dm not work
hit of OUTLET'S-SWITCHES,FI%E'URES 'L
hic ownrity h h es or improves th ro h d such intended h r er gh
hisownowever,dic provided thatsuch Impmveold wiurc nmew attopeered for NEW RESIDCNI'IALELECTR . SQ FT.
sale,If.however,the have
building provemem is at he did n t build or improve
the SQ,PP.FLOOR AREA ESQ.PI'.
owner-builder will hove the burden of proving that he did not build or improve for par-
, pose of sale). _ _ TOTAL: .4 r R1
1,as owner of the propetny,em exclusively contracting with licensed common.to 6J
cons."the project(Sm.70 ,Business and Professions Code:)The Conuaeors Li.
Genu Law does not apply to an owner of property who builds tar improves thereon,and QTY. PLUMBING PERMIT FEE Us .•� -
whaconlmeta forsich projects withecon.ctor(s)licensW..ossa.W the Corridors {/ 1 ��oC
License Law. PERMIT ISSUANCE
Ellam exempt under Sec. ,B&P C for this reason
J - - -
Owner ALTER-DRAIN&VENT-WATER(EA)
� - Date - - [hy'4lJgT10N
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby tffirm under penalty of perjury one of he followin,d 1 t n: _
' .,E]Qleave am]will maintain a Cen Irate of Coment to self-instim IrWorkers C mPen- - DRAINS-FLOOR.ROOF AREA.CONU ' I, STORIES TYPE CONSTRUCTION
provided for by Section 37W of the Luba Code,for II a paribnn ace of the - „ -
wok upermi1 is issued. I. - FIXTURES-PER TRAP:.,
eve end will maintain Worker's Compensation Insurance,as required by Section
3700of the Labor Core,for the perfcurromeoffle work for which this permit is issued. GAS-EA.SYSTEM.]INC.4 OUT LETS OCC.GROUP' . 'APN
My Wit, do ec e,Noy. GAS-EA.SYS TEMOVER 4 IEA)
Carrier��Polic)'No r
CL•RTIFICA EXFMNINNFR WORKERS'
COMPENSATION INSURANCE GREASFJINDUS'BI:WASTE INTERCEPTOR
' (Thissretion rt«d not Mcampined state penrtit is aurone hundred dollars(fl W) BUILDING DIVISION FEES
or less) G TRAP
PIANCH[CK FEE
I certify the,in the Ecrfo.antt of the work 6r which this permit iv issuW,lshall - '
not employ any Person in any manner se as to become suhjecno the Worken'Campen- SEWER ANITARY-STGRM Es,.2M fT. ENERGY FEC
Z satma Lmssof Cxlifien Date
ZQ 'Applicant -° - WATER HEATER WNENTIRLECTR GRADING FEE
Ir rn NOTICE TO APPLICANT.IL after making this Cenifcee of Exemption,you should WATER SYSTEMRRFATING
aM1ecome subject to the Workers Compensation provisions of the Lm,or Code,you mut _ SOILS PEE,
4>a
forthwith coiiply with such provision,or th s permit shall he carried rt ked WATER SERVICE!
CONSTRUCTION,I ENDINGACI NCY l_ • 'NHW RLSIDHNTIAIj PGMEI. SQ.FT. PAID_
lh"Ay it than lhanherc is.cw°active nl J g gmcyf II performance of Dile '• Receile#
the work(or which this r"Vin is Matta(Sm. 097.Civ C.7 '
Q F Lend NamA e a P" ta /vA 1 a
T— i
t,7 Lenders Address - %� p T a__� a AL: �t TOTAL:
A4 I certify that I have read chisapplication and that toe ahovu inh.nnutioa is f8��'•�.�.�,Yd BUILDING FEE
fn r '
correct,l agree comply wit all city and coumy o inunces end slate laws r relating QTY -• 8 6 ECHANICAL PERMIT FEE
U building constmctinn,end hereM1y uuthodze rcprcsem aril this city to tamer up son the, i... E 6 r SEISMIC FEE
oMvcmentinned proprny for insjrctlon pitre
(W'e)agrte msavq indcmnifY and kre hsarmlcasyt4gC' of Cupeni 'nsP P• SUAN E s ELECTRIC FEE '
liehilities,judgmema,cosi end expensei whir meeymorl}viFY OR ADD 'O MF,CII.
in conseyuencen milt. PLUMBING FtiE
AP D NDS AND( OMPLY WITH ALI,NON•POINT 'AIR HANDLING UNIT(TO I0.000CFM) ME
CAL FEE
so 11R R y4T10NS, <w:a?.c,. - c.,'° p. .•�::;J ..._..:.. .., '
'�I AIR HANDLING UNIT(OVER IO.UIIO CPM) CONSTRUCHON TAX
Signet -of Ap,liama nor ' Dam EXHA US I'0001)OVIDUCT, - HOUSING M1tI'TIGATION FEE '
HAZARDOUS MATERIALS DISCLOSURE, P
Will the upplirant or future building creature,store or handle hneundous material HEATINGUNI'E40'101L000111U) N•
as delisted by the 32( no Municipal Code,Chapter 9.12,unJ the Ilenllo,und$nlmy ,
Code;Section 25332(xa77)? HEATING UNIT LOVER IIIe,INNI❑Til) " -
❑Yee 'E]No I VENTILATION BAN(SINGLE RESID) PAID
Date Retiptk
,.Will the applicant it furore deducedding y the B use equipment.Aralilyor Min which t BOILER-COMP(BHPOR 117B,Dpn BTU) , t
x •emit ilt? na air contaminates as definrd by the Bay Areo Air Quality Managemem TOTAL: '
DisldcR
-
C]Yes i]Nc' B61LER-COA1P(OVI?R 100,000 BTU) - - -
1 have read the bmeNous mamdakuirements under Cha tar basis of the Cali- AIR CONDITIONER
rt9 M - ISSUANCE DATE
folie Healg does no Sauey Cade,Sections 25505,25533 M3 end 25574.I understand Net if the NEW RESIDENTIAL.MECH. SQ:FT.
building unm not currently have a mnanp that it is my responsibility C to notify m cantiont
pme,y.
of thertyuiremcnrs which mixt he ten prior to issuance ofo Cenificnm nf(kcurymcy.
Owner w i m smized agent Date TOTAL: ISSUED BY:
OFFICE