28649 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-Pal rRICAI. PERMIT N(l,
BUILDING DIVISION APPLICATION/PERMITO4PLUMBING-MECHANICAL. /I 9n
BUILDING PROJECT IDENTIFICA]'ION Q
�UILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
��N111 o 4q
O NER`S 1� F PfIUNE: C TR;CTOR:S NAME: LIC NO:
1 ` �Y I 6 NIC CONTROL.
ARCHITECf/ENGINEER: LIC NO: ADI ESS:
23 Charm L_.1
CONTACT: P11oMi: - BUILDING PERMIT INFO
,kat
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15 ❑ Consultant Fees Paid by Applicant(Initial) BL❑DG ELI❑iCl' PLUM SUCH
l� LICENSEDCONTRACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9lcommeneing ]OB DESC PTIO
�d'Z with Section 7ofaa Businessand Professions Codeend my license is RESIDENTI :
{{VV00 wt PERMIT ISSUANCE AL
Fit afull fomass effort. ❑SFDWL ❑KRCHEN REMODEL
<—U Lmcnm Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITIONIIMBING RE-PIPE
r Z L Dae Convector
ARCHITECTS O[CLARATION El MULTI-UNIT ❑STRUCTURAL
fvZ Iundersandm 1 shot[be used as blit records PANELS MODIFICATION
LOrn� typanssa Pu UP TO 300 AMPS
7Z ❑INTERIOR ❑CHIMNEY REPAIR
y u] Licensed pmfexsional 201-1000AMPS IMPROVEMENT
¢ J OWNER-BUILDER DECLARATION -1OVIiR 1000 AMPS ❑BATH REMODEVREPAIR
MDEMOLITION
Q I hereby affirm that I am exempt from the Contractor's License Law for the
U following reason.(Section]011.5,Brines and Profusvions Code:Any city or county SIGNS ELECTRICAL ElOTHER
whim nocuims a pert to construct,almr,improve.den fsh,or repair any ronurc
0 prlorto its issuance.also requites the applicant fin such permit o file a Signed.dreament SPECIAL CIRCUIT'/MISC.
F:yy that he in licensed pursuanOo the provisions of the Connector's License Law(Chapter 9
ti..00 (commencing with Section 70k)of Division 7 of the Business and Professions Coil')or TEMP.MUf'R Oft POLE.INST. \� COMMERCIAL:
L 0.cC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ge Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES '0TENAM1T ❑FOOD SERVICE
,too
not...'ban five hundred dollars($5006
IMPROVEMENT
=6 C] I,as owner of the Property,or my employees with wages as their sole comperionam. SWIMMING POOL ELECTRIC
will do the work.and the structure is nm imended oroffeted far salc(Sec.]OW.Business ❑OTHER
(Wet] m and Professions Code:The Contmcors License Law does nm apply m an owner of OUTLETS-SWITCHES-MIXTURES
a.3 property who builds or improves thereon,and who docs such work himself or though _
his own employees,provided Nm such improvements art not amended or offered for NEW RESIDENTIAL ELECTR SQ FL
sale.If,however.the building or improvement is sold within one year ofmmpletion.the SQ.FT.FLOOR AREA VlvQ.FT.
caner-builder will have the burden of proving that he did not build or improve for par,
Ione of sale.).
M 1,rot owner of the property,am exclusively eomruning with licensed contractee.to TOTAL"
aoustoct the project(Sr,](44,Biomass and Professions Code,The ma—tor',v t-
set.awdocsnmtapplytnanownerofpropenywhobuiltLarintprovulhemon.ane QTY, PLUMBING PERMIT FEE B lice
who contracts foe seen projects with a ronnactor(s)licensed pursuant to theCnmmemrs
Liccn,a Law. PERMIT ISSUANCE / SFp
1 um exempt under Sec. .B A P C f ll f is mason
ALTER-GRAIN&VENT-WATER EIA) CIIy AI-
Owner Dam T�
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE VI`
Ithereby afBrnorder penalty of ofConeneof the elffollowingdedker'sns: UUrrN t
Ihave and
rovidelmaintainfr eion37Cambial of the Latuo soe.fortfor Worker's Co mf dueen- DRAINS-FLOOR,ROOP.AREA.COND. STORIES TYPE CONSTRUCTION
wean,as hick his
for by Section 7]00 of the Lahr Calc,for the performance of the l
weak have
which will .troutis issued. FI%TURFS-PER TRAP
1 hove and will maintain Workers Cance o f e w Insurance,h required by Section
1]IXlofine Labor Code,far the performance of work for which this permit is issued. GAS-EA.SYSTEMA INC.4OUTLETS (X1C.GROUP APN
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CE LOU FICATE OF EXEMPTION FROM WOR KERS' GRIiASI%INDl15TR1.WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FEES
ILnisscclion need not be completed ifthe permit is fnrono hundred dollars($100) GREASE TRAP
or IesxJ PLANCHECK FEE
I ccnify that inthe Performance of the work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ uny person in any manner so as to become subject to the Workers Compact- ENERGY IEE
Z cation lrws of California.Data WATER HEATER WIVENT/ELECTR
C C Applicant GRADING FEE
NOTICE TO APPLICANT:IL after making this Certificate of Excmpmon,you should WATER SYSTP.MG-REATING
become subject to the Worker's Compensation Provisions of the Labor Code,you must SOILS FEC
forthwith comply with such provisions or this permit shall Ina decreed revoked. WATER SERVICE
7z
CONSTRUCTION LENDING AGENCY NEW RGSIDENI'IAL PWB. SQ,FT. PAID Data Ra o
UC I hereby affirm thatthem is a construction lending agency for the Performance of
{L(.y the work for which this Permit is issued(See.71197.Civ.C.) OT
ULenders Nana
{ll Lender's AJJrcas AL.
Pt 1 ccnify thin I have read this application and xtam that the above information is BUILDING FEE
h
correct.1 since to comply with all city and county vd;rances and state laws relating In QTY. MECHANICAL PERMIT FEE
SEISMIC FE
Uz huildingemnmainn,unJ herehy authoris n'Pra¢nwJvcs ol'thi,v city mcmcr ugnt the F.
above mentioned Property for inspection Purposes PERMI L ISSUANCH
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECT' C 'E
liabilities,judgments.cos's and expenses which may in any way accrue against said CityREGUL TIONSAl OR ADD TO MECH. PLUM N 'E) for
ce
in consequenof the granting of this parent.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICA FEF.
SOU fT;
ICSJill - AIH HANDLING UNIT(OVER 10,0110 CPM) CONSTRUCTION'AX
sig emof Ap UConconeor ,Date EXHAUST HOOD GVMUCT) HOUSING MIT 'ATION FEE
HAY.ARDOUS MATERIALS DISCLOSURE
Will thenppliciumorfovum mildingsecupant smreor handle hamardous annomd HEATING UNIT CTD 100,003 BTU)
as defined by the Colonial Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532m)? HEALING UNIT(OVER 100,"BTU) ifr
❑Yes El No VENTILATION FAN(SINGLE RESIDE PAID
Data ItmciptK
Will the Ppfa,m or fomm baildingo¢mpam use eymllnemor devices which BOILER OR 100.000 BTU)
nil h....dnm roa
air nmioanry av defined by the Buy Arca Air Quality Manam
geent
Di...0? HOl1.ER-COMP(OVER Ma"BTLH
❑Yes ❑No
I have Land thah nrdoas maedals n under Cbapter 6.95 of the Cali- AIR CONDITIONER ISSUA CE DATE
5.255
fomin Hulot&Scurry Cale,eaaion.25505.25577add 25574.I to al d the'ifdrc NEW RESIDENTIAL MICH. SQ.F1'.
bmikle redoes not currently have a mmol P that o is ne ice or a Certifi rote o fy vitt venal '
of the tequimmenu which must M met prior m is suantt of a Certificate of Occupancy.
Owner art authudeed
at Date TOTAL: ISSUED BY:
OFFICE