28521 (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-nH?cxnNlcnl.
1 28521
BUILNG PRO F. 'IDENTIFICATIIIN
BUILDING AUDRP 5: its NITARY NrI. APPLICATION SUHMII'IAL UAIE
It ais
�iijilll • 4 �d-3o-4S
'R'S Nis PHONE: NTRACI'OR'S NAME: LIC NO:
AM
M N/C CONTROL#
.ARCHITECT GINEF. LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO ts
1� /,s E:1Consultant Fees Paid By Applicant(Initial) BLDG ELECT' PLUMB ECH
(•/ LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm Lha l am licensed order pownina,of Chapter 9(commentingals JOB DESCRIPTION
GOO with Section 700o.fDi hut.3oflhe Busincssand Professions Code,andorlicensees
a. RICIDENIIAL
F1_ in full force and effect. y PERMIT ISSUANCE 1
W� � r WL El KITCHEN REMODEI.
�U V License Class_ Lich APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING R&PIPE
Q a Da¢— - Commcwr
Fpy A CHITHLTS DIiCLARATI( PANEIS ❑MULTIUNIT El STRUCTURAL
Z O m Z I understand my plans out be used as public records MODIFICATION
UPT0 200 AMPS
OZ—w ❑IMERE [I CHIMNEY REPAIR[F 4E'41 License sine 2UI-100(IAMPS - IMPROVEMENT
s OWNER BUILDER DECLARATION
CCC 6 I hereby affirm that I am exempt Tram the Contractor's Licome law for the OVER I(Xl(IAMPS BATH RGMOUEURIiPA1R DEMOLITION
K a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
3 a.� which wePror,a perms to cnnxtract.neer,improve,Jetm,rsh.or repair any omomre
Cg prior to its issuance,also requires the applicant for such permit a fimtem
le a signed sent SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant to the provisions either Contractor's License Law(Chapter 9
�2E!0 (commencing with Section 0000)of Division 3 ofthe Business and Professions Code) 'TEMRMETERORPOLEINST. COMMERCIAL:
a a that nc is eacmpt therefrom amt the I,vsis for ire alleged exemption Any violation of ❑NIEW BLDG/ADDITION El DEMOLITION
Scaler]031.5 by any applicant for it permit subject,the applicant to.civil penallyol POWER DEVICES ❑TENANT ❑FOOD SERVICE
teXanot more than five hundred dollars($50). IMPROVEMENT
❑Las owner of the proparty,or my employees with.,ass tbeirsale mmpe...tion. SWIMMING POOL ELECTRIC
'EL es will de the work.and the strvcturn is not amended oroffered for sale(Sec.70,LL Business ❑OTHER
aim and professions Code:The Cortr.em's License Law dans not apply to an owner of OUTLETS-SWITCHES-FIX'NNES
Pmpcny who builds tor improves thereon,and who does such work himself or through
his own employees,provided that such impmvements arc not intended or offered for NEW RESIDENTIAL.ELECI'R SQ FT.
sale.If.however.the building or lmpmvemaat issrld ,ohiaoneyeunl completion the SQ PI'.PL(�Wk•AREA. S/SQ.Pf.
owner-builder will have the burden of proving that he did not build or improve for porry 1 ��[ \/"\~T{
poseofsale.), 7 �J JJJ
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to C.
owmar the project(See,10,44,Business and poorest...CodeO Thc Camrmemr s Li- /_� a
cense Law docs not apply to an owner at property who bui Ids or i mproves thereon.and QT'Y. PLUMBING PERMIT FEE �OtIJ
who contracts for with projeats with a roemscons)licensed pursuant.,he Cumracmfs
Liceme Law. PERMIT ISSUANCE
1 am eaempl under See. .B&P C for ibis mason
ALTER-DRAIN @ VENT-WATER(EA) VALUATION
Owner Dane �.
(AV
WORKLR'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1..- Ihemhyaf0nnamder pcomlyol'Idiry one of the following duclonstions:
\�. ❑l Ist will mountain.CenificamofCowilllowif-inwim for Wodee,Compton- DRAINS-FLOOR.ROOF,AREA,GOND. STORIES ITYPE CONSTRUCTION
sedan,as provided for by Semon 3700 of the I.nhor Code,fnnhe pc,holosncc of Lha
work fm which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workces Compensation Insurance,as required by Section
310 of the WborCode,for the perfonommeof the work for which has perosis is issued GAS-h.SYSTEM-I INC.4 OUTLMS OCC.GROUP APN
My Worker's Pensatinn los 1pnce ea trend PolicynERP4 GAS-EA.SYSTEM"OVER 4(E,)
Cornice Policy Nn..
CERTIFICATEDCOMPENSATION
PITON PROM WORKERS' GREASHANDUSTRL WASTE INI'ERCEP OR
COMPENSATION IN511kANCli BU1f.U1 rU1VISION FEES
fThis section head not he completed ifthe permit is forone hundred dollars(SIM) GREASETRAP
or less.) PLANCHECK FEE
let thin int he pedomemeanfthe Werk fill shies this peRrlil is isueJ,lshalI SEWER—SANITARY—STORM EA.20 FT.
not employ any person in any manner xu ns m bar th t m the Vkers' pin- ENERGY
O z orlon Laws ofCuliforam.Data WATER HEATER W/VENT/ELECTIR GRADE F 11
Applicant l
NOTICE TO APP, N" a T nwk nb tnificam of Exemption,You should WATER SYSTEM/TRI7A1 INC, �
F "N" become suhjam m the Worker's Compensation provisions of NSOUS e Labor Code.yno must
WforthwithmmPly with wichpmvionnsnnhi,perhitahall hedermcd revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. ID
UO l hereby allimuhatthere i,a crnsuuctinn lending agency lin the perfmmunce of 1 e ReceiplM
the work for which this Permit is issued(Sec.307.Civ.C.) .�
OTOTAL:
U Lender's Name, q ( f�
D.1 Lender's Address
Ly, al—iii clarify that I have read this applicalon and ante that the above information is N Ffai \
L: l,l emcee.l agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT
(,)Z buildingeonswctioniand herebyauthome represeretivesofthis citymenterepon the
imsc menfohed property for impectina fampo,es. "l l r
(We)ageto save,indemnify and keep harmlu,the City of Cupertino against PIiRMIT ISSUANCE Ql'
r
liabilities,juJlptro .costs and expen.ws which may in any way a,cma a,mrol.arid City ALTER OR ADD TO MECIL I gla t
ine.wequcnce of the granting of this permit YLVMBTGP '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MI?CHANICAL BE
SOURCE REGULATIONS.
4D AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIO TAX
rgna App anVCnmtucmr Dam EXHAUST HOLD(W/DUC) HOUSINGMITIG ONFF,E I'•
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building coachmen slow or handle foreordains material HEATING UNIT(T01 BLOW BTU)
ss defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320), HEATING UNI"T(OVER 10.1100 W
0 Yes ❑Nr PAID
VENTILATION PAN(SINGLE RI?SID) Dam Receipt M
N911he applicant or future building occulc m use equipment or device,which 0,
HO)LER—COMP CHI
OR 1000 BTU)
• emit hazardous air nalmalm or,as defined by the flay Arc.Air Quality Management T T
Dinnct? BOILER—COMP(OVER 10.000 BTU)
E]Yes 0 N
AIR CONDITIONER
I have real the Institutions materialsreyuiemems under Chapter 6.45 of the Cali:
ISS NCE DATE
brow.IlcAlb A Safety Coda Sections 25505,15533 it 115311 undcr,mnd Ica if the NEW RESIDENTIAL MECH. SQ.TT.
buildingdocs not currently have o tenant,that it is my m,pomibility to notify the¢cugain �yy�
ofthe re4uiremehts whichnest bemet prior,,mano,eof it Catifcam of Ocer,'sy. ' ^g�•ll)
Owner m imhonzedagent Data - J ISSUED BY:�� '
OFFICE