28855 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SAL_ L POINT PEN ONLY
CITY OF CUPERTINO BIHLDLNO-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28855
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS! SANITARY NO. APPLICATION SUBMITTAL DAT
OWN:H'. AME: PHON CO. RACfORS NAME: _ LIC NO:
l0—1
In 11)Eq T L _ /> s e 90 , NIC COONIRRROLIE
�AR klll'[CT/13NG1 EER: LIC NO: (iLGi ADD !SS.� ❑ V
Zug Ks / S
CON'1'ACL PHONE: R BUILDING PERMIT INFO
.l .. _ .
❑ Consultant Fees Paid by Applicant(Initial) BLDG EC PLUMB MEC
LICENSED CONTRACT'OR'S DECLARATION - QTY ELECTRIC PERMIT FEE
C m Z 1 hereby affirm mart I am licensed under provisions of chVier,9(commencing - JOB DESCRIPTION
W00 with Section 7")of Division 3 office Buairessund Frefccdons Code,and my license ix PERMIT ISSUANCE RESIDENTIAL:
C W F Entail fore`end aSI`3 OSFDWL, ❑KITCHEN REMODEL
QUU Liccnsc -JJ Lic.N APPLIANCES-RESIDENTIAL '[:)ADDITION ❑PLUMBING RE-PIPE
NQ W Date - _(.'antr'Jclur
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT 'OSTRUCfURAL
Z O lin Z 1 undere.and my plans shall he umd as public records - MODIFICATION
O Z'C'O - UPTO 200 AMPS I CINTERIOR ,DCIIIMNEYRF.PAIR
F4I Jconsed EWE ax....al " - 2111-I dfM1AMPti IMPROVIiMENT -
OWNER-BUILDER DECLARATION OVER IWl1AMl'S- DBATH REMODEVRL'PAIR"El DEMOLITION
C N Q I herchy off..nahm 1 um exempt Irom be Contractor's License I'..for the
OW U following reuse.(Section 7031 5,Business and Promotions Cade.Any city or county SIGNS ELECTRICAL - ❑OTHER
W LL which requires n .it to construct,atep improve,demolish,of repair any swemm
F"LL'nog priortoits issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC. - v
E o�T that he is licensed pursuant o the provisions rfthe Contractors License Law(Chapter 9
H110 (commencing wish Section 7")of Division 3 oflhe Business and Professions Coast or � TEMP.MEfERORPOLEINSTL:
.' COMMERCIAL
-
a a e 5 that he is exempt therefrom and me basis for the alleged exemption.Any violation of - O NEW BLDG/ADDITION O DEMOLITION
KyLL Section 7031.5 by anyapplicanl forape.it subjecuthe applicenuo a civil penalty of POWER DEVICES •❑TENANT 'O FOOD SERVICE
W w not more man five hundred dollan(SSWI!
IMPROVEMENT=Q Dl,v.mwncruf the property.or my employees with wages as meirsnle cnmpcmation. SWIMMING POOL ELECTRIC
mp.0 will do the work.,and meatnctme is not intended ondfcred far sale(Set.7 .....inesx CQTHER
W and P . Croke,The Contractors I I J t apply t r of OUTLETS-SWITCHES FIXTURES-
0' prnismy is 1 hu Ids or i mprovesth I hit dise,such workb If or dion,lb
h i own c m pl y : pnoided that such it l rcanet:a.not intended noffeed nor NBW RESIDENTIAL ELECT'R SQ FL
sale If,howa ei,the building or improvement s told within one yearofrompleirn,the ,SQ.FT.FLOOR'ARY: - "$1SQ.FT.
-. mar-builder will have the burden of proving that he did not build or improve for par- '
pre of sale.). - -
D1,as owner of the property.am exclusively commeting with licensed romractorsto T OC O 1995
construct me project(Sec.7144,Business and professions Cosai The Cmaacmrs Li-
car.Law does not apply m an owner of propert,who builds or improves lhcmon,mW QTV. PLUMBING PERMIT FEE
who contracts for such pmjecta with a commons)licensed pursuant m the Contmaor's
License taw. PERMIT ISSUANCE .2 CITY UI 4urCH,IINC
D'I am exempt under Sec.' .B&PC for this Raton
• ALTER-BRA IN&VENT-WATER(EA) VALUATION
Owner - Data Jn�� .• n
WORKER'S COMPENSATION DECLARATION • BACK FLOW PRO'1'ECI'.DEVICE 60
• have
and nffmm under,pemJly ol'Periury nnenfllm following Jedumtiuns: s S IJLJ
OIhave mWwil lfor by neelion icon of the Labor
solGinfurther Worker'sQolthe DRAINS-FLOOR,ROOI!.AREA,COND. STORIES TYPECONSTRUCTIOt
noir,ox hick ted for mi Senir 3700 of the Lubar CWq for the performance ol'the
k for which miss Paton is issued. FIXTURES-PER TRAP
37'Tfaand will maintain for Workers ante of the w Insurance,hms Permed it is
Section � '
37W mf then Labor CMefor the performance of work forwhiJchp$emss pcmit is issued GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP APN
My Work .clic rcyy,�Ance caricv lcY No.y��YLd_�I/ 9'7 GAS-EA.SYSTEM OVER 4(EA)
Cartier.S7ATl�N _
CERTIFlCATE OF FXEMPr10N FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE. BUILDING DIVISION IT US
IThissectionnecdrotbecompleted if the permit is for one Itundraldellms(S IW) GREASETRAP - '
or less.) PLANCHECK FEE O
I certify that in the performance mf the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.203 FT.
Oil employ any penton in any mannerso r to baomasubjectto the Workers'Compen. 17NERGY FEE
OZ notion Lawsof California.Date WATER HEATER WIVBNI'IELI)CTR GRADING FF.F. '
77 O Applicant -
G NOT ICE!TO APPLICANT:If,Wier iiiaking this Ccnifcateof Excmption,youshould WATER SYSTLMC'REATING
a ? beanie wM1jecl m the Workers Compensation provisions of she Labor Code,you must _ SOILS FF,H -
forthwith comply with such pmvrsumsor this permit shall be deemed revoked. WATER SERVICE
7z CONSTRUCfIONLENDINGAGENCY NF.WRESIDENTIALPLMB. SQ.FT. PAID Data Receipt It -
_V 0 (hereby affum man liters is a commotion lending agency for me performance of
F she aark for which Ibis permit is i...cd(Sec.3097.Civ.C.)
U. Under's Name _ � TOTAL:
U Lenders Admaxs L'
y 1 cenify that 1 have read this application and slate that me above information.- BUILDING FEE
VI correct.I agree am comply with all city and county ordinances and state laws relating is QTY. MECHANICAL PERMIT FEE
V building constr inn;and hereby oulhorim representatives of this city m enter upon the SEISMIC FHB
chosemcnllane I p...penyfinalpecllonporposes' ' ".' , .VERMIT ISSUANCE.
(We)ugrec n,save,indemnify and keep It Mass the City of Cupetlie against I?LIiCfHIC FEE f
Iiuhilitics.judgmeno,costs and expenses which may In any way accrue against said City ALTER OR ADD'IQ MSCI I.
in consequence of me granting of this permit. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT TIO I0.000 CFM) '
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of AppliceVConrecmr Data - "K_HAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAT17RIAM DISCLOSURE .
Will the appIncome,future building occupanOtoreor handle havNous material HEATING UNIT(TO 100.000 BTU)
as defined by the Capetian Municipal Cole,Chapter 9.12,and me Health and Safety
Cole,Section 25532(a)7 - HEATING UNIT(OVER 100.000 BTU)
Yes .t _
s D PAID
VENTILATION FANS INGLE R ESID) -
Data, Receipt#
Will the applicant or firm' building occupant use equipmenl ur ileviets which HOLLER-COMP(311P OR IINI,UIX111'1'U)'
mil Itumdous air cemmiram.,of defined by the[toy Arca Air Quality Management III'AI'
Dle(nct7 W(LER-COMP(OVER 100,000 BTU)
❑Yes �W.e .
AIR CONDITIONER
I have lead the ha)allousnmxmid,on uimmcnu We,Chapter 695 of the Calm ISSUANCE.DATE: '
f,.ia Healm&Safety CMI:Seniors 25505.25533 and 25533.1 urWemarW met if the NEW RESIDENTIAL MECH. SQ.En
baildin oesamemorndyha)catewm that int iv mY¢xpmzibility to reify the occupant
oft what a manartworte aCeNfic of
D /ohe
er or amhonm y em � —D�aie -, TO ISSUED BY:
J: OFFICE