28805 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF,RMITPLUMBING-MECHANICAL 2 O oo O 0 C
BUILDING PROJECT IDENTIFICKFION LJ
H DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAD
/0/50 1'hax h0A , A19
OWNER'S NAME: �J PHONE: ONTRACID0.'S NAME: LIC NO:
d A/ VAA X ,��( NIC CONTROL#
�ARCHITECDENGINEER: LICNO: ADDRESS: - ❑
2S /S/9'l
CONTACT. PHONE: BUILDING PERMIT INFO
JO ❑•CoDSultant Fees Paid bye ppllcant(Initial) BLDG ELECT PLUMB MECH
AL ❑ ❑ ❑
LICENSED
am 'Rd under p DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm thin I nm licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
007• withSceti.n7(p07 of Oiviaion7nfthe Business anJ Profusions Cady and mylicense is RESIDENTIAL,
.W r PERMIT ISSUANCE
n fell furca s effect.
CCK �. ❑SFDWI. [I KITCHEN REMODEL
F, Dole-
Dole Class Carl, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
rA6� Date CanlmcCI
ARCHITECTS DECLAcAT10N ❑MULTLUNIT El STRUCTURAL
PANELS
Z O�z I understand my plans shop be used as public reanrds MODIFICATION
oz-� f. UP DO 200 AMPS '
2!�{Qil Licensed Professionui E]INTERIOR 11 CHIMNEY REPAIR
,3 OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
6 1 hereby affirm that 1 1. exempt s an the CosttractCo License Law for the
OVER 1000AMES ❑BATH REMODEUREPAIR El DEMOLITION
ip5s O V following reason.(Section]NLS,Business and se,d rmns Gavle:Any city or county SIGNS ELECTRICAL []OTHER
sw O f which requires a permit m construct,al¢q impose,h permed,or repair mymuseum
that
its iensedp,aNant to theor,the
ovisio so for such permit Licensle ae Lawned
SPECIAL CIRCUIT/MISC.
6 (cot heis licensed pursuant to the of Division
of the the
Licenselaw IC ode) 9
00
(commencing with Sectian]gNp of Division7ofthe HueinusanJ Professions Code)or 'TEMP.METER OR POLO INST. COMMERCIAL:
athat he is exempt therefrom end the basis for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION [IDEMOLITION
�
Section 7031.5 by any applicant for it permit subjects the applicant o a civil penalty of POWER DEVICES
W []TENANT ❑FOOD SERVICE
>>>>> not marc than five hundred dollars my
IMPROVEMENT
R6 ❑ Lus owner of the pmprny,or my cmploycre with wages as their sole mmpensmion, SWIMMING POOL ELECTRIC
O willJmhe work,and Ne sWcturcis not intended nr offered(urocele(Sec.]044,Buxinesa ❑OTHER
mend Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCH- FIXTUR
R' property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such imprmrcments arc not intended or offered for NEW RESIDENTIAL .LECTR FV
suer.If.however,the building in impnwemmul is sold withirem,yearn(cmntplmimn,the SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.),
❑1,as owner of the pmpcny.am exclusively comments with licensed convectors to 'TOTAL:
mnawa Me proper(Sec.70,14.Business and Profusions Code:)The Cmunicmrs Li-
cense law docs not apply to on owner of pmpcny who builds.,improves thereonend QTY, .UMBING PERMIT Nr
who comrei fersuch pmn
jcs with n convector.+)licensed putsuwruo the Condecmrs
License Law. PERM ISSUANCE
❑I am exempt under Sec. .H&P C( This reason
Owner Dam AI'Ek-DRTAIN&VENT-WAI7R IEA) VALUATION
WORKER'S COMPENSATION DECLARATION ACK FLOW PROTECT.DEVICE
I hereby efr.under penalty of perjury one of the following dacltataions:
❑I haveand will maintain a Certiycate ofComem to self-insure for Workers Comped- DRAINS-FLOOR,ROOF,AREA,COND.
setimn,as provided for by Section 37M of the labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which Nis permit is isxued, FIXTURES-PER TRAP
I have and will maialain Workers Compematim Insurance,as required by Section
37M of the labor Code,for the performance of the work for which Nis permit is issued. GAS-EA.SYSTEM.I INC.4 OUTI ' OCC. ANN
My Worker's Compensation Insurance carmer end Policy number arc:
Cartier: Policy No.: AS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GSFANDUSTRL WASTE I E BUILDING DIVISION FEES
(This section need not heccerneed ifthe pcmou is formic hundred dollars($100) GREA WRAP
or less.) PLANCHECK FEE
(certify thatioshe my manner of wren t work for subjectch this the an Wislssured.I'Comhall SEWER-
ntaemploy rorLawofC.Efun in any mannermumbecome subject to W.rkcrs Cmmpen- NITAR 'Ok . .200 • . ENERGY FEE
O ,'� Applicant
of California.Dem WATER BEAT WIVENVELECrk
qq 0 Applicata GRADING FEE
p ti NOTICE TO APPLICANT:IL atter making this Cenificam of Exemption,you should WATER SYSTEM EATING
become subject to the Warkees Compensation provisions of the Labor Code,you must SOILS FF.H
forthwith comply with such provisions or this permit shall be dermad revoked. WATER SERVICEWill
Q
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PLM .FT. PAID
UO Thereby affirm that there is a comuuction lending agency for the performance of Dam Receipt#
w H the work ser whichthis permit is issued(Sec.3097,civ.C.)
0 U Lender's Name TOTAL:
�. Lender's Address
1certify that 1 have read this application and nam that the above information is BUILDING FEE
VV) m
) correct. agree mcomply with all city and county ordinances and state laws relating to QTY. MFCHANICALPERMIT
EEE
building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-menti.ned pmeaemy for inspection p.w,r,. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE 0i
liabilities,judgments,costs and expenses which may in any way accrue against said City AL1'ER OR ADD TO MSCI I.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10d00 CFM)
SOURCE EGUI ATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,108 CFM)
S CONSTRUCTION TAX
re ol'Applicant/Comme ' Dam EXHAUST HOOD(W/DUCO
HOUSING MITIGATION FEE fi
HAZARDOUS MATERIALS DISCLOSURE /
Willy the Cupertino
ta furoreMunicipal
building me,Caata+senor huddle hazardous ad Safety HEATING UNIT(T0 100,(XNI BTU)
as definedio the Caperino Municipal Cale,Chupmr 4.12,and the Heahh and Sufery
Code,Section 23532(x)7 HEATING UNIT(OVER Unions)BTIO
❑Yev ❑N. VENTILATION FAN(SINGLERISID) PAID ReempTil
OCT 4. 995 -
Will the applicant or future building occupant use equipment of devicea which Dote
f emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME QHPOR 100,000 BT Of at I I NI- l ""—
District? TOTAL. 11(ICU
❑Yes CJ No BOILER-COMP(OVER 1010,000FITU)
I have read the hmardins materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE '
(.mice Health&Safety Code,Sections 25505,255]3 and 25134.1 understand Nal if the NEW RESIDENTIAL MUCH. SQ.EL
building does not currently have a mmnh that it is my responsibility to notify the occupant
of the requirements which must be text prior to issuance of a Certificate of Occupancy.
Owner or anatomical agent Uma TOTAL: ISSUED BY:
OFFICE
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�1AUG.31 195 9:20AM SO VALLEY PLUMBING 408 265 2509 P.1
j INSTALLATM GERTIMgATE •,.PLAN 'MEE _ CFVR
Nae 0 two yy�'''�the n*dMoo ror a use AdMMWMWVe Qeda to ytMMFeL bn 40 PMW+—Ino+ t '+ad
site Address Pernik Number
An iregitil8tie6 canilicate is required to be posted at me ti Aft site Ow tri•tate icsuanco of the CCOMaMy
j permit:(itis form may be used to mean these req 9mmQ= AN appliance 0 0c9ortes Amd trebw aro the acNat
kutril
tFwu appfaiaftee sixraLed on the certclta� d
to etoortapaaraoe(FFoorpm CF -1 TITh certd*016 W Rs better
4i
shell be presi'ww am by the perSONG) awumhv overall responsbuy'lot the Appliarne hww atlon.
Reter to tare re"rse side of this GaMICM for an BY WA Wrt Of kdwmadion required-
I,the urider*ned.vartfy ftt the equiparard listed in the category above 1hy afignatuna Is the 2=uai equtpmeot
to italfed and that the m;lWpMW4 nWgm or exceeds the requirements of the Appliarm gnciara y 8tQr4WS- -
. Ift.addiltort, I'l1al(e vemled tttffi the e�Iilpment S�yivatem 18 tK more rVAeerp the fair equtpmwit spet�red
tth tne'Ga�►�;ari'4a�p16stiee siibYtiltrie0 to gemt5nstrate mmpllaf+ce+xith'the't�teigyEts�rrty•9tafidards
for resitleniiel twSdRgs.
HVAC SVISTGMS:
i Heating *UIPment
Heaiirg 6quW'. OEO Certlled Antral Drtvmwlm+ Duat or Hesone LoW Noalin9
Typa(Pnd=6td Mapnf,Mateo A E1rw-e y Typo and Rpm Before Owr. Equipment
boor eery- emf Madel .u.hor (r4FUC am i 29SdM FWAlue %ji0a(Scum renenHv rox it.t
FURNACE I/ORK $6.$._ ATT%C. kaa d4-Sdb inn Q�q
p2MRD020Nda6et —
Cooling Equipment
CaoGng Equipm ni Actual
Type(Pad aiged CEO Caniftad Compesaor Una Efftdeney Deet ' Duet
N0T APDLItasLE - H miUM dN adAll be. _— ra�y t�aen JIMMlee
d--- ,
CO AIR C0! 20N1A1G .279637-
:.,.. MVAG&tberrenoesd(C L Nam.)
signattrfa, ata
vR oansraf eonuaerorot#awes
WATER HEATING SYSTEMS
Dbuib. Wat?r a.MCriml%d Energy 't Mk Insul Internal Pact PAW mar(
System Heater Manu►.Maine& Factor/ Vehrme Wrap tnsul. Standby U9ht Input YM O
•jj(eHa doh FrRC (91111%) It�f&1%1 �
, fl= = Sif l&
f � � � A=
i
RAu a SHO IVIER ttlidDS;
Alt talreots ehorrlUleaE! alad Jare IV" in the Comtolsasafla Dl qct1ry Of Grffffiod FarrpeaM Md Showlrlwsdd.
tent ' p s,5 r 2 Saedon.111.
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rinitLfe.Q7s'e- P u ni ft si bcormac�oor(C—flame)f.[;G yy,jb5 e-
OR Osrreral GDntredrert3ta Owner
FROW Decaffow ten
TpTQL P.06 •