28685 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LECI'RICAL - PHRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT DENrIFICATTON 28685 8685
BUILDINGADDRESS: 4 - SANI'TAItY NO. APPLICATIONSUBMI'IT/ALDATI
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OW EgIj NA PHONE. C0?ACfOR-S7k I,IC NO'. - �-
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ARCCHITE DENGGINEER: LIC NO: ADURIiSS: �• ,I' /� El.0 NC o sV /C YS -7s1 W- J 70�/" (i(/s ayw1Ase fi Of .
CONTACT ,/ PHONE: / BUILDING PERMIT INFO
/f {f // e✓ J 9G 0 9 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSE])CONTRACTORunOrpro'nDECLARATION QTY ELECTRICP13RMIT FEE
1 hereby emrm(hut I vat license)under provisions of Chvpmr 9(commencing JOB DESCRIPTION
th Section]0110)o(Divisinn 3.fibs Bminess end Professions Ede,and my li<eme ix R S[DENTIA .
OZO
qF in full force and effect. 1117RMIT ISSUANCE ❑SFDWI. ❑KITCHEN REMODEL
6VU License Class Lick 'APPLIANCES—RESIDENTIAL. � ❑ADDITION ❑PLUMBING RE-PIPE.
NQ 0. Date Contractor
f.,Dm ARCHITECPS DECLARATION PANELS .❑MULTIUNIT ❑STRUCTURAL
Z O�Z I understand my plans shut[be used as public records MODIFICATION
OZ G UPTO20RAMPS El INTERIOR ❑CHIMNEY REPAIR
IQp—�•�1ppp"YI License)Professional 201.1000AMPS IMPROVEMENT
y3uthat t-BUIL If a DECLARATION Cmar ON OVER IaWAMPS ❑BATH REMODEL/REPAIR ❑DEMOI.IT'ION
CC I hereby ul'Enn that m t from the Cnnvucmr'n Liansc Law for the
O y U following reason.(Sectio (131.5.Basin and Professions Code:An t count - - ❑OTHER
ip$, Y°'Y d Y SIGNS F.LF.CTRICAI.
I+t 3 W I" which rcyuims a permit o rnnawd,elter,v prove,demolish,or rtpair any slmnure
Os prior its issuance,al requirestheapplicam r such permit n file a signed statement SPECIAL CIRCurrmISC.
"y that he is licensed pu uram m,he pro mica s of th Conuacmr`s License Law(Chapier 9
G� (commencing with eclion]INNp o(Dwis int3oft Bmincssund P'ndessimns Gme)ar T'EMP.METER OR POLE INST. COMMERCIAL:
L�j Go C that he is exempt net nvn mW IM1e basis I'or the all zd exnuPlian.Any violmialt of ❑NEW BLDG/ADDITION ❑DEMOLITION
4W, Seelion"/031.5 any applicant for a permit subject. •upplicunun a civil penally of POWER DEVICES
u�—rn ❑TENANT [I FOOD SERVICE
FZonm m.mtban ehundred dollars($SW). IMPROVEMENT
❑I atim s.and
propedy.or mycmntendes withwred In hei(Sec.7ompensntinn, SWIMMING POOL ELECTRIC
will do the ors.ande: he Comisnot License Law
vl apply
an Rumness ❑OTHER
and Prof cions Cade:The Contmcmr's License Law does 9P apply m an owner of OUTLETS—SWITCHES—FIXTURES D
prepen who builds or improves thereon,a wh ees snQL hi self or dirough - 1,- -
his.1 mployees,providnl thatx&'h in ems e tror off..I for NEW RESIDENTIAL ELECTR SQPT.
such,If however.the building.,an v rs,.Id.i o ye compladon,the SQ.PT.FLOOR AREA,'i' S/SQ.FT
aname, ilJa,will have the burden o on as Ban yhydi�net In. ori rve for put
paseo[s le.). A\• ,J
❑ Las. rearoffind ape u incisively ends. lie,medomorporrato L, fi_ l
camwcl I project(S 1ry1 nfessjonv s�dc:)'1'ow Qmtr........... Li Y
nw Luw satanic net.fP ywhob 'ds or improves thereon,and QTY. PLUMBING PERMIT FEE
whocommact.ferstable with a contrmons)lien pursuant to the Commemrs NOV ����
License law. PERMIT ISSUANCE
❑1 am exemp neer Sec: ,R&P C for this reason _
Owner - Dna ALTER,—DRAIN&VENT—WATER(HA) VAIUAI[ON -
W KERS COMPGNSATI DECLARATION BACK FLOW PROTECT.DEVICI2 Uh LUYGIII IIYU
I hereby affirm er penalty of perju one of the fallowing dedamtiom
❑Iheve Inverted will maims[ Cenifica¢of nsem msel4insure for Worker's Cnmpen- DRNNS—MOOR.ROOF AREA,COND. -
sation,as provided far by See 3]W the Labor Code,for she perfmmance man,
STORIES TYPE CONSTRUCTION
w.
for which this Permit is issue . FIXTURES—PER TRAP
have and will maintain Worker's Compensation Insmnnce,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued GAS—EA.SYSTEM-I INCA OUTLETS OCC.GROUP APPS
My WnrkC..C(pe tmichisancecrd ol
Carrier. naicyicymMr��0Z!
FO GAS—EA.SYSTEM-OVER
CERTIFICATE.OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE GREASEERHOUSTRI,WASTE HTHERCEPfOR
(Thismetlon need ntn he completed if the pcmlit is fnnmc hundred dsollm (5 HN)) BUILDING DIVISION FH:ES
CREASE TRA
or less.) P PLANCHECK 17ER
I cenify that inthe performance nfma work(a,which,his permit is issued,l shall SEWER—SANT TARY—STORM EA.200 FT.
ersmy employ any union in y manner so as to become subtract m t the Workers Camper- ENERGY RE
ZZ sation Laws of Califomie.Dale WATER HEATER WNENTA LECfR
t7 Applicata - GRADING FEE
NOTICE TO APPLICANT:IF,after making Ibis Candi ale of Hurnapti.n,you lua d WATER SYSTEMO RHATING
abecome subject 1.she Worker's Compensation powisiors of the Iabm Code,you must SOILS PEE
D.1 forthwith comply with such provisions or this permit shall be dactual evokrl. WATER SERVIC17
0.
CONSTRUCTION Llending agency
NEW RESIDENTIAL.PLMR. SQ.FT. PAID
V O [forhereby which
thi that issued( m.construction0 len ding agency for the Performance of Data •iPtk
r.kTs U the work far which This Penni[is issued(Sec JII9],Civ.C.) -
Q W Lenders Name• JTAL:
r {til Lenders Address I TOTAL:
V) nee that I have ithJ this application and nate that the above information calming is BUILDING LLE
If—IZ building
lagrtetccomply
and hith reby atityand countyandstatcity to enter
upon the
QTY. MECHANICAL PERMIT FEE
LI,a7. building cannmction,and hereby vuthorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the Cityof Ccietaro ugairad ELECT rl'i'
liabilities,judgments,costs and expenses which may in anyway accrue again.n said City ALTER OR ADD TO MECH. -
inconsequence of starting of this permit PLUMHUD
APPLICANT UNDERSTAN D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010.000 CFM)
SOURCE REGULATIOp MECHANICAL FEE
�///7`y� AIR HANDLING UNI'T(OVER II,BIgI CFM) CONSTRUM[ON'AX -
Sir tar, Data EXHAUST HOOD(W/DUCT) HOUSING MIT)C TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT FDA 100,000 BTU)
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)1 [1 HATING ON IT(OVBR 100,000 of
❑Yes ❑Nm PAID
VENTILATION PAN(SINGLE RESIU) Data Rccipli
av
Wdeasll the air contamicant nfutureants
a building by ount use the
Area
Air
mlity or Mices nagemint BOILER—COMPEHPOR IW,WOBTU)
stab hazmJous sir contaminants as defined by the Ray Arta Air Quality Management TOTAL:
DistrinT
❑Yes ON. BOI I.ER—COMP(OVER 100,000 B'rU)
-
I have read the hazudouc ma¢rials requirements order Chapter 6.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
fonds Health&Safety Cale,Sections 25505,25533 and 255:X.I understand thm if the NEW RESIDENTIAL MECH. SQ.
building does not currently have a tent Nat it is my responsibility to notify the occupant
of the acquirements which most he at prior i.....cc of a Certificate of Occupancy.
Owner or authorized agent - Dam TOTAL: ISSUED BY:
OFFICE