28645 (2) -APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO '1 BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL nO �I C
BUILDING PRQLECT IDENTIFICATION L o 4 J
BUILUINGSANITARY NO. APPLICATION SUBMITTAL DATE
O ER'SNA E: 111 )NE: "RAC ORSNAME: � LIC ND��
,.( NIC CONTROL#
-�S lil'T CT/I3NGfNF.E .IC NO: DRESS ^ � P.. S2H/Q C/d/x ❑
CONTACT: PHONE: Nfl. BUILDING PERMIT INFO
M �-}o
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
IKE
X ❑ ❑ ❑
LICENSED CONTRSDECLARATION QTY ELECTRIC PERMIT FEE
I hereby vRm(h
rat I arm licensed
licenunderunder provisions of Chapmr 9(commencing JOB DESCRIPTION
Z with Section 7000)of Division 3 of the Businessand Professions Code,and my license is RESIDENTIAL'
�� in full force and effect.. PERMIT ISSUANCL
CSF' ❑SFDWL El KITCHEN R'F-PI EI.
F f„)U Date—
Class Liep APPLIANCES—RESIDENTIAL ❑pDDIT10N ❑PLUMBING RE-PIPE.
rn GZ V7 Da[e TSConDECLARATION
Pin
ARCHITECTS use DECLARATION PANEIA ❑MULTI-UNIT ❑MODIFICATIO
•z �Z i undersand my plans shall bu used ns public records� MODIFICATION
11PT0 2W AMPS
�Z'-'p C1 INTERIOR - ❑CHIMNEY RI7PA1R
r-4 1S used Professional � 201.1000AMPS IMPROVEMENT
J OWNER-BUILDER DECLARATION Commences
OVER 1000AMP5
Y C1 BATH REMODEIIREPAIR U DEMOLITION
K 1 hereby affirm that I 1 exempt from the Comrncmrs License Law for the
36 U following reason(Section]03son Business and improve.
d and Code'.Any eqs county SIGNS ELECTRICAL ❑OTHER
[•�.ur C which reyvirea v permn c mns(mm,alcor,improve,demolish,or repmr any avacmre
that rm heslits cesedp..ls...Imo mthevpionaia for tich Cormarmino file tx Law(Cmemem SPECIALCIRCUITMISC..
ga
that he er iti,wiit pursuant come provisions of the eBomirmra Liansc Law(Chapter9
uI 00 that he I.idgwith Sectionirman ad th Divisionfor nof o inlBusinessand d.Any
Code?or TEMP METER OR PULL!INS COMMERCIAL
d e C Nm io is exempt rhertfmm and rhe basin for Nc alleged exemption.Any l violation of - ❑NEW BLDG/ADDITION. []DEMOLITION
+ ^ $ectinn]OJLS by any applicant Enrp permit subjects the�pplic�ntmacivil penalty nl' POWER DEVICES
^'m ❑TENANT ❑FOOD SERVICE
�•m notaoremsafvehvndmddollars($500). IMPROVEM lx
��{••Q+++ O ❑hos nwntt of the pmpeay.or my employees with wages as their sole campenmtion, SWIMMING POOL ELECTRIC
a � willdodoworIt,and thvxmmmrea not imended-ornffnred Eurasia(Site 7W4,Business - []OTHER
W and Probosions Code:The Convenors License Law docs not apply to ad owner of OUTLIE'fS—SWI'I CITES-FIXTURES
6 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended te offered for NEW RESIDENTIAL 4.IlCTR SQ FT.
sale.IL however,the building or improvement is sold within one year of completion,the SQ:Fr.FLOOR AREA $/SQ.t1'.
Pnv-builder will have the burden of proving that he did not build or improve for put- A p g�
p sc i f saleJ. LV Y 61
❑I,as owner of the properly,um exclusively convecting wi[h licensed aw ranors to TOTAL.:
construct the project(Sm.7044.Business and Probations Code,The Contractor's Li- Q DEC 2 0
cense law does not apply to an owner of property who builds or improves thereon,and TY. PLUMBING PF FEE 1995
whocantmcts for such projects with a contmnaax)heensed pnrtmentm me Conwnar'a /s �/JJ
License Law. PERMIT ISSUANCE 017
❑I am exempt under Sec. .B&P C for this reason Ur, Uut L-H j
181(1
Owner DataALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 herehy affirm under penalty to perjury one of the fnsum ing Mclwminn.c.
❑Ihave and will for
inection 37W of the Labor
sod,forthe Wmkera Camped- DRAINS—ILOOR,ROOP,ARL'A,GOND. STORIES TYPE CONSTRUCTION
sation,as provided lar by Section 3]00 of me Luton Code,for the performance of the
workv d r
this per is issued. FIXTURES—PER TRAP
❑ 1 have
an
and will maintain Workers Compensation Insurance,m respired by Seaton
3p00 of the labor gnsatior theperfom(anceofthewuxk for which this permit is issued. GAS—EA.SYSTEM-1 INCd OUTLETS OCC.GROUP APN
CnrticrMy rkatp Co�(s#nswiny� �IDasuaracco�rria Policy No.:
nuyr rpq� r'1/# GAS—IIA.SYS9'EM-OVHR4LEA)
kit
OF EXEMPTION FROM WORKERS' O(�1
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR IIUILDIN DIVISION FRES
('Nis section decd not be completed if me permit is for one hundred dollars($1OO) GREASETRAP or)a..) PLANCHEC
I certify that in the perfann:mce(if the work for which this permit is issued,I shallSEWER—SANITARY—STORM EA.200 Ff.,
not employ any person in any manner so as m become subject to me Workers'Comped- ENERGY T'E
O z sation Laws of California.DowIf
DEATER WNF,NT/ELEC18
O Applicata GRADING
NOTICE TO APPLICANT:If,after makingthis Certificate of Exemption, h IJ
uN.m pion,you s ou WATER SYSTP.M/1'REA'1'ING
a � become subject with
Worker's Compensation permit
of the Lahr Code,you mon $OILS FE.
L$I forthwith comply wish such provisions or this pemrit shall he deemed revoked. WATER SERVICE
� CONSTRUCTIONONLAGENCY NEW RESIDENTIAL PLMB. SQ.FT
U O ter that them isaconstruction lending agency for the Performance of
the work for which this permit is issued(Sec. 09], P
ate ReceiptX
Cie.CJ r ,
O U Lenders Name TOTAL:
WLenders Address TOTAL:
Lis I certify that I have read this application and slow(bat the above information is - BUILU G FEE
LAI carter.l agree to comply with all city and county ordinances and slam laws atto QTY. MECHANICAL PIiRMIT FEE
U 4a building convection,and hereby authorize representatives of this city m enter upimme SEIS CFEE
am
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hunnless the City of Caperton against PERMIT ISSUANCE ELE. NIC FEL?
liabilities,judgments,costs and expenses which may in any way name against said City ALTER OR ADDI'0 MECH. '
in consequence of the granting of this permit PL MBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10,000 CFM)
SOURCE RE y�S. /ash ` M.CHANICAL FEE
AIR HANDLING UNIT(OVER IO.IIW CPM) C NSTRUCPION TA%
Signnwre of ApplicanUCommnorOF Date EXHAUST FOOD(W/DUCO HOUSIN GATION FEE
HAZ RDO . MAT BRIALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous material IMATI NO UNIT OEG Ino"DID)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Healer and Safety
Code,Section 2,5532ho? HEATING UNIT(OVER 100.00)BTU)
❑Yes 7N - VENTILATION FAN(SINGLE RESID) PAID
Use Ruem X
Will the corrosion,
or futurefuturebuilding occupant use equipment or devices which BOILER—COMP(3HP OR 100,0010 BTU)
.mit corrosion,air ll cortsmeminamn as def ted by the Bay Area Air Quality Manugemen(
DisWaTOTAL:
R
❑Yes ❑NnBOILER—COMP(OVER 100,000 BTU)
.
I have tend the hawdous macziais requimmems under Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
[aceta Healer&Safety Axle,Saviors 2.5505,25533 and 255.W.I understand that if the NEW R17SIDENTIAL MECH. SQ.FT. �\
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which most he met prior to issuance of n Certificate of Occupancy.
Owner or avthadzed a gent Dom TOTAL: ISSUED BY:
OFFICE