28562 (2) APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT,PEN ONLY '
CITY OF CUPERTINTO BUILDING_-ELECTRICAL PERMITNO. 28562
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION -
BUILDING ADDRESS:. - - y- SANI'1'ARYNO. APPLICATION SUBMITTAL DATE
OWNER' ME: L �� 1'HON i:- !4 -6 CO f ACI'OR'S,NAMIi:. OL . LIC/O:L
6 �. NIC CO 01.
ARCHITECT/ENGINEERi LIC NO ADDRESS:
CONTACT: PHONE: ' HUILDING PERMIT INFO '
' - ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT . PLUMB MECIi
/ LICENSE:DCONTRACTOR'SDECLARATION - QTY ELECTRIC PERMIT ' ITC ❑ ❑
1 nanny affirm that I art,ucantad ander provkirm of chapter 9(commencing` JOB DESCRIPTION
wo, withSwtion 70001 of Division3ofNe Business and Professions Code.and mylicense is, d RESIDENTIAL:
F in full force and effect. t PERMIT ISSUANCE
.W r Licenu Class_ 'hlc.p _ C SFD W L ❑KITCHEN REMODEL
HG6 Date ,,. Contractor APPLIANCES-R[SIDHNTIAL ❑ADDITION
T [I PLUMBING RP.-PIPIT
pm ARCH]rEC'I"S DFCLARATION t ❑MULTI-UNIT [I STRUCTURAL
Z0Zj - I understand my plans shall Med as uspublic records 1'ANL'LS MODIFICATION'.
OZ O UPT02NAMPS CINTIiRIOR .a C CHIMN17Y REPAIR
'rt,,F-M Licenud Professional 201-1000AMPS IMPROVEMENT '
g�ji OWNER-BUILDER DECLARATION OVER IOW AMPS' -- C BATH REMODEUREPAIR El DEMOLITION
aMpa5a :I"'a I hereby affirm that 1 am exempt from the Contmnm's License Law for the
x+34
.. (allowing rensan:(Section 70ll s,Business and Prufessinre CW nyti coSIGNS ELECTRICAL ❑OTHER
. whit eq p 't tcrammer.'alt mipm a dent I'. pe y� etunty re
�� pnarl t '. I y the applicant h to rile
signed nt SPECIAL CINCUIT/MING -
`gY that(commencing
licensed pursuant t N provisions Ill t sl L (Cb tr9
�00a (coat sc.co,o iSectn71and tof he vtsin the Businesstend Professions¢ Tor TEMP.METER OR POLE(NST COMMERCIAL:
6—o W That he is exempt Iherefront mA the fit,Ihe.nllegeJ cxertnion.'Any vinlmibu of C NEW BLDG/ADDITION C DEMOLITION
px, W Swoon 7071.5 by any applicant a permit subjects the applicant to a civil penal) of POWERDEVICHS
L+l^m ❑TENANT FOODSERVICE
.F. P not more Non 0vehandrulJ m . .IMPROVEMENT
fC ElI,os owner of the prop y,or my yempemployees with wages us th' sole compensatit SWIMMING POOL ELECTRIC 4' C
y� willdnthewmk,andlh fracture is not intended oroffered for sale .sa,71,Rusincs a 19 OTHER
ul and Rofesslnns Code c Contractors License Law oc not y to an owner f OUTLHTS-SWITCHES-FIXTURES;
6 3— proper who builds impmvex thereon,and who J ,it) self or Ih his own employees, rovided that such impnrvements d f� the�H NEW RESIDENTIAL HLECTR SQ F1'.
cmI,1fhowever.th Inildingorimpmvementi. wit ' neyearoyfa��'jtfyrbJtlQQ/v(�IIff3��Jth ,SQ.IT.FLOOR AREA $1SQ.FII
owner-builder will methdbu ofpn t u Bol o Jo - n
Iwsaofiale.). 1h/s o`/ -
C'I,as owner of he pntpen' t vcly co a tag 'NyVn,ad con cats In TOTAL:
cerse Lo the pro•a tits ]M4� r�J The C- maters Li-
c1mccorwdoes otapply w an ow fpr y ea dpsusumpn aComustors, QTY. PLUMBING PERMIT FEF-
whocontmcwf such,rojenswM amtmcpitt�i s) sed pursuer Babe Cnnuanure -
License Law. PERMIT ISSUANCE
❑'Iain exam, under Sea. ,13&P C for this reason -
ALTER-DRAIN&VENT-WATER(EA) VALUATION rd
Owner - .. Date /��(q. .�
WORKER'S COMPENSATE)O 'Cafolim ON BACK FLOW PROTECT.DEVICE //J/ A
Ih..d affnn nndar penalty of perjn uofihe following declarations ;c/"
tritium,
as and amaimain eCenificate of num msdf-ins.rc for Worker's Compcn DRAINS-1100R,R001'.AREA,GOND' S7Y) 15 TYPECONSTRUCTION
workr pvwl ed fnr•by Seniors 37q the LaMar Code,for aM1a perfomtance of the
wink fnr which i¢permi(is issu - ITX'1'ORES-PF.1t'1 RAP ,
1 hove and wt maimm.W ccs Compensation Insurance,as rtyuired by Section
9700of Ne labra e,I a armormace iifthe work to, huh this permit is issued. CAS-EA.SYSTEM-I NC.40ULXTS.
4' OCC.GR0UP APN
Mynotrkern Compcnsauo n rend Policy nu in a OOH GAS-EA.SYSTEM-OVER4(EA)
Carrier.� (Zr l'oliay Nu:�.,�{.fcat _ ,
C:RTIF ATF.OFHXEMPIONFROM WO KERS' I-
.COMI'I:NSATIONINSURANCE GRIiASUINDUSTRL WASTE INTERCEPTOR
•'(Thisixtinn Bad nmhecompleted if Ne tisforonehundr dolls (SIM) _ - BUILDING DIVISION FEES
pemtt G
or 1<DaJ REASETRAP PLANCIIECK FEP.
Icymythatint irony onnmwofNewbuckrta,mlchlhisparmifisiss-Cmech SEWER-SANITARY-STORM P.2W FT.
not employ any person irony manner xo as m bsotne subject m IM1e Workers Compen- -
O ,z xzdon Laws of Celifnmia:Date - - WATER HEATER WNENT/ELECTR °' `_
ENERGY MH
A"hassm - - GRADING FEE
y NOTICE TO APPLICANT:If,tiller making Ods Cedifnnc of liump(mn,you should, - /."
Wxt ER Sys mohTREATING
bccome subject to the Workers Compensation provisions of the labor Code,you must _ - SOILS FEE
0. forthwithcomply with such provisionsor this permit shall he deemed revoked. WATER SERVICE., t
Q
5z CONSTRUCTION LENDING AGENCY NEW RESIDEN9'IALPLMB.' SQ.IT. PAID
IV t1 Ihertby teff nnlhm there isaronsWction lending agency fnnhe perfnrmancu of Data Receipt#
Ir^•t the work for which this permit is issued(Sec.3097,Civ,C.) t -
Q Lender's Nana t TOTAL:
Lenders Address - TOTAL:
�.a I certify that I have read(his upplicol lnn and swat,that she aMrve information is BUILDING PEE
i... (4 correct.l agree to comply with all city and county ordinances and state laws relining m QTY. MECHANICAL PERMIT FEE SEIS
�/ MIC HE'V G' mildin,,, stmnion,mod herebymuhoriee rtepmummivesoffhlsally loader upon the
above-mend bad Pmpeny for inxpedion phopo cs. • V
(We)agree to save,indemnify and keep harmless the City of Cttpeni m against HERMIT ISSUANCE ELECTRIC FEE
liabilum.judgmems,costs and expense¢which may in any way ammo against said City ALTER OR ADD TO MECH.
inennsequencebuflhegmmingof this permit - PLUMBING FEE
APPLICANTUNDENSTANDS-AND•WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) ' MECHANICALMH '
SOURCE REGULATIONS, _
- AIR HANDLING UNIT(OVER 10A.,CPM) CONSTRUCIIONTAX'
Signamteof Allorm VConanmor a Date EXHAUST HOOD(W/DUCT) -
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEE ,
Willtheapplicant or fuwrcbuilJing nreup:uv nnrc nr hnnJle haaurdous material HEATINGUNIT(TO I(l0"HTU) r'
as defined by the Cupertino Municipal Col Chapter 9.12, it the Health and Safety
- Collo,Section 25512D)? , HEATING UNIT(OVER 100,000 BTU)
❑Yes CNo t. - PAID ,
VENTILATION PAN(SINGLE RESID) Dam Receipt#
Will the applicant or future building occupant use equipment or devices which - ,3
emit hmafdous air contaminants as defined by the Bay Arca AirQmlity Management BOILER-COMP GHP OR 100,000 BTU) - ,
TOTAL:
District', BOILER-❑OMI'(OVER 1 W,IXq BTU)
❑Yes Nu
- - '
- , i 1 1't AIR CONDITIONER
I have bod she nominalism,mmenme(
als da,mocns under Chapter 6.95 of the Cali- - -ISSUANCF DATE
hernia Health&Surety Code,Sections 25505,25.533 and 25534,I undsswnd that if the NEW RESIDE1,H]AL MECIL SQ.FR
building does be,contend,has,.iemtm,that it ism,resforannlity to notify aheoacupam
of the fequitemenw which must be met prior m lssuanw of a Cenificme of Occupancy.
Ownerorumhorisdagent Darr TOTAL: X0(9 ISSUED
— OFFICE