28530 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES=USE BALL POINT PEN ONLY "
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO
BUILDING DIVISION APPLICATION/PERMIT PLUNIBING-MECHANICAL- . - '" 28530
IIIIII,DING PROJECT IDF"FICNI'ION
BUILDING ADDRESS: - - ✓r.'1:' _ SANITARY NO. .' APPLICATION SUBMITTAL DATE
6� 4�
OWN NA li: / - H E_x3 'ONTRA 'SNA L LIC NO:
+1 nIJV/ NIC. CONTROL M
CHITECDENG EER: ,IACNO. ADDRESS: - 0
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) .BLDG qE T P U NEC
' ❑ „ - •
LICF.NSI:D COMkACfORS DECLARATION QTY ELECTRIC PERMIT FEE
nmreby alfrn that I an licensed under p f Chafer,9(emnnte 'tg " JOB DESCRIPTION'':
�0IQyaZ with Smoon700d)of Divisimnofine Bostnessand Profession,Code,md my bcense ix RESIDENTIAL:
0 in full force and eRm. PERMIT ISSUANCE
�W ❑SFDWL• El KITCHEN REMODEL
UZ(❑❑❑❑,�FLicense Class CanL . APPLIANCES—RESIDENTIAL. - TBADDITION ❑PLUMBINGRE-PIPE
ARCHITECTS•N6 Date c. I TSSDECI.ARATION - ❑MULTIUNIT ' ' ❑STRUCiRAI.
Fly PANELS
1understand my plans shall M:used public snN, •• aq - MODIFICATION
UP'IO2W AMPScc
a r/�)klLicensed Profess anal { _ ❑INTERIOR El CHIMNEY REPAIR.
CYC, OWNER BUILDER DECLARATION 2UG1(Nk1AMP5 IMPROVEMENT
CC 6 I hi by M.chat I con exempt for. h Contractors License Law f-the OVER I"AMPS ❑BATH REMODELiREPAIR El DEMOLITION
a LLU f.11.wi.g romann (Section 7031.5,Business d Professions Calc Any city or couirly , 'SIGNS EL,EM Ie1CAL ❑OTHER -
which q perm I I c n.t I II r mpr ve 1 h rep Ystructure _
k?� pricom itsen alxn rvqrirexdue applicant fch perincithi Men tiguedttmen SPECIAI,CIRCLE E/MISC. E n »•M1'yy
rW�} IM1atM1 Ir, eJ puesuaml tti p n: fIh C t t I' I ICh pier9
do he is exempt
with Seciiond studdr basis
Sof the Uusmess nlica.Asons Code)or TEMP.MITER OR POLE]NST COMMERCIAL: : t
6 d e oC riot he is eaempi therefrom aced the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4•^}QD Sectn]BJ LS by anY aPPlc mEf Permit subjects thet 'I Penalty of POWER DEVICS
❑TENANT ❑sFOOD'ban SERVICE,not morefive hondrcdd l
E]I tovner ofthe property, r myemployees
mpl Y e with g s1compensation, SWIMMING TOOL ELECTRICEMPROVEMEfi1 •
will dothe wark it t informed T .1 (S as 1 . 1 , ❑OTHER _�J
and Professions CwMsh"M1e Cnnramors License Law does not apply In onowner
of OUTLETS—SW ITCHES—FIXTURES
property who builds or improves thereon,and who J«s such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ Ff. a 'aide If.however.the building or improvement is sold within ane yearnlaempletionthe SQ.14. 1.1OR AREA $/SQ.FF.. _
owner-builder will have the burden of proving that he did not build or improve for par- a - ��
pose ofsale.l. ,i. 'FS
❑1,n owner id the Property,nm exclusively contracting with licensed comio',mrs In "> '• -
onstmcl the project(Sec.704T,Business and Professions Code.)The Canocclou
me law does not apply to mowner of property who builds or improve,mercon,end QTY. PLUMBING PERMIT FEE
who conwcu(m xech projects with a contranogsl licensd pursuant ne the Can niccmis
License Law, PERMIT ISSUANCE
'
E71 am m &P exnpt under Sea .R C for this reason
Gosim, - - x Dice ALTER—DRAIN&VENT—WATER(EA) _ VALUATION "•
WORKERS COMPENSATION DECLARATION BACK 11-OW PROTECT'DEVICE
I hereby affirm under penalty of perj ry ant ofth following declarations:
» ]have ane win mainm n a Certi fic.teafConsent If nsurc for Worker's Compen- DRAINS—FLUOR.ROOF,AREA, ND. STORE IT CONSTRUCTION
cation,es provided for by Section J]W of the Loha Code,far the performance of the
weak for which this permit i,ismed., TEXT,URPS
XTURHS—1'P.R TRAP
❑I have and WE ma ti .W set's Cournaborition insomme, q E by Serbon -
37011LmurCodef id pert fth .,k for M1 hth pi itis issmo GAS—RA.SYSTEM-1 INC.4 OUTLETS OGG.G �APN
My Workers CnmEw...rose Insurance artier and Polity numbs ore.
Carrier, Policy It GAS—EA.SYSTEM-OVER 4IRA)
CIERTIFICAI'1.OF EXEMPTION FROM WORKERS'
COMPE SATION INSURANCE GRFASFANDIISTRL WASTE IM'ERCEPTOR
Rill D ION FEES
. (This section need not he complelediflho'peonit is fore...buMmddnllars($I tD) GREASETRAP -
orleisJ A + ` PLANCHECK ITE
I really that in the perfommnce Mme work lin which this permit is issued,I shall SEWER—SANITARY—STORM F.A.200 Ff.
not employ any perstm in any manna was to become suhjecl to the W..kers'Camped- ENERGY FEE
,Z cation Laws of California:Dale WATER HEATER W/VENTRLECfR
Applicant r _ - GRADING FEE
F[yI NOTICE TO APPLICANT:Ih after making this Cenilicme of Exemption,you should. WATER SYSTEM/TREATING SOILS PERai becomesuhject to the Worker's Compo
enaation pb,,i.. ns of me Lahnr Cade,you most _
.W faMwith comply with such povisiomor this permit shall he deemed revoked. WATER SERVICE
Q
Uz CONSTRUCGONLENDING AGENCY NEW RESIDENTIALPLMH. $Q.IT, PAID
U 0 hereby which thi thaubere isucomweion lending agency for performance of _ Dole Receiptp
L4 U
'he wmk Mon, ch this permii is ioual(Sec.JIYd],Ci¢CJ
Lend r' N a TOTAL:
� Lentl l�AlJ r • Lt
I cerfily that 1 have r,cal application ad surne that the above information is BUILDING FREE
LI fA courser l as=to comply with all city and county ordemences and state laws refuting to QTY. MECHANICAL PERMIT FEE 5.
U z
building construction,andhereri
by authoze p mam
senves ofthis city enter upon the SEISMIC ITE
Ir above-memiuned progenyfor inspection purposes. - PERMIT ISSUANCE - -
(We)agree to save,indemnify and keep Tema les,toe City of Colston.against �� ELECTRIC FRF.
liabilities,j udgments,a»ts and ell'Cases which may in�Iryway.,,,a,agum,'raid City ALTER ORADD TO MECH. °• �t
inronsequence M'hegiantingol'this permit. PLUMBING FEP. t
APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000C FM) -
50 GGULAY'IONSa qqMECHANICAL PEE
g_31_ AIR HANDLING UNff(OVER 10,000 CETD CONSTRUCTION TAX
Signora fApplicanUComra Tor Date EXHAUSTHOOD(W/DUCT') HOUSING MITIGATION FEii
HAZAIIDO MATERIALS DISCLOSURE •'
Il the applicant or future building occupant smrc or handle hazardous material HEATING UNIT TO 1000PI BTU)'as deGnal by the Cupertino Municipal Code.Chapter 9.12,and no Health and Safety 10 p
Code,Section 25532(m? - HEATING UNIT(OVER IBQOW BTU). n I Lj
El Y., ❑No ' VENTILATION FAN(SING LE RISID)- PAIDW,11 '
Dom p -v
and the ar'lieurdconte (taro bridefined
by the oar Bey
eea Air cuordevice,whsh P •f
droit haruJaus u r contaminants Jchned by the Dvy Arca Air Q alny Management � BOILER—COMP(JHP OR IBO,B(kI RTU) ,y
Dimmorl
-t ❑Yes 0 N , BOILER—COME(OVE100.100.000I . O RTU) ILIA
C� ..� L
AIR CONDITIONER -
.^I have mad tlic hazardous materials requiremcna under Chdpmr 6,95 of Ne Celi- r ISSUANCN,DATE '
fomia Health&Safety Cecile,Sections 25505,25533 and 255]4.1 undersand mat if the s - NEW RESIDENTIAL MEC]L' 5 .Ff:building]ria,not arrenll have mutant,that It Icor ._ lhilit hinolil Iheoexu Q G1, '
g Y Ymapoas Y Y Pant,
of me requirements which must he metPuerto issuance orCenifc:ne o(Occupancy.
Ownero terflu beta em -Date L: ENSUED BY: I'•(7VVk;Irr//r/`��•`](\
OFFICE,. : r