28811 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'j '•'PRyllai". .- BUILDING ELECTRICAL PERMIT NO.
w �a
BUILDING DI VISION APPLICATION trip IT PLUMBING-MF.CHANICAI. lyl� ylJ( "y'
BUEMRG PROJECT IDENTIFICATION _
BUILDING ADDRESS: * SANITAKY NO. APPLICATION SUBMITTAL DATE
a 3 $S a oma r �on 3_C 1d'� 'S
OWfli"S AME: PHONE CONTRACTOR'S AME: LIC NO:
(G—
G /vn Remeso -,6aoo lJeonen N/C CONTROLts
ARCHITECT/FNGINEER: LI NO: ADDRESS: E]
CONTACT: PHONE: BU
/�-sILDING PERMIT INFO
ee e a e/� y'9;19js'-6 06/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG EEC PLUMP MECH
tz . R 0
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby ofOrm that,1 am licensed made(pmvismas of Chapter 9(commencing JOB DESCRIPTION
OlzZ with S
�0enion]17)10 of Division3 of the Business and Pmlpssions Cwlp.and my licence is
0 PERMIT ISSUANCE.
m full fume end effect.
W SFDWI. [I KITCHEN REMODEL
LicenseFNa 7in Class Lic.N
Dte Sr
APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE
PIPE
' Ab7FDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURA.
yo lundecs(anJ my plans shall e used us public records
MODIIHCATION
O Z UPTO 200 AMPS
❑
y O INTERIOR [I CHIMNEY REPAIR
F.. t�i Licensed Prefirsional 201.1111DAMPS IMPROVEMENT
�99 a
OWNER-BUILDER DECLARATION OVER["AMPS ❑BATH REMODEUREPAIR El DEMOLITION
C Q I hereby affirm on I nm exempt an the ConOarmr's License Law for the
p(36F fallowingmaum.locators]onsu r.Businesshend ve demolish.
Cale:Any city orcountySIGNS ELECTRICAL ❑OTHER
YY1I LL.tan which requires n permit to construct,titer,improve demolish, fi repair any swemm
me,heit,censece.elso rcyaires thovinc sof for mchPermit ev License
Lasdnamtmm SPECIAL CIRCUR/MISC.
�y (cot mincing with
pursuant to the pmvivision 3 ft eBusi torsUreose Law(s Code)or
c.=00 (commencing is pound tSection firmen lit of basison3ofthee and Aasiom Cale)or TEMP.METER OR POLE INST. COMMERCIAL•
a a o E fhnf he is excmM thcrefmm end the basis for the allegal exemption.Any violation of ❑NEW BLDG/ADDRION ❑DEMOLITION
rn Section 7031.5 by any applicant fore permit subjecatthe applicata m a civil penalty of POWER DEVICES
nut mum than five hundred do]).($500).
[]TENANT ❑FOODSERVICE
(-=6 O 1,as owner of the property,or my employees with wages as their solecompensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will duthe work,and the structure is not intended maffered for sade(Sce.70,14,Business ❑OTHER
6'3 Fand Poressions Code:The Comforters License Law does oat apply to on owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own emplayees,pfnvided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ
late.If.howescr.'he huildingor improvement i.ssaid withinoneyearmfcompletion,the - SQ.IT.FLOOR AREA SISQ.FT.
Per-builder wil l have the bntJen a(posing that he did not build m impmve for par -
se oLsowne
EI 1,its uownernl'Neproperty,.Bexcess veld contracting witted TheCawaaar',i. TAI: V
construct the pm)cm(Sa.]004,Baseness and Prnfq�sioas GdcOThe CnnOumnrs Li-
censeLewJaesnot+pply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FL G/BO lJ7
he contracts far such projects with a contmetor(s)licensed purru0
ano the Counselor's 7 T�
License Law.
WPERMIT ISSUANCE
I am prompt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATIO[NNy
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE yt L 0) 7 a�
I hereby affirm under Penalty of pe jury one of the following declarations: ate' I v� o
❑I have and will maintain a Cenificme of Cotamm to self-insure for Warmer Campers- DRAINS-FLOOR,ROOF,AREA,COND.
notion,as provided for by Section 37M of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Immune,as required by Section
37W of the labor Cafe,for the perfomunce of Ne work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR
(Thiseation need not hecomplefW ifthe Ferrarais forms,hundred Dollars($U10) GREASE TRAP BUILDING DIVISION".IS
or lass.) PLANCHECK FEE a�
Loy any that in the performance the become
this permit is issued,I SEWER-SANITARY-STORM EA.2071 FT. �1
not employ arsyperson irony manner so as to become suM1jedmthe Workcrn Coopers- INERGY FEE
,Z Afiducaws of Culifnrnin Use WATER HEATER WNENT/ELECTR
�77 O Applicant GRADING
G NOTICE TO APPLICANT,If,inter making this Crou^cafe of EmmpJon,you should WA'I'F.R SYSTEM/IREATING $OILS FEE 10
[' become subject to the Worker's Cmnpensotion prwi sof the Lebo Cnde,you must VsJ
{✓:10 fordwiWcomply with such provisions or this permit shall be deemed revoked, WATER SERVICE "ly,
ut-
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID l .M
I hereby affirm that(here is aconswefion lending agency for the performance of Dem Receipt qtV
OPthe work fur which this permit is issued(Sec.309].Ci,C.)
U Lenders Name TOTAL:
Lenders Addro eTOTAL:
y1 certify that 1 have read this application aM state that the above information is BUILDING FEE r�
In camxr.I e m comply with all cit d roomy ordinances and state laws minting m +
g� pY he city g QTY. MECHANICAL PERMIT FEE .'O
V Z building construction,etM hereby authorise representatives of this city to enter upon the SEISMIC FEE
F-t above-mentioned prapeny for inspection purposes. PERMIT ISSUANCE
(We)agrte m save,indemnify and kap hmmless fhe City of Canadian against ELECTRIC FEE
liabilities,judgmems,comsend expenses which may Bony tiro,wemengainmseid City ALrERORADDTOMECH. �.p
in con once
the Too ting ofshis pcntdf. PLUM BING FEE
APPLICANT DERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE fps
SOURCE ,ULATIONS. > / a as 4
AIR HANDLING UNTT(OVER 10,000 CFM) CONSTRUCHONTAX �- 6
SQmmie of Applicant/Comrucmr if / 000"DDDate
EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcam or future building accup+nt score or handle hazardous nominal "BATING UNIT(TO 100,1710 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,.and the Hcahh and Safely
Coda,Section 25532(+)'? HEATING UNIT(OVER 100,000 BTU)
El Yes ❑No VENTILATION FAN(SINGLE BESIDE PAID
Will thea applicant or furore building occupant use equipment or devices which Dam Receipt M
pp g e Area
n BOILER-COMP(3HP OR 100,1100 BTU)
emit hazeNous air cmnmminams as Mfined by The Bay Arca Air Quality Manugcmcn( - .LOYAL:
District^ BOILER-COMP(OVER 100,00)BTU) t7�
C3 Yet [D No
I have mad the Inumblaus materialscements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
requi
forma Health (cry Code,
;Wrm25505,2553]esti25534.I tanoVy the
if me NEW RESIDENTIAL MECH. SQ.PT.
building tine murtenOY her" nano that it is my responsibility tano'Yfhe mcuponf
of the �mJemv,which Igglorlic trim Poor tn issuanre ofa CCer ifc �f0peu ,'.�.
Qy�Ac or uuthumud agcm /O O` vU/am�( TOTAL: ISSUED BY.
OFFICE