28809 (2) I
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY 01 CUPERTINO y �_! I ". BUILDING-ELECTRICAL PERMITNO.
Bt APPLIC I ATION/PERMIT -MECHANICAL
DILDING DIVISION PLUMBING
BUILDING PROJECT tDrbnrIFICATION 28809
BUILDINGADDRESS: SANITARYN APPLICATION SUBM DATI
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e CONT3A=R'S NAME LIC NO: (C—)77 cl'�
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ARCHITECTIENGII, LIC NO ADDRESS E3
CONTACD. PHONE: BUILDING PERMIT INFO
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
6 0 6 ic I 'IS TK
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LICWED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FE-E
I hereby MEM,that I..licensed tude,poommom,.1 Chapter 9(emorMating JOB DESCRIPTION
QXZ R!SIDENTIAL
Poo in fall Moc,add effect. PERMIT ISSUANCE
License Choo—Lic.N FDWL [I KITCHEN REMODEL
Data—C.M.1.1 APPLIANCES-RESIDENTIAL r11ADDITbON 0 PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS [I MULD-UNIT 0 STRUCTURAL
z0F,z I understand my plans mall be,used as public recouls MODIFICATION
__4 M_ UPTO200AMPS [I INTERIOR 0 CHIMNEY REPAIR
cil Licensed Picusit...I 201-1000AMPS IMPROVEMENT
gOVER I"AMPS C3 BATH REMODEUREPAIR [:1 DEMOLITION
I:I OWNIiR-BIALDER DECLARxrToN
< I hereby affirm that I and exempt from the Contraclor's License Law for the
U following reation.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL 0 OT14ER
0 which equates.feannit 1. mumouct.air,,,improve.dearololtor repair any somemm,
prior to its siliurce,also requires the applicant for such twout to rile a signed scomarm SPECIAL CIRCUITIMISC.
'hot he is licensed purisuant to the previsions(if 0in Contractor's License Law(Chapwr 9
lecounercia,widt Section 7(XX))of Division 3 of the Hominess add Nor..MasCcdc)., TEMP.MBI ER OR POLE INST. COMMERCIAL:
hat he is exempt therefrom and the basis for the alleged exemption.Any vu'lation Of El NEW BLDGIADDITION El DEMOLITION
Section 701 IS by any aliplicam for a permit subjects he ii,plicam to,civil penalty of POWE DEVICES
R []TENANT El FOOD SERVICE
not a.than five hundred dollars($500). IMPROVEMENT
E)1.as owner of the Property,Or MY CMPIOYMS With wages as their mile compensation, SWIMMING POOL ELECTRIC
will miae .,k,.nd he smicatim or.,inacridecimmTeed for.1c(See 7044,Business E)OTHER
ad Profession,Came:ne Cismassam's Lt...Law duc�l a.,apply to An moser of OUTLETS-SWITCHES-FIXTURES
property who builds M,inaterwas therem,and h.it.,,such w k himself.,armulth —
his own employees,previdad that such improvements am not intended or offered for NEW RESIDENT IAL ELECTR So pt�r,
sair,11 least an,building or improvement is sold%ithin one year of completion.the — SayFT.FLOORAREA $/SQ.FT.
owder-buililer will have do,burden ofpcoving that lit did not build or improve for pur,
prom, fxalt,�Y
1,assoame,offlo,propsoy,sou,scluviyel,,onnowfing will licensed communchmaw TA(I 01/ 00
project(See 7044.Business ad Proicialmis Code:)The Courteou's Li- —
cense Law does not apply to an Owner of property who builds or improves themon,and QTY. PLUMBINGPERM17 FER
who contracts for such projects with a contracturts)licensed pursuant to the Contractor's
License 1... 3"?
E] I am exempt under.Sce. R&P C lot this reason PERMITISSUANCE
Owner ALTER-BRAIN&VENT-WATER(EA) VALUATION
Dole
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I menchrdfirm Maker penalty offecary one of the killowing declarations: .1,
C]I have and will maintain a Certificate ofConsem in sall-maire forWorker'.Camper- DRAINS-FLOOR,ROOF.AREA,COND. STORIES 11 TYPECONSTRUCTION
sman.as Provided for by Section 37M I the Labor Come.for tho peff...ec of the —
work for which this permit is issued. FIXTURES�PER TRAP
[]I have and will maintain Workars Compensation Insurance,aii required by Section —
37M of the Labor Coade.for doe perfAntrance of the oury for which this permit I,Boost. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
MY Wculat Compensation Insomniac,carrier and Poll,,manalat xsm�
Cancer. Policy No, GAS-EA.SYSTISM-OVER 4 HIA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUNDUSTRI.WASW.INTERCEPTOR BUILDING DIVISION FEES
Or less)Clux sectimaractirid k completed tribe permit is formin hundred doll.(SIM) GREASEIRAP PLANCHECK FEE
1,enify dust in the ps,fornamosifth,otork far which this peorit is issued.Idaill SEWER-SANITARY-STORM EA.200 PT. ��
ENERGY FEE
Z adimi Lia,sofC.1ifiermit Date
0 WATER HEATER W/VENTfELEC7R
Z Applicant N GRADING
N kCOMC m1loject to the Workers Compensation provisions of the Labor Code.you must soil's_FELOCT 27 IMF—
OTICE IOAPPLICANT:If, Be, eking this Ctrdfiodeof Usempfle., .a should WATER SYSTEN47REATING ME
farbasith comply with such previsions or this permit shall be deemed revoked WATER SERVICE V,7 3
W,I UP ot
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID �J)
U 0 Do. Receipt#
'he work for which this permit is issued(See 3097,Civ.C.)
Lender's Name TOTAL:
0 UndmeaAddress TOTAL:
CL I cenify that I have mail dus application and state that the above information is BUILDING FEE
l,!) correct.I agree to comply withal]city add county ordinances and mate laws refining to QTY. MECHANICAL PERMIT FEE
latfildiralcurchooti.mmethemb,mancrim,otpreirromists fibia city wemertuamthe SEISMICFEE -
sibown-inumationed limperty far iMpostimi imulaosei PERMIT ISSUANCE
(We)Hipme to save,indemnify and keep harmless the City of CuKrfino against ELECTRIC FE�E
liabilities,judgments,costs and expenses which may in any way accom against said City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence Of the granting of this Perri 6%72
APPLICANT UViRSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO HO."Clon MECHANICAL FEE
SOURCE RED ATIONS. A%7.1
AIR HANDLING UNIT(OVER lf,000 CFM)
CONSTRUCTIONTAX
SittraliffirelifApplicitrUCmummar e a, Kate EXHAU,STHOOD(W/DUCG HOUSING MITIGATION ME
HAZARDOUS MATERIALS DISCLOSURE
WHI ilitiriplicaut or future building oc,itporum.m.,handle hersoommus noterid HEATING UNIT(TO 100.002)BTU)
as defired by uc Cupertino Municipal Code.Chapter 9.12,and are Health mal Safety
Codo,Section 2553200? HEATING UNIT(OVER 100'"BTU)
E]Yms FIN. VENTILATION PAN(SINGLE RESID) PAID Data Retain'4
Will be itittelix.ra or future building occolistat use equipment or devLes,x which A 0--
it becumhous air contanninants te clefined by the Bay Am Air Quality Management BOILER-COMP(3HP OR 100."BTU) T
District[?D Yes []No BOILER-COMP(OVER 100,000 BTU)
11haversuall hatimmus materials requirements under Chapter 6.95 of the Cali.. AIRCONDITIONER ISSUAN
roodan Him",,S
a He"" S "YC�te,S�tionq25505,25533�,n,tZll34.1��d��,�.dffi.tifffic NEWRI'morw0st.stwn. SQ.IT
dins cas ame ocal
1, is/dmsu�ntly have a iW,that it is my responsibilily to act th1h,ocXom
he us ents,shch m 'p..Or to"Mar"of I C F,,nl
re, at,vs, 11
e
miu&.ee_ _1ISSUED
moss,r t 00 TOTAL] ysy�e
OFFICE