28814 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BUILDING-ELECTRICAL PERMIT NO. ^ a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L 4
BUILDING PROJF.L r IDENTIFICATION
BUILDING ADDRESS: [� /y t p� SANITARY NO APPLICATION SUBMITTAL DATE
V/Q/(t/m.l�tbS a# // . ! O I
O Rf AME:1 11ONE CON'FR RU'S NAME: LIC NO: l
/ a.l'i Da dI7/¢$ gw-6i" per NIC CONTROL#
ARCIETECUENGINEHIL LIC O: ADDRESS:
CONTACT: PHONE: - BUILDING PERMIT INFO
1 e� c� er 40p/ 4 061 ❑ ColtanLS t Fees Paid by Applicant(Initial) BLD EPLUMB MECH
I'1 llLICENSED CONTRACTOR'S DECLARATION nsuQTY ELECTRIC PERMITE YAr`51 ICS
1 hereby vfr Nat 1 am licensed under provismas of chapter 9(commencing JOB DESCRIPTION
�aZ Ith Section?(NM)of Division 3ofthe Businessoad Pmfesslo.s Codo.and my license is
0 n full force and effect. PERMIT ISSUANCE ;KFDWL ❑KITCHEN REMODEL
UW Date Clay Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
NQS Dote Cnmmemr
Dm ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
IunJemm�dm 1 PANELS
QZ y 7, y plans shall be used as public records � MODIFICATION
:J pppp UP702MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional' 201-IWOAMPS IMPROVEMENT
CC yEa(
y a 1 herthy nffrm OWNER-BUILDER DECLARATION
but I.,it exempt from the CrmttucmYs License Law forme OVER 1000 AMPS (]BATH REMODEUREPAIR ❑DEMOLITION
x 36 U following reason.(Section 101 IS,Business and Professions Code:Any city or countySIGNS ELECTRICAL
❑OTHER n .-Os • -
li] O which requites a penNt to construct,almr.improve,demolish,or or'ir any strvcmre g
proton its issuance,also requires Nevpplicamfranch permitto flatid,redstatement SPECIAL CIRCUMMISC.
} that he is licensed pursuant to the provisions ofthe Convectors License Law(Chapters)
GAO (commencing with Seeuon'Ifl(gl)of Division3of Ne Busineu and Proressinns Cade)ur TEMB METER OR POLE INST. CoMMAR&I
q o y
that he is exempt therefrom and NN
e basis for e alleged exemption.Any violation of QC❑NEW BLDG/ADDITION'9 DEMOLITION
Section 70115 by vnyapplicam l'or a permit subjects the applicant o a civil penalty of POWER DEV ICES 04 ANT ❑FOODSERVICE
1WF.Zy
at moo Nen five hundred dollars Will E f f l�
pq6 Las owner oftheproperty.orm employees with wants as theirsole cram tion, IMPROVEMErNT tfYl /'
C2C2 tC+0 ❑ tYB ,ansa SWIMMING POOL ELECTRIC
IJ�y
will do the work,and the hemacaumCou is not intended License Law do for sale(gee.)M4,owner
of ❑OTHER
W and Professions Code:The oommereos License law docs not apply tom owner of OUTLETS-SWITCHES-FIXTURES
property who employees,
or improves Hereon,and who does such work himself or through
his own employeese provided that such imm a,sol w are not intended or'terra,for NEW RESIUCNTIAI.ELECT SQ IT.
.R.If.holder will have
building., a,sold did nd build oimprovetfor put- SQ.FT.FLOOR AREA &SQ.PI'.
'-builder will have the burden of proving that he did not buil)or improve for poli- /x I ��
pmeeo(saleJ'
❑I,as owner of The property,sm exclusively contracting with licensed contractors to TOTAL:
convect the project(Sec.70fq Business end Professions Cade:)The Cm memo's Li-
cense Law does not apply to an ownerofpropeny who builds orhapeoves thereon.and QTY PLUMBING PERMIT FEE
whacommcts for such ptojects with a cotnmxor(ad licensed pursuantto the Covtncm/s
License law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reason
Owner Date
ALTER-DRAIN&VENT-WATER(FA) VALUATION
/�.
WORKER'S COMPENSATION
he
DECLARATION BACK FLOW PROTIiCf.DEVICE '/7 �� 7 C10.
I herebyaRtm hy under,angper
pry of jury e o(Ne following dMarations:
❑I have and will maintain aCenificate of Consentto self-insure for Worker's Conti DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sari..,as..t vided far by Section 3700 of the Unit Code,for the permnnance of the
work far which this Permit is issued. FIXTURES-PER TRAP
❑I have and will meinmin Workers Compensation Insumvus,as required by Section
J]N)of Ne Lman Code.for the performance of the work far vi this permit is issued. GAS-II.SYSTEM-I INC.4 OUTLETS OCC.GROUP -APN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXI!MPTION FROM WORKERS'
COMPENSATION INSURANCE GRI?ASE/INDUSTRI.WASTE INTERCEPTOR
(This section peel not W completed ifthe parrot is forme hundred dollars($1 00) BUILDING DIVISION FMS
orlessJ GRF.ASE'rRAP PIANCHECK FEE 0
I certify Net home perfanname of the work for which Nis permit is issued.I shall
not employ any person in my manm manner cert to become subjectto the WorkSEWER-SANITARY-STORM EA.2W FT.
Worker.'Compen- ENERGY FEF.
Cz action Laws of California.Date WAIF EE HEN]ER WIVENUELECTR
zO rot GRADING ME
s-s y
NOTICE TO APPLICANT,If.after making this Certificate of Exemption,you should WATER SYSTEM/fRPATING
ai heome subject to the Worker's Campensatimi provisions of the Lmar Cade,you road SOILS FEE
LiI fonhwithcomply with such provisions or this permit hall far deemed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDINGAGENCY NP.W RESIDENTIAL PCMB SQ.FT. PAID
LJ Q I hereby affirm that Nare issued i xcti097,Cis,agency far the performance of Dole Receipt#
{L H
are work for which this permit is issued(Sec.J09?,Civ.Q)
Q Lenders Name TOTAL:
L) Lender s Address TOTAL:
Ha 1 certify that I have ithJ this application and stem the the above information is BUILDING FEE -��a
h
contact.)agree to comply with all city and county ordinances and citystateto
relating a QTY. MECHANICAL PERMIT FF.B
LJ building hereby mthon urposes. moves of Nis city to eater upon the SEISMIC FEE Q
above-mee)und agree
for indmnifyan keep ha PERMIT ISSUANCE
(We)uglier m cove,indemnify and keep hay in an the y ac of Cupertino idCtagainst ELECTRIC FEF,
liabilities,judgmentse granting expenses thisPermit.
may in any way ewrve against said City ALTER OR ADDTOMECH. /7 16U
.consequence of Nc Bmmipg of this permit. PLUMBING FEIi O 77
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) MECHANICAL PEE 17,114511
SOURCE ULATION
AIR HANDLING UNIT(OVER 10,gMCFM) CONSTRUCIONTAX
/0%/93 36s;66
Si nwre o(Applican Ai?lARcor RE EXHAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the appllcum or future for Iding occupant store or handle hazardous material HEATING UNIT LTD IOILDW BTU)
az refined by the Cupenino Municipal Code,Chapter 9.12,and the Health sand Safety
Coda Section 25532m)? HEATING UNIT(OVER 10k"BTU)
❑Yen 7 N PAID
VEMILAJ'ION PAN(SINGLER&SID) Data Receipt#
Will the applicant or future building..,sum use equipiner,at devices which BOILER-COMP OHP OR IOO,t%I0 B'DB
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL: Q
Distrix?
❑Yes ON. BOILER-COMP(OVER 100,000 BTU)
I have read the harrdate
aous materials mr,iaments under Chapter 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
forma Heald&Safety Code.Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDEMIAL MECH, SQ.FT.
building Ngg�gg�jjJ��Jnntcurtentlyh atenanL that it it my reslamsibtht ns nomfyi par
ofthwhi sr'Foe met prior to massa cq�a �Enta�"A
Dinner or auto hnrimil agent /(!'—J Dote TOTAL: ISSUED BY:
OFFICE