28815 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM IT NO. t1/� //�1 .E r
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /}( ]eF l
BUILDING PROJFICTIDENTIF'ICA'1'ION L 8 t8 11 5
BUILDINGADDRESS: ,pp - SANITARY NO. APPLICATION SUBMITTAL DATE
ev tat Va/armors P14n4*3 .4ot*/c7 !6 2
O R'S AMF: PITON CONTR OR'S NAME: LIC NO:
Gt /Bq Ori{♦ B as=6aeo �"-Vn er N/C CONTROL#
ARCH11TCT/ENGINEEIL LC N4 ADDRESS: _ ❑
CONTACT. PHONE: BUILDING PERMIT INFO
gss=66 6/ El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MCCH
7
LICENSEDCONTRACoORPS,prolOmoof CON QTY. ELECTRIC PERMIT FEE
I hereby n.l that I,m licensed under pmvixione of Chapter 9(commencing JOB DESCRIPTION
X00 withSectionodeffafDivisionSoffit,Busincssand Profesxi.nsCee,and my license is RESIDENTIAL'
WO in full farce end effect PERMIT ISSUANCE
�WU License Class Lie.# - ❑SFDWL ❑KITCHEN REMODEL
Date Connector APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION MULTI-UNIT (:1 STRUCTURAL.
ZO' I understand my plans shall Is,users public re cords PANELS MODIFICATION
O Z— UPT0 2W AMPS
r4H ,, INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 20141100 AMPS IMPROVEMENT
hP mat I...examDHR m the RATION
FFyi7 CC 1 hereby affirm that I um exempt from the Contractor's License Law for the OVER IOm AMPS El BATH REMODEUREPAIR 0 DEMOLITION
sd 3 6 U following reason.(Section 7031.5.Business and Professions Code:Any airy or countySIGNS ELECTRICAL [IOTHI7R
YI Y. which requires a permit to commuct,alter,improve,demolish,or repair any structure
m.]�a2 prion,IN inuance,alsn requires theapplicam for such permit 3o tile.signed statement SPECIAL CIRCULPMISC.
aZ that he is licensed pursuant to the provisions of Ne Contractors License Law(Chapters
GCO (c.mmenemg with Section?Hough.'Divisinu 3ofthe BMincnind Prefesdans Coda)., TEMP.METER OR POLE INST, COMMERCIAL:
6 c m that he is exempt themfrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'^ Section by any applicant far,famulsubjects the applicant to acivil penalty of POWER DEVICES
-sy ❑TENANT ❑FOODSERVICE
s„ p., umom man five hundred dollars(SSW).
= - IMPROVEMENT
SaF�
El 1.as owner of the progeny,or my employees with wages as their vole compensation, SWIMMING POOL ELECTRIC
will arms work,and the structure is not intended Or Offered for sale(Sce.7044,B.dness - ❑OTHER
and Professions Code:The Commences Licence Law does dot apply m er owner of OUTLETS-SWITCHES-FIXTURES
property who builds nr impowes thereod,end who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENT IAL ELECTR SQ Fr.
ma.If.however the building or improvement is sold within one year ofeompletion,the SQ.FT.FLOOR AREA &SQ.pT.
-buildeder will have the burden of Proving that he did oat build or improve for pun I
g���Posit craft.).1,as owner of the progeny,am exclusively contracting with licensed connectors to TOTAL:
ceramic,the Project(Sec.7W4,Business and Professions Code:)The Commenus Li-'
cense Law does not applyman owner Ofpmpony whobuilds orimproves daemon, Q'T'Y, PLUMBING PERMIT N� rE. (/V
who contracts fill such projects with u connectors)licensed P rommuo the Contractor's
License Law. PERMIT ISSUANCE
lam exempt under Site ,B&P C forthis reason
Owner Data ALTER-DRAIN&VENT-WATER RIA) ^- ' VALUATroION
WORKER'S COMPENSATION DECLA RATION BACK FLOW PROTECT.DEVICE N/GJ ail 7. r
1 hereby effidn under penalty of perjury one of the following declarations:
❑I have and will maintain a Contrition of Consenuo self-insure for Worker's Copper. DRAINS-FLUOR,ROOK AREA,GOND.
sation,as provided for by Section 3710 of the Labor Cade,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is round. MCPURFS-PER TRAP
❑ I have and will maintain Worker's COmpunsadnn Insurance,as required by Section
37W of the Labor Code.for the performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Worker's Compensation Insurance carrier and Policy number me:
Cartier: Policy Na.: GAS-EA.SYSTEM-OVHR 4(EA)
CERTI FICATF:OF FAEM"ION FROM WORKERS'
COMMNSATION INSURANCEGREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIV]
ThiSION FI?ES
( s section turd not he complete ifthepamdt is for one hondredaIIMv(El W) GREASETRAP
nr less,) PLANCHECK FEE a�
literary that
pecom in performance r...bek rine which this permit is issued,I SP.WER-SANITAkY-STORM EA. FT.
not employ any#erten in any manner m as m become subjecuo the Worker%C.mpen- ENERGY FEE
s,tion Laws of California.Date Wgl'Ell HEATER W/VF.NT/EI.ECTR
7 Q Applicant GRADING FEE
q NOTICE TO APPLICANT.If,after making this Carrolton,of Exemption.you should
WATER SYSTEM/TREATING
ai become subject to the Worker's Comparison..provisions of the Labor Code,you at SOILS 17EE
{kI F.t
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
4. ^ wherebyink
afflmuhatroni issued construction lending agency for the Performance of Doe - Reoeiptp
4.0[[[.y... ohework for which this permit is issued(Sec.]09],Civ.C.)
Lender's Nadu TOTAL:
Lender's Addmsa TOTAL:
1 certify that 1 have rend this application axil state that the above infonnetion is BUILDINGFEE
to correct,l agree to comply with all city and county ordinances and suite laws relating to QTY. MECHANICAL PERMIT FEE 7�
V Z building connotation,and hereby authorize representativesFE
Of this city to enter upon the SEISMIC E
above-mentiored property for inspection Purpose.. PERMIT ISSUANCE m
(We)agree Rs save,indemnity and keep harmless the City Of Cupertino against ELECTRIC FEE 03i
liabilities.judgments,costs and expenses which may in any way accmeagainst said City ALTER OR ADD TO SUCH. PLUMBING FEE
in nscquente i f the granting of this permit.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBJAO CFM) MECHANICAL FEE /ry
SOURCE GULATIO' /)tel �3N o
.// Xtn4 / j /�aAIR HANDLING UNIT I0,00CFM7
(� CONSTRULTIO 11 . 66
SI uoureof Applicant/Contriffaor EKHAUSTHOODOV/DUCT) HOUSING MITIGATIi
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or furore building omupnm nom or handle harmrdous material HEATING UNIT CPD 100,000 BTU)
as defined by the Cupenino Municipal Cale,Chapter 9,12,anti the Health and Safety
Cade,Section 25532(.)7 HEATING UNIT'(OVER I TQ(W BTU) g�/P
CI yes C]No PAID(It_ _
VENTILATION PAN(SINGLE RESID)
Will the applicant or future building Occupant use equipment or devices which One'rsT// Receip t#
emit hazardous air conmminonts as defined by the Bay Area Air Quality Management BOILER-COMP IMP OR 100,000 BTU) r as
District?
Yes El No BOILER-COMP(OVER 100,000 BTU) #
I have reed the hazardous material.requirements order Chapur 6.95 of the Cdi AIR CONDITIONER ISSUANCE
DATE
fomia Health at Safety Gdq Sceoinns 255(15,25513 and 25534.1 understand that if the NEW RESIDHN'1'IAL MECH. 1
buddingd muncndy termist,that it is MY resp.s b'I'ty to ndify the accused t
of mmenrsw ' ust be mm Prior to lsytat,Xe eCelti(yttgyyf'Qnupancy. ����.[/J
Oorized agent t �b// ~,Dam TOTAL: ISSUED BY:SLTI'
OFFICE