28828 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CI TY OF CUPF.RTINO BUILDING-ELF,CTRICAI. PERMIT NO. 28828 a�
BUILDING.DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L ISlJ CYJ'LJ
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: / SANITARY NO. APPLICATION SUBMITTAL WM
D zAi5 ArL"ia PkX B 30 •?,6
1� PHONE: COM CIOR'S NAME: LIC NJO,: N/C CONTNOLM
' a 10-nROM0 SV SS-6060 ( Cunei- 38'9a
ARCHITECVF.NGINEER: - LIC NO: ADDRESS:
CONTACT: - PHONE; BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed order provisions of Chapter 9(concing JOB DESCRIPTION
WOE• withSectinn](g10)of Division)of Ne Business aJ Pmfcssions Code,and my license ix
in full force andeffect. PERMIT ISSUANCE. VNFQWL ❑KITCHEN REMODEL
�U License Class Licp
Date Crrwcmr APPLIANCES-RESIDENTIAL AD ION ❑PLUMBING RE-PIPE
n' ARCHITECT'SDECLARATION
PANELS ❑MULTI-UNIT ❑STRUCTURAL
z p Fi Z� I understand my plans shall be used as public records MODIFICATION
O Y JJ UP TO 200AMPS
O ❑INTERIOR [I CHIMNEY REPAIR
ASICC"' Licensed Professional 201-HIOOAMPS IMPROVEMENT
�IX OWN[.exempt
Rm Ce CommoDN OVER 1000AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
IX.x.16 I hcrehy affirm on 1 am exempt from the Gonion License Law for the
O"y U following reasna Permit
compact,
t,alter.
improve,
Professions h,or Came: sty tiny nr county SIGNS ELECTRICAL. ❑OTHER
sea 3 LL Fm¢ wM1ich requires n pcmtil to construct,olner,impmvq demolisM1,or rcpau any structure
prior to in iswance,also requires theapplicann fm such Person 10 Ile a signed"element SPECIAL CIRCUIT/MISC.
y thatlarklicemedpurauam to the provisions ofrhe Contractors License Law(Chopter9
W`yO0 (commencing with Section]ogp of Division 3 of the Business and Professions Code)or TEM P.METER OR NILE I N ST. COMMERCIAL
W0M that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 101 Ll by sty applicant for u peandiul erl,the applicant madvil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
no'
more than five hundred dollars($500). IMPROVEMENT
.= a owner ofthe pamvmt,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
y2 wdldothework,and the suucwmisnol imm�dedoroRarW for sale(Sec.01W4,Busineu ❑OTHER
Y1 err Profes.inns Core:TIm Conuaztoe,,License Law does ort apply nt m owner of OUTLETS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or through — ?
his own employees,provided but such improvements are Irl imerded Or offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.If howevca the building or improvement is sold within one yearrfsmmpleiok,the S ---- --- $/SQ.FT.
owner-builder will have the huNenof proving shut he did nm build or improve for par-
pose of sale.)).
C]1,as owner of the property,am exclusively computing with licensed cnmuactas no TOTAL:
construct the project(Sec.]BN,Business and Professions Calc)The Cnntracwrs Li- (y
cense Law does not apply to an owner of property who builds Or improves thereon,and QTY. PLUMBING PERMIT FEE ( CCC
who comtmcts forsuch projects witha contracminG licensed pursuant to the Conuaeors
License Law. PERMIT ISSUANCE
1 an exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(IiA) VALUATION '�J
Owner Date / L✓ l
WORKER'SCOMPENSATION
on DECLARATION BACK FLOW I'RO TECf.DEVICE
1 herebyill smi under Certify of perjury one of the following Wakm's Coupler-
oo
❑Ihave and will main by econl37Mcate of Coastal Later Code,for
for Worker's Comp the DRAINS-FLOOR,ROOP,ARFiA,GOND. STORIES TYPE CONSTRUCTION
smirk,as provided far by Section 3](X1 rf the I�rbor Code,for the petfonnaae of the
k for which this permit is issued. FIXTURES-PER'1'RAP
37th have and will ode.for Workers Compensation work
which
h required by Section
3]00 mkt, C rix, for the performance of the work for�1pwq�phV�ijdrynrrhgqis permit is issued. GAS-EA.SYSTEM-1 INC.40IITLETS UCC.GROUP APN
MY Policy
Card Policy
u2cnLppri Poly N.:nlJL//!/�9rqGAS-EA.SYSTEM-OVER 4(EA) r(� �.
//__ lICERTIFlCATElIOFtYtt�33(EMPT'ION FROM WORKERS' P A
r COMPENSATIONINSURANCE GREASNINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION MUS
(This section need nm be<omplcted ifthe permit is frronehundreJ dollars(g11U)
or less) GREASB TRAP oe
Iccnify morin the tvaynmtaaerftheworkfa which to
permiti.ers'Col Wall ENMG ECKFFM1Eg
SEWER-SANITARY-STORM EA.200 FT.
not employ umy perann in any manner soon to hearme suhjce In the Workers'Cooper- ENERGY FHn
oZ cation Laws of Cal ifomia.Da¢ WATER HEATER WNENT/ELECTR (B
z � Applicant GRADING FEE � '•f7/If�•U
L.•.y NOTICE TO APPLICANT:If,sitar making this Certificate of Exemption,you should WATER SYSTEMITREATING
�i become subject 1.the Workers Compensation provisions of the Lobo,Cade,you and SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENUINGAGENCY NEW RESIDENTIAL PLMB. SQ.PI'. PAID
U O Iborw which
his
that them iss issued(Sec.
ding agency for the performance r( Dnm Re<eiptM -
LT. '•� the work for which this permit is issue)(Sec.)119],Civ.CI ,
O� U Lenders Nance TOTAL:
FaLenders Address TOTAL:mu / •-�
I certify Nal I have J this application and stehimhimle the above inLrnnatME
is BUILDING E Y
In correct.l agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
L) z building consaucnion,andhereby authorize representatives Ofthis city tanner upon the SEISMIC FEE �Sje
r stave-mentioned pr.,ny for inspection purposes. PERMIT ISSUANCE p p
(We)agree Io save,indemharmless
nily end keep the Cary of Cupertino against ELECTRIC FEE
Iiabllifies,judgments,costs and expenses which may in any way secure against said City ALTER OR ADD TO MECH. PLUMBING FEE 3y,'Sr�
in consequence of the granting of this permit. If
APPLICANT 'NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO FLOW CFM)
SOURCER ULATIONgMECHANICAL PER 113e T�I'
.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTIONTAX LGeaf
SilLoifink of Applicant/ConmctOF Our�{2 EXHAUST HOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant orfmurt building occupant store orhandle hmmdous normal HEATING UNIT(TO I00,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely r
Code,Section M53200? HEATING UNIT(OVER 100.000 BTU)
E3 Yes ❑No
VENTILATION FAN(SINGLE RFSID) PAID
Will thea applicant or future building cu ant use e I or devices which Date Receipt It
pp gat a yuipr Qu BOILER-COMP(3HP OR 100,001 BTU)
mit hazardoms air contaminants as defined by the Bay Arta Air Quality Management TOTAL:
-17
District?
E2 Yet ❑Nn BOILER-COMP(OVER 100.000 BTU)
Ihave res the haardous artificial.responders under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCEDATE
man is
Health afcly Code,Smlions 25505,25533 and 25534.1 urdernn al(hut if the N13W RESIDENTIAL MECH. SQ.FT.
building d of currently hal •ant Nat it is my responsibility to tify Ne cupant
of the morms.hich amen prior no issuance ofu Ce�f (/yylu/mom
O aul�io�n�zW egem /I� [)are TOTAL: IgSUED BY:
OFFICE
01/19/1996 15:59 4089858668 MACKAY & SOMPS PAGE 02
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01/19/1996 15:59 4089858668 MACKAY & SOMPS PAGE 03
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TRACT No. 8887 CITATION HOMES
CORSICA at PORTOFINO WMA awu. MIF001A
cu NO CALWORNIA SCALE:1--20 DATE: i/IS/W jJC8 NO. 15230-1
01/19/1996 15:59 4089858668 MACKAY & SOMPS PAGE 04
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TRACT No. 8887 c 1 TAT1 O N 'HOMES
CORSICA at PORTOFINO SARA CLARA. CALW MIA
Cup=N0 CALIFORNIA SCALE;I--20 GATE: 1/1e/io d()B w0. 132x-1
01/19/1996 15:59 4089858668 MACKAY & SOMPS PAGE 05
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