28821 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDINGELEcrRICAL
P1;0.MIT NO.
BUILDING DIVISION APPLICATION/i'ERMIT PLUMBINGMECHANICAL.
BUILDING
NG PROsPROJF CT IDF,NTIFICA'1'IUN 28821
BUILDING ADDRESS: �et 't'lgtarin /3�Qn SANITARY NO. APPLICATION SUBMITTAL DATE
OW RU (SC�/wt'S- L,eyy( LI
N/C CONTROL#
49 1 ARCHITECT/ENGINEER: LIC NO: Al2DRESS
Oq�'
CONTACT. PHONE: BUILDING PERMIT INFO
ALoe Coqo er Consultant Fees Paid by Applicant(Initial) BLDGELECTEELEECT PLUMB M.EEC(H
2r L9 JO .C?
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm Net I am licensed under provisions of Chapter 9(commencing JOE DESCRIPTION
nogZ th Section 9000).f Uivision3of the Business and Pr.fcssionx Code,enJ my licenm ix RESIDENTIAL: «
_0 wt PERMIT ISSUANCE ❑KITCHEN REMODEL
F W in full!urea end effect
�U License Class Llc.# ' APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
�<L Dom TSDEmr
F+ ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
Z p�Z � 1 understand my plans shell be used as public records � MODIFICATION
oz—, UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1-,4t; Licensed Profession.] 201-IM)AMPS IMPROVEMENT
14�� Oat I am BUILDER DECLARATION
Contractor's
OYER I(IOO AMPS - ❑BATH REMODEUREPAIR ❑DEMOLITION
�yj C 1 hereby affirm that 1 OWNER-BUILDER
from the RATIONr's License Law for the
Sit 9 d U following reason.(Section 7031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHERR A 0 r1
u7 W which requires a permit In conxuuct,.her,improve,demolish,or repair any structure
Ponrm its is.usnce,slsorcporex the applicant far such pe.it o Elea signed anearem SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
apo (commencing with Section']000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. "
L e C Nat he is exempt marefmm and the basis for the iffi,ed exemption.Any violation of yEW BLDG/ADDITION ❑DEMOLITION
�y Section 7031.5 by any ap,herimt for a permit suhjects me.pplicanno a civil penalty of POWER DEVICES ' EW
IaUt' ❑FOODSERVICE
hg.. y not mate than five hundred dollar($500). - _11 I Iltl V
p_6 I,as owner of the rt,orm employees with woes as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Q ❑ trope y my in Y B P []OTHER
will do fework,Carand the he Cia isnot,Lior daraw do far sale(Sec.1.an Business
mrd Professions builds
The oyes tacmts License Law dams not work
hi s if owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves Narcan,Baro who does much work himself or through
his awn employeese provided that such mentis old w ate not intended or offend for NEW RESIDEMIAL ELECfR SQ FT.
ss
sale,ILhowever,wll have the
en of
is hwithinone yew of tbuildr improve
SQ.FT FLOOR AREA 5/SQ.ET.
cof,a]],.) will have the buNen of proving that he did not build or improve for poo /�'�►�
Pon uLsowne TOTAL: vl 1 "/
❑s 1.ssownerofthe proleny,em exclusively Professions
with:)licensedcontainersi. 0IIt1 / '/_
i nswm the project(Sec.904,Business and Professions Code)The Cnnaamols Li�
cense law does not apply to an owner ofmiorty who builds or improves thereon,and QTY. PLUMBING PERMIT FEE �
whocuntmmruct
ms forsuch projects with scoa(s)licensed purawattothe Ceremonies C,. q
License law. PERMIT ISSUANCE 39'�/
❑1 am exempt unser Sec. B&P C hats;reason
Owner Data ALTER-DRAIN&VENT-WATER BDO VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE v#/ /�g'to 7
170
1 hereby am u
ffirnder penalty of perjury one of Ne following dec]urnium,
l have and will maintain a CerrilicanofConsem to self-insure for Worker's Camps. DRAINS-FLUOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTION
cation,as pmvidcd for by Section 37M of the Labor Code,for the perfonaince of the
d for which this Permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workees Compensation Insurance,as required by Section
00 of the labor Cede,fnr the performnnce of ehe work for whioM1 this permit is issued. GAS-FA.SYSTEM-I INC.40UTLETS OCC.GROUP APN
My Wark sCnm sat n �rpotrial ay�M1MZ92neV GAS-EA.SYSTEM OVER 4 BUG
Gorier. ' !icy No.: WOR '
CERTIFIC COMPENSATION
ION FROM WORKP.RS'
COMPENSATION INSURANCC GRF.AS[JINDUSTRL WASTE INTERCEPTOR -
(This section need notbe completed ifthe permit is farone hundred dollars($100) BUILDING DIVISION Fp)(S
or less) GREASETRAP PLANCHECK FEE OgaO
I cenifythat in the porfamutaeof the work for which this permit is issued,I shall SEWER-SANITARY-STORM F.A.200 FT.
nos employ my person in any manner sa as m became xobject to the Workers'Compeer - ENERGY FEE
Z and..Lows of California.Date WATER HEATER WNENT/ELECTR
Applicant GRADING IEE
tzr` NOTICE TO APPLICANT.If.after making this Cenificme of Exemption,you should WATER SYSTENMEATING
a ' become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
forhwith comply with such provisions or Nis permit shall be deemed revoked. WATER SERVICE
Q
=fz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIU SQ.M. PAID e¢ eceiPt#
L)Q Iwhi Rrm thctthem isnconswailetdin6agency for perfomrance of
for
B. the work for which this lunnit ix issue)(Bea.300Cl,C99, )
Q U U Larakeev Name TOTAL:
Landale Address - TOTAL: MIM W I certify that I have real thirty an c iun y ordinances sate Not ate show iws relatinn is BUILDING FEE
YA comingconeetoco,and withy cityandeeuntyaivesof.nd stateto enter
ntr upingm QTY. hiEClIANICAL PERMIT FEP. SEISMICFEE
U ,z buildingctmstmdinn,and hereby eoUorize representatives of this city to enterupon the
above-mentioned property for inspection pw,,xe, PERMIT ISSUANCE,
(We) nom save,indemnity and keep haemlesx the City of Cupertino against MCIN
/
Iiabilitics,judgmentx,casornnd expenses which may many way..a.......said City ALTF,RORADDTOMECH.
in nmseyuence.Toho granting ofdria#Bat he.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10,(00 CFM) E /'�S'a
SOURCE GULATI
/J«�a/.4� AIR HANDLING UNIT(OVER 10,0(1!1 CFM) y�ps�r
� J i lm
X aignamre ofApplicant/Contrater Ume EXHAUST HOOD(WMUCT) ATE) E
HAZARDOUS MATERIALS DISCLOSURE.
Willme applicant or future building occupant store in handle h...ideas math.] HEATING UNIT(TO IW,art BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Sectlom 255310)'1 HEATING UNIT(OVER 100.000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which an Ratti #
•emit hazardous air contaminants as defined by the Bay Arta Air Quality Management BOILER-COMP THPOR 100,000 BTU)
T TALI
Oisnlm4
❑Yes []No BOILER-COMP(OVER 1011,000 BTU)
I have reed Ne havvdoix materials requirements under Chapter 6,95 of Be,Cali AIR CUNUI'fIONER ISSUANCE
burns Health&Safety Cede,Sections 25505,25533 and 25534.1 understood that if the NEW RES IDENTIAL MECH. SQ.ET.
buildefgad nna Curren hsveounan0 that itis my responsibility to notify Ne eccuPant
of Ne encs nue sit be met priorm issuance is �c nf�Zenc,.
c i
CAA authorized agent Una TOTAL ISSUEDB .
OFFICE-