28846 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
•CJTY OF CUPERTINO I I ,BUILDING-ELECTRICAL _ PERM]TNO.
r'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -
BUILDING PROJECT IDENTIFICATION 28846
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
. OWN M1 .PHONE: 'O 'S ME: e- LIC NO:
NIC CONTROL p'
ARCHITELT/ENGINF.. : VV x, � / I.V �/ AU ES ' CF<�/!/I��ZSr /T�•l�V'. ❑ ��
`` CONTACT: PHONE. - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE(7 MECH
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under previsions of Chapter 9(commencing QTY
B DESCRIPTION
�aZ with Section 7")of Division 3 ofthe Business and Professions Code.andmylicense is1!0
WOO PERMIT ISSUANCE RESIDENTIAL:
F�WF in Cmceand effect. 2--5 /7/ ❑SFDWL HEN REMODEL
aVV LicenT usI 'untr J—�J •7 7l APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE
. yea Damrx� Cnntrncwr /�
ARCHITECTS DECLARATION
OZ _ PANEI ❑DMULTI-UNIT El STRUCTURAL
zc,rz MODIFICATION
1pT02tMPS
INTERIOR 11 CHIMNEY REPAIR
F�^ cen. J Prote: oat - ,201-1(RX)AMPS . IMPROVEMENT
OWNER�BUILDER DECLARATION '
C4 J y o' n p License Low for the - OVER 1000AMPS ❑BATH REMODEIJREPAIR ❑DEMOLITION ,
Q 1 hereby Ilia the 1 ore exam ffoiit the Commnors
314 F following reason.(Section](131.5.Rosiness and Professions Code:Any city m county SIGNS IiLCCTRICAL ❑OTHER
m which requires a permit to cnnstin t.alter,improve,demolish,or repair any swmure
E' pnnrt t i.:uane al:nrcyul c:the applicaml such pc iu fl g ed smtement SPECIAL CIRCUIT/MISC.
la dente Ic dp . tl the p ns fth Contractor,L Law(Chapter9 15
W 00 (commence, nh Secti n7000)of D' :ion 3 of the Ba,inessand P C..bus Code)or TEMP.METER OR POLE INST. COMMERCIAL: .
0.a cy mat he is exempt therefrom and the hese.for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC^u• Section 90315 by any applicant for permit subjects the applicant m a civil penaltyof POWER DEVICES
W^rn ❑TENANT (J FOOD SERVICE
R. not more man five hunr lata (p).
w=C I,as owner of the proper) n mpinyecs with wages ��1555���I555III���comp11irsi oq SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
a,F.o will do Ne work,undrhawor a t intendcdomffermlf if ]O14.Business ❑OTHER
aim and Profs a sCaMe: names Livens d not 44 man owner o. OUTLETS-SWITCHES-FIXTURES
Property who it so i 'a,thntrnn.and s loch cork himself or through
his own amp a vided that such imply, s aim not intended or offered for NEW RESIDENTIAL ELEM11 SQ FT.
ede.IC he adding 7rnNs d withinoneyearofmmpllam ma SQ.FLFLOOR ARFA\, SISQ.FT.'
mer-builder leave the bP �virtu the he did not build or improve for Pur- - V' Lu U IJ .
Text of mlc.). 1
01.as owner of the proi am exclusively contracting with licensedcontract...m SEP 2 1995
construct the project(Sec.7044,Business and Prefe.sumas Code) „, Li-
e Conwabr'I
cause law does not apply to an owner of property who builds or improves thereon,amt QTY. PLUMBING PERMIT FEE
whoeontmetsforsuch projects with a mntmemr(s)licensed pursuant m the Contaaywes •t•� n�11
License Law. PERMIT ISSUANCE CII I Uf UUMHI�NO
❑1 am exempt under Sec. .B&P C for this mason
Owner
ALTER-DRAIN&VIENT-WATER(EA) VALUA'JION
Date _
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO I'ECL DEVICE (� �•N/R�k�
Ihereby affirm under penalty of perjury one of the following declarations:
•�I huveand will ntuinminn Ccnificate ofC...cntuimlf-insurcf..Woder..Cmr,m DRAINS-FLOOR,R(IOP.AREA.CONE, - STORIIESTYPE CONSTRUCTION
sation,as pnvi lad on by Section 39[X1 of the Luber Code,for the performance of the
work fur which lhic permit is reseed. FI%TURES-PI7R TRAP
❑I have and! ll onainai.W k Comp r l c 9 d hY$eginn
37m)of the 1-abor Code,f [lie performance f the workfor wh hd':Patron is issued, GAS EA SYSTEM-I INC.4OUTLET9
OCC.GROUP AfN
My Worker's Compcnsution lnmmnoe currier and Policy number me
Csaicr: Policy Na: GAS-EA.SYS'11I?MOVER 4(BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASBn NDUSTRL WASTE:INTERCEPTOR
BUILDING DIVISION FEES
(Thi ,11lionnmd not hccompload ifthe permit is tome hundred dollars SIM)' GREASE TRAP /
.r less) - PLANCHECK FEE
Ia.Ify that in the parformarae of the work for which rids permit is issued,)shall SEWER EA.200 FT.
n mploy .any penton in tiny ma99pp�Cr so��as��to become subject rat die Wmkeis'Compen- ENERGY FEE
OZ anon law.ufC /I WATER HEATER WNENT/ELECTR
RAApplicant LG YY � GRADING FEE
.mi, NOTICE� :IE after making this Certifcae of Exemption,you should WATER SYSTEMITREATING
Fa > become subject to the Workers Compensation pr.visions of the labor Cri you must SOILS FEE
(El forthwith comply widawth previsions or this permit shall be domed revoked. WATERSERVICE
ap
Uz CONSTRUCTION LENDING AGENCY. NEW RESIDENTIAL PLM1/R. SQ.FT. PAID Dare
VQ l for
rwhich ren marmiteisaed(Seconstruction lending agency for the perf.rmanee of
me workfor which this permit is issued(Sec.3097.Cie C.) '
F' Lenders Nanta TOTAL:
V lender's Add...x
I certify that I have read this applicmion and state that Ne above information is BUILDING FEE
y coal Iagree it)comply with all city and countyordineares and state laws offering to QTY. MECHANICAL PERMIT FEE
(.) ,7, building construction,and hereby authonzerepiesentatives of thiscity to emeropon the SEISMICF
above-mentioned progeny for inspection purposes. PF.RMITISSUANCE237 ./�
(We)agmf to.save,indemnify and keep harmless the City of Cupertino against ELECT
liabilities,judgments,costs and expenses which may in anyway terms,against said City ALTER ORADDTOMECH.
inconsequence at me granting of this permit. - PLUMBIN EE
a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI,(TO P),Pod CFM)
' SOURCE TION' /� MECHANICAL/3 I-'
La� AIRHANDIJNGUNH(OVER 10,(WCFM) CONSTRUC'PI NTA%
le
, gnamre ,,Hrant/Conmuctnr - Dalle EXIIAUS'TI OOD(W/DUCT) HOUSING MI'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building weepart store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defurad by the Cupertino Municipal Crede.Chapter 9.12,and the Health and Safety
Coda Section 25532001 HEATING UNIT(OVER 100,000 BTU) ,
E3 Yet MN. - VENTILATION PAN(SINGLE RESID) PAID
Will the a iirmo ur farum buildin t use e t or devices which Date Receipt 0
pp gwcupan 9mpmea BOILER-COMP(3HPOR Ifq,t100 BTU)
r hazardous air contaminants as def neA by the Bay Ae.Air Quality Management TOTAL:
a isuict? Yes ❑NoBOILER-COMP(OVER 1110.011)BTU) ..
❑ '
AIR CONDITIONER
I have read the hv:emous nmtednls aquimments under Chapter 6.95 of the Cali- ISSUANCE ATH
forma Hea1N&Safety Coda.Sci ions 25505.25533 and 25534.1 u whandand that if the NEW RESIDENTIAL MECIL SQ.Cr. /r l
building does not comedy have a mnwr.Nat it is my responsibility to ramify the mcuprem
.f the mgmamenu which must t e ma poor to ixoumice of Cemacare of Occupancy. -
Owner or authemed sulfur - Date ” ISSUED BY.
OFFICE
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