28291 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-K('ECTRICA], PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING DIVISION BUILDING PROJECT IDENTIFICAI[ON' o
291
BUILDING ADDRESS: /) n/� q t�k SANITARY NO. APPLICATION SUBI`MITTAL DATE
O 1 J t L skx a\ ort UNIT# LOT'#
OWNERS NAME: ktpNE / CONTRA TS NAME: LIC NOn N/C CONTROL#
on\c R �6�"OK6 J /gJEwS/g� 1 er {gni
-� ARCIi1TF.CT/ENGINEF,R: LIC NO: ADD/\c+' ( ❑
CONTACT: - PHONE V BUILDING PERMIT INFO
//�� ,!p' ♦/ QTY. ELECTRIC PERMIT FEE
1?66 �4�I�r i� PERMIT ISSUANCE BI ELECT PLUMB MECH
LICENSED CONTRACTORSDECLARAeri)( APPLIANCESRESIDENTIALJOB DFSCRIPTION
py.Z Thereby affirm CBeit I ENS niiTuS i ECLARapler9(commencing with
WOO Seaion7")of Division 3 ofthe Business and Professions Cade,and my license is in PANELS
~ F full force and sheet.
Fdyp"j License Clvss Lie.# b � UP T0200 AMPS
yQo- Datu Cmaracmr f 201-I(100AMPS
FyZ ARCHITECT'S DECfAR r SQ.FT.FLOOR AREA 5/SQ.fT.
ZO,n— Iunderstandm 1 shall be used public records. OVER If100 AMPS
OZ—O ,pans. a
I;,w F; SIGNS ELECfRICAI.
s
Licensed Professional
"CWU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO c- I hereby affirm Thal I am exempt from the Cnnuacon,License Lew for the
mei t+-rFir following reason.(Section"1031.5,Business and Professions Code:An eftymeanty TEMP.METER OR POLE INST.
1_¢C, which requires a permit to cooamet.alter,improve,demolish.or repair any structure
to its issuance,alkom Ibeu applicant for such 'Ho Bleasi U,liumot POWER DEVICES
I1sse� poor ,alma pp Perm, gree
yCOp that he is licensed pursuant the provisions of the Contractors License Law(Chapter
aKoce 9(commencing with Section 9000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_w or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
�ZCSection 7031.5 by any afflicted In,apron,sabjemsme appli.mm a civi l penWt,of OUTLETS-SWITCI II?S-FIXTURES
yt: not inorcihan five hundred dollars($500). NEW RISIDENTIAI.ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
❑ I.mownerofthepopeny.mmyempinyceswithwagesatheirsolecompensation,
a3= will do the work,and the structure is not imendedoroffered forsale(Sce.]033,Business
and Profess rvs Code The Contractor's License Law does not apply to an owner of
pommy whi,milds or improv..tneroon,and tom mi,,s such work himself.,flhom,lblu,
own employees,providedthnl such improvements are notineended proffered farsale.If, J OCC.GROUP RIS.UNITS
however,the building orimprovement is sold within one y<arofeumpletioo,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ I,ssownefnnbepropeny,ames.lasivelynmra.tlng with lieensedcomen,torsm QTY. PLUMBING PERMIT' FEE FLOOD ZONE APN
oerruct the project(Sec 9W3,Business and Pmfe..ions Code)no Contactor',
License Lawdoesnot apply to an owncrofpropcny who builds or improves thereon,and PERMIT ISSUANCE
who contractsforsuch projects with aconnsctm(s)licensed pursuant in the Conuac m's
License Law. ALTER-DRAIN&VPNT-WATER(EA) FEE SUMMARY
❑ I am exempt under Se.. ,B&P C for this reasonypCK PLOW PROI'IiLT.DEVICE OUTSIDI.FEES
SANITARY Y N
Owner Dun RECEIPT#
• DRAINS-FLOOR.ROOF,AREA.CONU.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑Workers
reby Cmaffrmon I have In....aeor.evienf consent to,twoof(Sosure,m Lah C.ichichmod FIXTURES-PER TRAP RECBIPrN
Walle ployeeiondertunemrncertifeAmpytherenf(Sca3gW.Lure C.)which PARK FF-2 V N
covers all employee under Inia permit. GAS-IIA.SYSTEM-1 INC 3 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FE-ES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenified copy is hereby fumisfw41
❑ Cenified copy is fled witnme city iroproner division, GREASIONDUSTRI,WASTE INI'ERCF,PTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundreddollan($100) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or le".)
Icenify that in the pertmenncmf Ne work for which this permit is issued,I shall WATER HEA MR WNF.W/ELEC'IR
not employ any person in any manna.o m m�«q�y b'ect io the Workers PAID
Compcnsminn la fCyifomiay�'m Y7e / WATER SYSTEMKREATING D tteipi#
Z Applicant 1 L i I r•.'�T/�I-�1—
z O NOTICE TO AI"i,CAN :ILnftcrmakinglhm Certifcamol Eimniptimt.you0muld NEW RESIDENHAI.PLMB.—SQ.17. 'TOTAL:
F-' f/) becmnesubjanothcWorker's Cmnpen.ationprovmis'ortsoft bor Codgyoumus,
forthwith comply with such previsions or this pertsh deem dievoked. BUIWIN E
CONSTRUCr1ON LEN G AGENCY SKIS 1 F
I vflinn trent them isumnamc' leading ageneyf r,h pa[ormanw of
V O the work for whicnthis permit is i,aued be.3097,CIv.C.) TOTAL: GLEC IC iE
tenders N.,
—
"E'S
F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMB GF
V 1 certify mat 1 nave d th6'application rend store ma,the information is MECHANICA FEE
r�" W correct. lagree to cit Ywilb all oily and comity nNinanccwmd stale a .minlingm PBRMIT I$SUANCI? _
tDO building corevo 'm.and Inmbyswhorim mpresentativesofmis city, a crupnnthe
In p1 CONSTRU ON I'A%
(� z abovr1l,
edpropeny for inspection ryous. ALTER OR ADD TO MECH.
e m save,indatin'!y nnJ k p M1armless the ,r Capenino again tmtics hmayinanya against said City AIR HANDLING UNIT(TO 10,000 CFM)
of the gaming ot'miss /MVV 11 AIR I ANGLING UNIT(OVER 10.001 CFM))
Simon cof AppI a ns or\ I Dam EXHAUST HOOD(W/DUC) PAID
AZARDOUS S1ATERIN ISCLOSURE HEATING UNIT(TO 100,000 B'rU) Date Re ipt#
Wil hcri,dic lerfutambuildingoc ant store tehandlehaaardou.materiel HEATING UNIT(OVER 1(X1,000 R'IV) TSL:
u defined y the vino Municipal C e.Chapter 9.I2,and me Health and Safay
Coda Seco n25532(m? VENTILATION FAN(SINGLE RESID)
Yes ❑No
ISSUANCE DATE
Willlhe plicantrrf rebuilding occupant useeyuipmenmrdevices which emit BOII,BR-COMP(3111'ORIOg000BTU) p p
•
Noair nam is as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) • N 1 D
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. AUG 01
1 have read the haaanlou materials requirements under Chapter 6.95 of me .995
Califand.Health&Safety Cod,.Semon.25505,25533 and 25533.1 understand their
if the building does not currently have a¢man,.that it is my responsibility to notify the CII Y JF
n<cupani of In re. < whmn mea n< pri m . ,nil nr a cogfl arm of .I IN(J
aatq,aney. m
Owner or aumorisd agent Dme all
TOTAL: ISSUED BY:
OFFICE