28761 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLECFRICAL PERMIT NO. �k n 6 1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL La
BUILDING PR W F,Cr IIIE:NTIF'ICATION
BUILDING ADDRESS: I - SANITARY NO. APPLICATION SUBMITTAL DATE
10 f L C pCt ttio ►� prN A�t-oqS
OW sR'SMNA41E - ••,, PHOr�'E: CO ',NAME: , LIC NF
01 •�'L W S/ '� O I Rq1 Oy 1.C. Orf' er �IV/����Z N/C CONTROI:p
RCHITEC[/F. NEER: LIC NOAn . ADDJ 31 O/ ��r y" ✓C V�� ❑
CONTACT PHONE,1 / /� ) PHONE: . •' BUILDING PERMIT INFO
.Y.,T r../Y!A ^ 147-
4 7- V� ❑ Consultant Fees Paid by Applicant(Initial) B ELECT PLUMB MECH
1�
LICENSED C�ONNTRACfT'O/R'5 DECLARATION• Q QTY ELECTRIC PERMIT FEE -sp ❑ ❑
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section 7000)of Division 3 of the Business and Professions Cod e.. myheimseis RESIDENTIAL:
Of 0 in full force and effect. e PERMIT ISSUANCE
JL 6. Q '�" ' ❑SEDWL (:1 KITCHEN REMODEL
Quu License Clayys� Co
6a Doc Contractor r APPLIANCES-RESIDENTIAL (]ADDITION ❑PLUMBING RE-PIPE
ARCHITCCTS DECULC
sFial rSLARAr N ❑MULTI-UNIT ❑S'fRUCTURAI.
FyZ 1 'Jrsly yp sshnll euard hlic 111jjJ111it PANELS _ MODIFICATION
-
O-cn '^� � UP T0200 AM1iPs - El INTERIOR C]CHIMNEY REPAIR
F�aF. LccndP Professional _ �``����� 201-1000AMPS - IMPROVEMENT `
4 f� - OWNER-BUILDER DECLARATION -
a a C 6 I hereby affirm that 1 am exempt from the Contractor's License Ldw for the OVER 1000AMPS - ❑BATH REMOD 1 ❑DEMOLITION
k 3 6 V following...(Section]031,5,Business and 1nifid,ons Code:Any city or county SIGNS ELECTRICAL ❑OTHER
t1,in which bell a permit to construct,alter,improve,demolish,or repair any structure
FW0-5 prior to its issuance,also requires rise applicant forsuch permit o file a signed statement SPECIAL CIRCUIT/MISC.
EEN that he is licensed pursueu
no the provisions of the Commences License Law(Chapter 9
MM( commencing miN Suction]000)of Division 3 of the Business and Pmfecsi...Cols)., TEMP.METER OR POLE WST. COMMERCIAL'
d 6 ey that he is<xnnpi therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC^LL
Section LS by any applicant for permit zuhjeas the applicanuoacivil penalty of POWER DEVICIS
W^y ❑TENANT ❑FOOD SERVICE.
col more than five hundred dollvrs($5M).
FZY IMPROVEMENT
p6Q 01, frh p pent' y ply II g: 'N I M I SWIMMING POOL ELECTRIC
wtlld tl k dth r r r t dJ ff Jf sle(St.7044 R : ❑OTHER
{y�m
and l f n:Cute.The Contractor'sI r La J tapply t of 1 OUTLETS-SWITCHES FIX IURES
props rt' h builds or improves thereon,v d lt d .such k himself through r
his own employees,provided Nor such Impr vemenrs arc not intended or offered for NEW RESIDENTIAL P.LECfR SQ FT
sale.If,however,me building or improvement ixvsold within one year of completion,the SQ.FT.FLOOR ARLh - ) $ISQ.F,
owner-builder will have the burden of proving that he did not build or improve for pur-
few of sale.). A
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to - TZ
conshotel the project(Sec.7041.Business and Professions Code:)The Convenors Li- - C� �`A• B
nse law docs not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE �• ,
who mmrwns for such projects'with acontortions)Iicensed pursuant rtr the Commcrors
License Low.
PERMIT ISSUANCE 1g
Iamexemptundersec. ,B&PCfim,msoaoa LG
M1r
.Owner Dam ALTER DRAIN&VCNI' WATER(FA) VALUATION +.
WORKER S COMPENSATION DI d21 id Ed 10th OWPROTECI DEVICE
Ih by uffirmu d penalty of perj ry n I'd<Odlowing do mm
❑ Ih nd ill mammon.Ccnf mofC :cu 1fm, refer Wo < n URA.$-FLOOR.ROOK.AREA COND, STORIES TYPE CONSTRUCTION
,anion,a,provided for bJ Section 37M of the Labor Code,for the to t i n thr' - -
work for which this permit is owned FIXTURES-PER TRAP
❑ I h.v and will maintain Workers Compensation In iced See o
37W of the labor Code.for the perforrwnce of ch work r c 'h iispernt islssued. GAS-EA.SYSTEM-1 INC. OUTLETS OCC.GROUP- APN
My Workers Compensation Insurance carrier and Policy ram: - -
No. GAS-EA.SYSTEM-OVER 4(EA),
Carrier. Policy FROM
'
CERTIFICATEOMPESATIONIEXEMPTION IRAN RKERS'
COMPENSATION c INSURANCE GRF.ASFIINDUSTRL WASTE INTERCEPTOR
BUILDING )IVISIO' i:E
(Thisswrinn neednothe completed if the pl'mtin is for one hundred dollars l8l W) GREASETRAP
nrlmsJ - PLANCHECK PEB
1crify that' the pf or(he kl IichthM t .',: JI hit(
I SEWER-SANITARY STORM EA.21q F1'.
nor e II y'any'e—i y t .: M1jca h W k :C per. IiNIiRfYtTe
O ,$, :ale L v t f Cul f ref D WATER HEATER W/VEN PELECTR
z O Applicant / b GRADING PE[
t-+ V) NOI ICE 9'O APPLICw t .ince,mak ng to C tit sane of E empuon,you should WATER SYSTEM/IREATING
F ,. twcome subject m the Worker,Compensation provision,of me Labor Code,you most SOILS IEE.
Wfimmv,'ith comply with such provisions or Nitniondlshall bedcemedrevoked. - WATER SERVICE
az
CONSTRUCTION LBNDINGAGENCY NEW RESIDENTIAL.PIbf B. $Q.FT. PAID
•Z Da RccciprM
U O_ Inerenr arum that mere is mmlmg.gener Rnrme cerrnrmananV. r
Ne work for which this permit is issued(See.3097.Civ.C.) �Aj
C) U Lenders Name 'TOTAL:
U Leader's Address s - TOTAL:
' a
lesnimthat 1 have d this application and state donflod abovefornmion i, BUILDING FEE �..
cmrcrl g to comply with all city and county ordinances dart laws relating to QTY. MECHANICAL PERMIT FEE
U Z bnBding eUnlmlioll .
, en,and hereby representatives of city to enter upon the
F.L[CTRIC
SEISMIC FEE
if
cove on.mianeJ property t.,,n,,,, a parpuue' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against F[E
liabilities,judgmen¢.cu,ls anJ expenses which may intuy,wayscromr,imisuiJ City ALTER OR ADDTO MECH.
consequence,in of the printing of His form. PLUMBING FEE
APPLICANT UNDERSTANDS AW WILL COMPLY WITH ALL NOON-POINT AIR HANDLING UNIT CTO 10d M10 CFM) r MECHANICAL E
CE :G S •
SOURgl
�--QJ// AIR HANDLING UNIT(OVER IU.IXIO CFM) CONSTRUCfIO TAX
Signature or ApplicanbCommetor Date EXHAUST HOOD(W/DUCT) HOUSING MITIG TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willrhe.pplicam or turn.buildingoce.purn,meor handle haeafJous muterial HEATING UNIT CFO 100.100.00C. O BTU)
as deinW by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Coda.Section 25532(a)a HEATING ON]'I'(OVER IM.000 ifl'U) - -
❑Yc: E]No PAID
VENTILATION FAN(SINGLE RI31D) Date RecciP
Will th .pplicar flu hildingwctpat use equipment or devices which BOILER-COMPQHPOR loo.oco Bru) '
emit Instructions an contain .a t. defined by the Bay Area Air Quality I' Management
District I
C]Yes No
BOILER-COOP(OVER 100,000)BTU)
❑
I have read me haurdou,materials resurrections under Chapter&95 of Ne Cali- AIR CONDITIONER ISSUANCE DA L '
Room.Hwlth&Safety Code,Sections 25515,8533 and 25531.1 undersand thio if the NEW RESIDENTIAL MECH. SQ.Pn
building does not commly have a mount,that in is my responsibility to notify me wcup tm .
of me"emotions which must be met prior no issuance of a Certificate of Occupancy.
Owner or authorized agent Dom TOTAL: ISSUED BY: '
OFFICE
Y
V' S
17 f
Lot PWT PLANs
MCK7 B_
DATE..I.
I PLANNING I PTa
[�
DATE
I a
BLDG. DEPT. I !',:�k�e.;o:;' �•�1.�L� t`.;
OFFICE COPY 3 :
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