B0434 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0.
28526
BUILDING DIVISION APPLICATION/PERMIT PLUh1BING-MECHANICAL, pOn�i
BUILDING PROJECT MEN '
BUILDINGADDRESS: SANITARY NU. APPLICATION SUB. 'FI'AL DATE
JOagO Lock G/am0 pRl ✓E /`/ 9
I OWNER'S NAME: PHONE: CONT'RACTOR'S NAME: LIC NO', N/C CONTROLII
NiR BK Alkmnu-s aN� 7ys73
ARCfll iCl'/ENGINEER: LIC NO: ADDRESS: 70 e.nJ/f/ A00 ❑
SS /ILLK eA - �9
CONT'AC'T: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI.DG ELECT PLUMB NIFCH
1:1 1:1A ❑
LICENSED CONTRACfOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provision.a of Chapter 9(commencing
WOZ w hSection 7000)of Division 3 oftbe Business and Professions Code,and mylianse is RESIDENTIAL
IAp� n PERMIT ISSUANCE
t-1- mfullfarceandelfec SPDWL D KITCHEN REMODEL
z u[- License Cl Yt —34 Lic a �S'13
¢ U aajj���/}'� APPLIANCES-RESIDENTIAL. ADDITION L3 PLUMBING RF,-PIPE
F Z cc
Doc
V .� / / Cotnractor
m6a ❑MULTIUNIT DSTRUCI'URA[. j
ARCHITECTS DECLAR ION PANELS
E+7 rn MODIFICATION
ZOO-Z 1 understand my plans shall M used as Public menrda
UPTt121p AMPi DINTIiRIOR DGHIh1NIiY REPAIRH4LW Limnscd 11 ocsional 201-1000AMPS IMPROVEMENT F]SWIMMING POOLS
yd ; OWNER-BUILDER DECLARATION OVER IOW AMPS D BAIII REMODEL./REPAIR ❑DEMOLTI'ION
=W< I hereby onion that 1 um ev,o,1 frmn the Cnmmcmda GCense Law for lbs.
F O W ❑OfHL'k
W mU whit g s (Sicilian 90115 0 : : JI f .Cod A, 0 unm"lY SIGNS ELECTRICAL
W3 y whichrequiresape a ci t t h tP d Ish ym tore
F'�OJ
that
the t '1: req the applicant
nsoft suchpermitis g od ¢mem SPECIAL CIRCUIT/MISC.
Y thaU licensed p n Chep s fmheContractor hapnnY COMMERCIAL:
a1�00 (commencing with Section 701)0)of Division 3 of Ne Busm s to f. sCode)or TEMP.METER OR POLE INST.
a a c Iz that he is exempt therefrom d the basis for the aIle, a p' Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X-ka-H Scamr7031.5bysnyapp'antforapemitsub'ecuthe Uo O'd,enolryof POWER DEVICES [I TENANT DF.
FOOD SFkVIC
FZ} not mom than five handre dollar,($500). IMPROVEMENT
-=C ❑ L asownerofthepro ryormyemployeesw agesa th irsolecompemmtimn, SWIMMING POOL ELECTRIC
p. will dothe work,andth suumureisnotimendedort snle(SecJ6I4,Businesn ❑OTHER
a i m and Professions 1 Code c C t t :Lice se La d t apply to an owner of OU'ILETS, SWITCHES PIXq URFS
p rp ty h h Id. unpowc,thorron.mol h 1 toh work himself.,Thr ugh
h': ply 'd J❑ r: P t: I' r d d R d for NEW RESIDENTIAL ELTCTR SQFr.
Ic.11l Ih Id g 'n vl Ili y' (c pll nlhe SQ.PI'.FLOOR AREA $ISQ.17.
cr bu Ido
will has M1urdc of poor tb Ther hr 'd nut build mr mpr a fnr puz
,I,c of sale.).
1,as owner of the property, exclusively attracting with licensed contractors m IUl'AL:
msuucr the project(Sec.701-1, usinco.and Professions CedcO The Con memor'1 Li-
censeLaw does no[apply loan o er of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
xbocommams for such projects wit aconwactoosllicenxdpursua ttotbe Contin tors
License law. PERMIT ISSUANCE
El I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WOR KER'S COMPENSATION DECLA RATION BACK FLOW PROTECT.DEVICE
ka I hereby affirm under penalty of perjury one of the following declarations: wVV f�V
fesIhest and willn...man,a CuniBenm of Cnnxem to adf-insure for Workers Comlxm- DRAINS-FLOOR,ROOF,AREA.COND. S TRIES TYPECONS'I'RUCfION
'r os provided for by Section 3700 of the].;,No Code,for the performance of the
_ work tin which this Permit is issued. FIXTURES-Plik TRAP
❑I have and will maintain Workers Compmuminn Insurance,as requital by Seaiov
370(l the Labor Code.tothe pcounwnacoflhe work liir whichthls permit is ioued. GAS-EA.SYSTEM-I INCA CUTLETS OCG GROUP MIN
My Worker's CnPT L n hlsufan{cfurtier and y No:n 4 W /"O
My Wo r7 yFom an Panic No:mon-e, VJ�A GAS-EA SYSTEM-OVER 4(EA)
CERTIFICATE OF EXFVTI(IN FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
(1hia section need not be completed ifthe Perot is foronehuilreddollan($100) GREASETRAP
or less.) PLANCIIIiCK FEE
I certify that in the performance of the work for which this permit is issued.[shall SEWER-SANITARY-STORM EA.2017.
not employ any Person in any manner so as m subject become subjeco the Workers Comper- ENERGY FEE
ZZ ,ition Laws W Califronim.Dam WATER HEATER WNENDELECTR GRADING PEE
Applicant
r•1 h NOI IC17 TO APPLICANT:If,after mekin,this Cerrito of Exemption,you should WATER SYSTEMITREA'1'ING
- a ; bccmnc e,bO,,m the W..kcrs Compensation Powi or mf the Lamm Code,you mon SOILS FEE
W Iimhwitb comply with such pow,,ior,mr ihlelamnil such be deemWrevoked. CIO,04
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN, SQ.FT. PAID Date BveclPla
U O I hereby union that there is o rnnam ci,m lending agency for the pcffomm rve of
L. F the work for which this vermil is issued(Sec.3097.Civ.CJ
0 LenderTOTAL:
Lenders Name TOTAL:
Iamders Address ' ,� (J
1 ccnify that 1 have read this application and sure firm the above information is BUILDING F PEG
F' h contact.l agree m comply with all city and county ordinances and state laws mlatingm QTY. MECHANICAL PERMIT FEE SEISMIC 9iG
U Z building construction,and hereby nuthmme rcpresematives ofthis city taemerupon the
aMn'omentioned Property for inspection pur,wes. PERMIT ISSUANCE ELECTRIC PEE
(We)agree On save,indemnify and keep hmmlcss the City of Cupertino against ♦
Robot ties.judgments.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH. J,
PLUh1BING PLG
in nICANTcro
e of the, ndo,of this permit.
APPhICANT UNDERSTANDS AND WILL COMPLY WI'1'II ALL NON-P(11N"f AIR HANDLING UNIT(TO I100IfIC1:M1 MECHANICAL FEE
SOURCE REGULATIONS.
In
Mn, � /]� V/Q" 6-3 _135 AIR HANDLING UNIT(OVER DXX)CFM) CONST RUC'I ION TAX
SignamreofApplican,�V�nocccou �C4j✓ Data BXf1AUST HOOD(W/DUCT) HOUSING MITIGATION PEP.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material 14CAl ING UNIT(TO 10.110X)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 2553 [00.0011,HEATING UNIT(OVER IBB.IBTU)
_
(:1 ye, /No VENTILATION FAN(SINGLE RESIDE lU Re I,
Wil the applicant or future building occupant use equipment or devices which BOILER-COMP 03HP OR 100,001131 U)
mit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAI
District f BOILER-COMP(OVER 103.001[3111)
�Yu No JUN 0 8
J have renA the hvunlnus mmcrinls mcryirentcnis under Chi,,,,6q5 of the Cali" AIR CONDITIONER ISSUANCE DATE
fnmia I cath&Sefety Coda,Sec Jons 11101,11111 and 25534 1 understand that if the NEW RESIDENTIAL MECH. SQ.17.
building does nor camnaly have a tenant,that II is my responsibility to unify the o ecu(wnt
of the requircme t which most t prior to issuance of a Crainec 4
cupanc
Owner or amhnrizcd agentDmc TOTAL: '1:U
OFFICE