28783 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 28783 8 7 Q K
BUILDING PROJECT IDEMIFICAI']ON LV \JN
BUILDINGADDRESS: SANITARY NO. APPLICATIO SUBMITTAL DATE
IOaCO N ANT-AiA I ILS
OWNER'SNAME: PHONE: CONTRACTOR'S NAME LIC NO
Allow TALI6clyl - T c 6/ ccT 357400 "" CONTROL,"
AII=YENGINEER'. LIC NO: ADDRESS: f ❑
3�rrV�r� asses. Sao L.0SPyC ; sllisrn CjATA
CONTACC PHONJ - BUILDING PERMIT INFO
`1 51 1 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MELT
CI _rTry' 6 ❑ ❑ ❑ ❑
LICFNSID CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hrrcby.Moon that I.liccnrnl under,laoviaimrc of Cltyua 9(.racing JOB DESCRIPTION
Coy Ief Sfcmce indenter i on 3ofIW Buvirrse and!Prnfa.i�m.Code.and lny Yanm is RESIDENTIAL "
O PERMIT ISSUANCE
ul tCO' C I '35� oo ❑SFDN'L [I KITCHEN RFh10DFU.
¢W Uwem`Ja on'wdur aL APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F.7y
ARCHITECTS DECLARATION PANELS ❑Mum.usiIT ❑mucrURAL
ZOrVJZ IuMastad my places s!Wrecords
I be used as public MODIFICATION
OZ— I UP TO AID AMPS . 'r' ❑INTIiRIOR El CHIMNEY REPAIR
I-•�F'O
Licensed Profincsinsual MI-IOOOAMPS IMPROVEMENT
g9xy IY 1 hertby affirm Ona am BenetLDER p him.N,he CCommcar,,License law for the OVER 10011 AMPS CLARATION El BATH REMODEIJREPAIR DEMOLITION
W 3 LL F Bodmving reason.(.Stnion 70315,Duairess and Profession,Gde:Any city or county SIGNS ELECTRICAL ❑OTHER
O ya which req ires a permit to cantmth alter,itnpcovx,demolish,or repsor any zurn,
prior to its issuance,also requiiv the apylicem for such permit to fie a signed'wet—' I1 SPECIALCIRMITNISC.
yy thnthe islicen'N purauent mthe pmvimrma nflh:Cnmmcmr'a Licanclotw(Chap110
W no (mmmercing WN Saban 1000)d Uividm Jof do Busircsserd Rofadovs C,Jc)m TEMP.MUM OR POLE INST. COMMERCIAL
6 y o q Uw he is e.aempl thcrefmm and Ih basis for the alleged exemlNion.Any violation N ❑NEW HIDGIADDITION EI DEMOLITION
>ufl 4•
Sent.7031,5 by any applkom for a lzxmit subjects the applicant to a civil pewlty of POWER DEVICES CITFNANT ❑FOOD SERVICE
z•} txN ctnrtthan fve huodrN idlers(5300). IMPROVEwxr
—$Q �1,aswxr Mthe prvPatY,amY cmployeca with wvgcs os their.solc compenvo0on, SWIMMING POOL ELECTRIC Ar
FO silldin lbawerk.vNl Oc xtmcwrt is.intended muRered furaale(Sca.7)TUBusIMw ❑OMER
ori Profasiam he Cods:TConuacters license how des rd aptly tom owner of Z Ott as-SWITCHES-FIXTURES
d 3 pmpaty w1W builds m improves thcmon,anal w1W hes such work himself a derough
his own employees,prnvked that ouch inPowerenta are not immrtkd tr off..d for N13W RESIDEMIA ELECTR SQ IT.
ae.If,Wwaver.area building«impovemcnt is sokwlthinmeyauofeumpleeirm.the SQ.FT FI.00R AREA VSQ.IT.
nwmJ'uilder will hevc the burden of Ie—in,Out he did out bulk or imrmve for Iso-
, Tumof vole.). .
construct
o 1,u t Cher of th S al. am caducively matmeting with licensed mnunceq w TOTAL
terse Li the project(Sec.o no woe,r.f mlianit ny who Wilds
Code:)The es,dratals Li-
nselawdoonot
ontruly mma,ith ri nfpmpmy whosroarem mthe themn,vd QTY. PLUMBING PERMIT FEE
who c,nitule poison projecu with•contru�urrt.)licensed pursuant m the C,ntmctds
Ga.Vx', PERMIT ISSUANCE
1aNexemptunder Sec. ,B K P C for this racoon
r ALTER-DRAIN&VENT-WATER(EA) _
Owner DeVACUA
Date
WORKER'S COMPENSATION DECIARATION BACK FLOW PROTECT.DEVICE
I beebyri lrm under pcaltyn1 Perjury me of the following deal..ons:
❑ IhaveWMllnuWnaC�iudCa ilo.self-imuref,c Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND.
RIES TYPECON CTION
aeOah as provided f«by S,issued
J7tq of do Isbm Core,for tie perfmrunra M the
wnrI fur sai thisrentor Ix is.wcd FIXTURES-PER TRAP
1 have and will ode.f,air Woc
C,mprnsbion Ouur c,h fm
by Section
J'ril0 of the lsbm Code.fm the paf,rnumc of thcwM fm which d'u pemdtu iawtd. GAS-EA.SYSTEM-I INC.JOI1TLf:IS OCC.CROUP � PN
My W'mker'e Cnmpenvihxt Insururca currier mW Policy numhcr arc:
Cxniee Policy Nu: CAS-EA.SYSIT:M-OVER J EEA)
CHKIIFICATE OF EXEMPTION FROM WORKERS r 1
COMPENSATION INSURANCE GREASNINDUSIRI,WASTE INTERCEPTOR BUff-pi UVISI
('ITB sstlou teed mlhcomPletW if thepmNtis[more hurWdd,IWs(SI00) GREASETRAP
or less.) PIANCHECK FEE
I certify that int in peHomnnmo theres t bewrirwuflbj bo do,Woket is m'Con,a11 SEWER-SANITARY-STORM EA.YIIO FT.
not employ anY perwan in any tanner so as to bemrte subjett to de Wrxken'Cvmpcn- IJERGY FEC
',Z .Ovn Lawsof Celifomu.Cele NATER HEATER WNINTAIF,CfR
O Applicant GRA G FE-
h NOTICE TO APPLICANT':If,eller raking this Ccnifmte of L'xcmttitm,you should WATER SYSTEM/TRFATING
F' becmre suti ect to Oe worker's C Provisiom S(111S FEE
1 ,mpewanm U ire Imbor code.you mow
Wfuthwith comply with such provisions mthisprnnit shell4dccntW revoked. WATER SERVICE
d Q
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENT1AL PfA1B. SQ.Fr. PAID Dare ttei X
U O Ithereby which tM1erdere iasucitihuy)7,Clending egrnryfa the prrfonantt of P
LL. F' thcwmkfnr which thispermit is iswed(Sa.7157,Civ.C.) yTAL
Landcls Nvnc
L) IsnderI Acidness - TOTAL:
P+ � BUILDING FEF,
F I ceni[y tlwr T lova re�W this upplicaitn and sae that the above inRRmwion is
rn nxrect.I epee in comply with ill city end county,Nirurces amt were laws relining to QTY. MECHANICAL PERMIT FEE
U rZ huddlingnnstrunion•end bereby euthceirs rtpr,%cnutivas a Ods any to cora upon the SEISMIC FEY
uMve-niendoted ptolerty I Impaction pun*m'. PERMIT ISSUANCE'
(We)ape to save,imkmnify and keep huml¢a the City or Cartoon,agweirELECTRIC FEE
liaNflia ,judgmrnttcosn and cspcores which may in any way attmeagmnstsak City ALTER OR ADD TO MECH. PLUMBING FEF,
io coowa,ar ce of de graming of this perrnil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL PEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.001 CFM) CONSTBUCPIONTAX
Sigoaumof Applice coarscnor Dote EXHAUST HOLD OVIDUCO HOUSING MITIGATION FEE
IIAZARDOUS MATERIALS DISCLOSURE
Will theapplic-.un or future buildingcacupant'toreor hmNllcharaNus freer it HIXrING UNIT(TO 101,000 HTU)
is Wired by the Cupecutn Muruipel Cade.Chapter 9.12,and the Hath acrd Safety
Code.Section 25532(x)? HEATING UNIT(OVER 101),00()BTU)
Yew ❑Nn
VENTILATION FAN(518GLE RESIDE PAID
Data it kReaipi�'
Wdl.lte applicant or future building acup.nt use eco,orcnt or Mitts which
emit luivdaux yr vrortmntianu as dcfneJ by the Bay Ata Air Quality Meragemern B(IILEft-COMP(IEIPORJOfl.lpO BTUI TOTAL:
District? GOT! 9
[3 Yes DN. BOILER-COMP(OVER 100,00)BTU)
1 beve read Oc hvmrlau anterial'onto cu under Chapter 695 of the Coli- AIR CONDDIONERISSUANCE DATE
fania lbadds&Safety Code.Sttm 25505
tio .'_5533 and 2551E 1 mtdaswrd that if the Nf1
NEW RESIDEAL MECH. SQ.IT ��I Y Let .,urth I INU
hiking des nth currently have a tenant,thin it is my oeparoibility m notify the nculmnt
of tk eiquirtneou»Lich rtnnr h net prior.iswarec of a CmiBcuc of Occupancy. I
Owrerorauth",rrl agent Date TOTAL: ISSUED BY: 1-�� ��•
OFFICE