28870 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO " BUILDING-ELFCTRICAL PERMIT No. 28870
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJFCT I wriFICATON
BUR.DINGADDRESS: SANITARY NO. APPLICATION S1UBMITT"TE
OWN iR'SN 0V: PHONE: CONTRACTORS NAMP LIC NO: "
N/C CO 01.e
�AjPrrUcTdEbiq'j4EUR: LIC N : ADDRESS: ❑
NTACI':
PHONE BUILDING P R INFO
YA y C !3s t 7 �(//IQ1 ����(� ❑ Coluvltent Fees Paid by Applicant(Initial) DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ELECTRIC PERMIT FEE
ZZ I Wrcby afi.that Ian Ecerm ander.provi.dor5 of Chpaec 9(cunintemmg Qom' - JOB DESCRIPTION
X0 C) loSection]000)cfD,vieiut3ti Basiacssand Proksoicns Cafe.nndmy license ie RESIDENTIAL
NE � PERMIT ISSUANCE
F<UZ ho full fare and cRca. ❑SFDWL ❑KTfCHFN REMODEL
. NQS Hue kms Ccaoana APPLIANCES-RESIDII.TIAL
d ❑ADDITION El PLUMBING RE-PIPE
DH ARCHITECTS DECIARATION PANELS ❑MULTI-UNIT ❑STRUCRIRAL
Z Z, IuManan]my plans shell be used v public acorda MODIFICATION
oz- UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
1-.`� Licenmd Pmfexi'nal 201-100CAMPS IMPROVEMENT
5Q OWNIiK BUILDER DEC1ARAFION OVER ISCAMPS ❑BATH REMODILREPAIR DDEMOLMON
I thereby affimt than,1 oro esemps from the Coriancim's License Law fur Ne
x�x O a U following reewn.(Section 7031.5,Bosuns and Profe.ui.,Coale:Any city a county ❑OTHER
W LL O¢ whmlim a
ich upanp
us to avn.,slier,imo-c.Japadi Jc a o pe r stay srruc,urt
SIGNS ELECTRICAL
.L prior mioi uscancc elsorecsaii Ilse applicva forwchperrod tabk a signed sutemnd SPECIAL CIRCUIT/AMSC.
f } Mar M is BcenseJ farmant to the provisionsoftGe Caansebi Iaw(Cat tar9
apo fcamrcnetng withSxtion'/LGO)of Division sof tic Husi,scs dud PmfrniauCNe)�r TEMP MEf1:R OR POLE INST. - COMMERCIAL
a 0m he,Is eaempp 0aefmm and the beds far the illegal exemptia.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
N Section 7031.5 by any npplicant for a permii suhjcom the ap kart to a civil penahy of POWER DEVICES �IFNANT El FOOD SERVICE
G will
mirt Nan five M1 grope property,
urry ISSm).
LI• wi LBonvoa]L and
the eny.m my employmwitM1wage+arto i((Sec,
04,1.Bmtinn, SWIMMING POOL ELECTRIC OTHER EM'M'
F_
Ism Oawak.aro tM strvnure is rad inlcnJid orrBemlfa toe(Sec.]I)14,tludnhexr [I OTHER
��d
Is13� sial Profesivos Code:The Cwmxmrs license law dues ria apply to an woo M OUTLETS-SWICHFS-FIX'NRFS
L progeny wtw y is s or wm that
tbcaau.rad xtw Joss sech wort himself of duough
his awn enWloyeq Wililmd than such n.,isamrnu thin ar amendedolfc ar offend fa NEW RESIDENTIAL PlECTR SQ FT.
svvocr- maws,the Wit ate hoonymivcom isdhsold within orcildrfcompletforthe SQ.FT.FLOOR AREA
nrr-builM will love the baNm of proving Jul he did nn hid a improve for pur-
pvso Wen)C
sof the aVaert,. ,dyand cattrveting with:)nrn C amcaorey i- TOTAL:
onW rs oma project(Sm.]I W,Business and Ihofcaviome CNet Thr Crmrecmr'N Li-
r.Law does nor applym an owner a property who Wild,oc cr vcs thcmon,and QTY. PLUMBING PERMIT FEE
who contrecu fm such c njau with a cnmmaa ts)IicerueJ puouan„o dhe CoamcrMs
Lie.law" PERMIT ISSUANCE
I vm<aeropt uMa Sec. .B k P C fm Jus mwam
05 —liF&I ALTER-DRAIN&VENT'-WATER(EA) VALUATION
Dere
O KFR:S COM SATO .CLARATO BACK ROW PROTECT.DEVICE,
I herebyeffimt urdm pcnnhy of perjury flhe following declantionu
❑ Ihave mid will meinainu Cenibu,c nfCaLsrnnn xdGinsurt fa Worker's Corrigan- DRAINS-19.00R,ROOF,AREA,CONI]. STORIES TYPE CONSTRUCTION
Nation,an provided fa by Section 3]W of W Labor Code,for tic,pedfurmmhee of the .
work for which 0is permit is issuad. FUTURES-PER TRAP
1 hove and will maintain Wukef's Compert4ion boalmo cin,is;nequ'va1 by Section
37W4 de,labor Code,fa,he perfunwcc ofdc work fa wbRT dos permit is owed. GAS-G.SYSTEM-I IN aOULETS OCC.GROUP APN
My Worker's Compensation h ouurce canis and Policy number art:
Canricr. Policy Nu.: GAS-EA.SYSIU' 1-0VER )
CERTIFICATE OE EXEMPIION MOM WORKERS'
COMPENSATON INSURANCE GREASWNUUSTR W'ASTEI IBTOR
SION FEES
(This smdon card]na h complaed ifthcprmtil is for..hundred Mlaa H 00) BUIVIVOD
a its.)
GREASE TRAY PIANCHECK pu O
I cenify that in the performance o0he work for which this permitRissued.Nall SEWER-S . 1A f I A.NMI FT. is
nM employ any Te—in any manrrr to as to hcnrle subject to the worleer:Cnmpen- ENERGY PEE
ZZ rumn La sof Cssifania.Dina WATER FM/FL,ECIR GRADING
y NOTICE TO APPLICANT.If,afro mado,this Ceniftca t,of Exempuor,ym should WATMR.9YSIi6VFATING
501
tcarorte sumW'ater's Compensa,iinry
pviiomda,M
of dbar Com
Crate.you oth
forthwithwith coompplyy with
w
h ch prnvisua
ialhia Permit
Dull he deemed revoked. WATER SERVICELD z v -
d Q CONS7fRUCTION LENDING AGENCY NEW RBSIDIiN HAL PLMB. SQ.EL PJ
U O I hereby affirm dal dem is u uvuwttiao lending agency for the pr9bmwnc of U c RaeipN
O Newoh for which Nis permit o o,aiM(Sw.3097,Civ.G)
(.ender'.Nuue TOTAL:
EH.1 Lender's Achlems TOTAL
Pi I certify Blas I have reed dos applicuum andsum that Jc above infarmedm in BUILDING F4r r2AO&� �.�
ret crrrtet.lagrte,o comply with ill t;ty and camty uNinnnces enW Hare lstws nelving,u QTY. MECHANICAL PERMIT FEE
U Z buildiogcowrvcdon,end Mtbyauthoriaecepresenarive,of,hiscirym emaaryn the SEISMIC
alrove-menuated popeny for iwpatim purports PERMIT ISSUANCE.
(We,)egra to wee,indemnify mall kap humJe. the City of Caamitm agoing ELECTRICIVE ,
luhilities.judgmems corn and expen¢r which may n any way acemc ugeirst suit City ALTER OR AILD TO MECH.
icomwequmaofticgmmingnf,hii,permit. - PLUMBING I.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT JO 10(101 CITM
SOURh1ECHANI L FE
AIR HANDLINGUNIT(OVER I0.0000I11)
CE ULATf CONSTRU 'ION TAX
iguammof AppWanUCwnB v EXHAUST HOOD(WMUC l
HAZARDOUS MATERIALS DISC RE HOUSING M GATON FEE
Will the epplicvm nr future bunting occupant uie handle harurdnus matcnel HEATING UNIT TO 100.000 BTU) �x �i a I.T
m defined by the Cupertino Municipal Code,Chapter ,and the He,ul,h vtd Safcy J'
Code•Sobs.25532(e)1 HFALNG UNIT OVER 101,001 BTU)
FI Y. Fl No VENTLATON kN(SINGIE RBSID)
Will the aplRican,a future building arupant use cquipmem ordavica whicfi BOILER-COMP(LHP OR 100.0X10 BTU)) -/�f`-- (
emit lr aAan ev cantnvunanrs is defined by the Bay Area Ad Quality Manatemmt r 1 f .I 11-'L V e two.. OTAL
Distract? T�y
BOILER-COMP(OVER 10/,000 HT)
[D yes, ❑No
1 hrc need the has rdous arou ,nvoimircms undo CTapa 695 of tie Culi- AIR CONDITIONER ISSUANCE DATE
t'umin Health&Safety Ctxk,Ssaian 25505,25577 and 255M.1 urdcnmrd that If IM NEW REWDMNI'IAL MECH, SQ.Irl'.
WiW ����/r^�' /,)
iny m
naw nor comm,have a crown,that neaTvit is my Nlity to polity thcr
tupam ``V
of the te9uharcnu which mus,h moi prior to k,..of a Cert fin.of(kivparcy.
f]wrcroraulhan legrnt Date TOTAL ISSUEDBY:
OFFICE