28507 APPLICANT TO FILL IN_INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII,DING-ELECTa1CAL PERMITNO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMB INC-MECHANICAL,
BUILDING PROJECT IDENTIFICATION 28507
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
6a /ing: Sig 08 3-
OWNER'SNAME: JPHONII: CONTRACTOR'S NAME' LIC NO:
0.`Q! O WC CONTROhX
•A -HITECTIENGINE.PR: - LIC NO: ADDRESS: - ❑
CONTACT: PHONE: BUILDING PERMIT INFO
/ ❑ Cw Irma t Fele Paid by Appllcmat(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑mgz ❑ ❑
I her .firm IIW 1 un Boned untkr QTY ELECTRIC PERMIT FEE
y pmvtsicas NClulscr9fcumrcrcing JOB DESCRIPTION
{{�]00 with Snlioo]OBO)olfT.ision3ollhc Busirtw ud Pmfessiom Cadc.md mylicenseu RESIDENTIAL
Fes-f in full forte sMeffecn. PERMIT ISSUANCE SFDWL ❑KITCHEN REMODEL
-
y,mf(C�.�..s
F ID Date Clan Coo Xract« APPLIANCES-RE9IOENTIAL ADDITION ❑PLUMBING REPIPE
L ARCH='S DECLARATION ❑MULTIUNIT ❑STRUCTURAL
ZO Z IuMcrswW my Plans shall be tri puhin,retards PANELS MODIFICATION
O Z O UP TO 2W AMPS []INTERIOR ❑CHIMNEY REPAIR
F4t:W Iicrnsut Profca 1 NII-IOUOAMPS IMPROVFSIENT
�y OWNER-BUILDER DECLARATION OVFRIOWAMPS ❑BATH RFIODEVREPAIR ]DEMOLTON
CLL 1 hereby affirm bar I em exempt fr«rl dal Conlncrer's Ilceme Jiw f«the ❑OTHER
36 U following reason(,Section 7031,5,Bumim,mal Profeeeoos Code.Any city«lemony SIGNS ELECTRICAL. 2 .�� � `/
LL which requiresa pernw m constnwl,alter,impmve,all.lish,u repair any .r6
F0 pri«Ioits usuarwe,ulw rryuires the g �"
eitionsnln.Cour ,or,IOkasi redstmcmem SPECIAL CIRCUI'IIMLSC.
rWO} Ihmhe illi with
punuanl wlheofD"tms of the C«tnioesls LICCh.m IUW(Omgtt9
ly oo (commn,esm ilh Section]and!th liss,for of Ne Buunessr,lich .,i Codeof TI?MP.METEROR POLE LNST. COMMERCIAL,;
6 K to he u excmls Olnefmm aril to beux f«to dlegd exemryim.Any vidlation of ❑NEW BLDGIADDITION ❑DEMOLMON
'ALL Smim]03136Y Xny yplicsu for.pcmEl whjecu Ne epplicam loacivil pevhy of POWER DEICES
-y V ❑TENANT 0F-0OD SERVICE
f„Zy o«mae rami five hurdrd dollus lSSW). IMPROVEMENT
❑oSWIMMING POOL ELECTRIC
'ill 11s,to woh,soilthe croctuaismr.fferil] Sec.]D .Bus.
OTHER
td NTlx ConitaclN.1...e l,.does. PIY wrer of OUTLETS-SWITCHES-Fl(TUR[S1C
Pnrycny wlw builds or oonvcs demon,azul wlal docs such work him.sel I«through
his own empinyeea.Iravidcd lila tach impruvemcnts are.9 int rJed oroffeml for NEW RPSIDLi TIAL III.ECTR SQ I-n
ule.If,howevn,the huildingorin,ovemenl is will within me year ofclnn,] tam the SQ.FT.FLUOR AREA S/SQ.FT
wvnm-buildn will lose the Imsdea of soon,Thar Is,did twit build«irrya0ve for Isar-
pow,of sale.).
❑I,u owocr of the ProPe^Y.uriexcllwvelyconuectivg wish Hamed conaoCmrs w' TOTA 52so0
c«ubum to prui(,Sec.7044,9.a.ud Prob ssiom Coce:)The Conaaclofs U-
rnseUwdonnuragllymwowner ofpnr,sny who bollds or improv.,till.,and QT'Y. PLUMBING PERMIT FEE '
who comscu for much l rojceLs with a contmauf(e)lirc xsl pursuan,to the Convector's
Liccmc law. PERMIT ISSUANCE
I am eXempr Unlet Sec. ,B&PCfMffiilrmwn ,
Oxler DateALTEIR-DRAIN&VENT-WATER(EA) VALUATION OJ
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hes �(40 J �-
el Y eRrm under pinJry of perjury orc of the following dceltuatlum:
❑ IhaveWwill maintain.Cerincwe of Cnnsem to self-insure fur Workefm Compeer DRAINS-FLOOR.ROOF,AREA.COND.
urian,u provided for by Secliun 37W of the Claw Cade,fork scifrn.of Ibt, STORIES TYNiCONSIRUCTION
wort for which lhix Nront is tcsuett IIXTURFS-PiR MAP '
❑ I have end win maintain Women,Compers+aliltl?.ltutun�ae.;.
31W M the labor Code,for to perf.e ahf«which Illi,gamut is iwud GAS-EA.SYSTEM.I INCA OUTLES
OCC.GROUP APE
My Warkef,Compellvrim tsurvne emriE'uW Policy rmmbn me:
Cmrim '-Poticy�No.: GAS-EA.SYSTBMOVER4/EA)
CERTIFICATE OF EXEMr ON FROhf R
COMPFNSATI(R4 INSURAN s GREASEBNDU,6L WASTE INfERCEPOR BUILDING DIVISION hTFS
(ThisuctionrcW.s CMPICW ifthe Mrmilis fy�^�huodrtd dollen(51 W) ) GREASE '
or Ica.) - ` , ` t', ' Q 1 i —T PLANCHF.CK FEF,
certify Nat in lM1e perfonuncc of the kl whit permit it i.rs MII SE NI'TARY STOP
T0 EA.2W F1'.
no employ arty Pe.in any ntemcr w u m wbjen to thew'«km ENERGY FEE
Z vtion law,of Celifamie.Uerc
zO Applicuu R�M /LIF.CTR GRADING FEE
h NOTICE TO APPLICANT.If.ifre,making*,Cl,kt.of Escmption,you.sticuld WATER SYSTL\f/TREATW((
1" ^ become mb)eel tothe oflhe laMr Cod�e�,�y�� ir, _ - SOILS FEE
IaSI ti forthwith comply with such rovi .,or this pemltishilDiedAem rEJdl1Q'��-`-� WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLFIB, SQ.FT. PAID
UO IMcby efBrnllMl Bete isarntstmnirn Boding egrncy fm the Mrfomtarxe of Dan, ResiptN
P. Ibc work for which tis Permit is issuW l.Sw.309),CIv.C.)
0f~ Lanai Nuns TOTAL_
WIafldefs Ad�esL
s TOTAL,
y I lenity tat 1 have reed tis applicvrion ant stare that the above infomat
rion is BUILDING FEE
IA cvmct lafiremC.Ply with all city and or,udvtaaa mrd elate taws leletinglo QTY. MECHANICAL PERMIT FEE
U building coostnLCLIM.ural hereby authorac repo,sernativnofti,city locmnamn Ne SEISMIC FEE
obuvnlrcmiancd Pnrycny fur inryahat purryssec. PERMIT ISSUANCE
(Wq agree m.wve,irticmnify and kccp as hanolche Cay M Cupertino against ELECTRIC 19iE
Iiabilidn,jud r nts,cou„ndexm.swhich may in my way accrue egunst mind City ALTER OR ADD TO MECH.
in camcglcsee of to gram.,of Ous permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR HANDLING UNIT TO IO.OBO CFM)
MECHANICAL FEF.
SOURg REGULATIONS
MA ( 1n /I p�PTv/ln� AIR HANDLING UNIT(OVER IO,Of10 CFM) CONSfRLTLiI0T1x
$igrut fAW1icw n aNlOr YAC/) IA /Xr_7i/1-bite P.XHAUSTHOODOVIDUCT) HOU"Was
HAZARDOUS MATERIALS DISCLOSURE
Will to mppliCan(«!marc Euilding onvpunl ume or hurdle hvnNous ruteriel IIGTING UNIT TY,IgL0110 BTU)
u defined by the Cupertino Municipal Code,Chs mer 9.12,ud the Health and Safety
Coda Semlop 25532(.)] HEATING UNIT(OVER IOILOW BTU)
❑Yn ON. PRIM OF %,urbillN J
VENTILATION FAN(SINGLE RESID) pate RcailsX
Will the epplieenl or future budding«cupid use equipment or davits,which
emir haru air conmminenb m defined by ilia Bay Area Air Quality Management BOILER-COMP OHPOR IW,WOBTUI
TOTAL: Sz,
Tom., TOTAL
0 Na BOILER-COMP(OVER W,00r)BTU)
I have red an,hazaNws marnial,onsminerni miler Chelsea 695 of Ile Cali- AIR CON, IT10NCR ISSUANCE DATE
rami,health&Safety Crile,Senium 25585.25533 soil 25533.I urdnwrd thv lde NEW RESIDENTIAL MECH. SQ.PT. 'n
balding d®n«evnrntly hao,a Bnanl.tv it is my respauibility to sadly he o«usm TV's ,^�`-'r(�(,/C�.'
of rtgtrevlelas nit naso mer pnorhisuurtaofac incest fl]ec - Tpr�gL//' Xbw-A.M
r authndredxa c t Marc TOTAL: ISSUED BY:'vele`/ 19r,46v`
OFFICE