28967 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 28967�k
8 9 7
BUILDING PROJECT IDENTIFICATION Lv 1
BUILDING ADDRESS: . '� SANITARY NO. APPLICATION SUBMITTAL DATE
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C.
OWNER S NA Hr- PHONE:' 'TRAC" 'S NAME:�-s, LICN .14 F +
Y"/ y� - /` NIC CONTROL
1
qR CT/F.NGINEER: LIC NO: ADDRESS' uuU!! D ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under visions of Chapter 9(commencing QTY. ELECTRIC PERMIT FEE
r a rrt� v g - JOB DESCRIPTION
CWZ thSation]000)of Division3ofthe Business and Pndeszibns Code,and my licenacis RESIDENTIAL,
wo, wI PERMU'ISSUANCE
�I�� nfullforce=de c— � I - I ❑SFDWL ❑KITCHEN REMODEL
QV�j Licen s Lic.p gppL1ANCFS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
crQ c, Dam Contractor .
RCHITECTS DF.CLARAT OV ❑MULTI-UNIT (_1 STRUCTURAL
Z O on Z I understand my pl:ms shall be used as public records a' l� PANEIS MODIFICATION
102..0 UPTO 200 AMPS 0INITRIOR El CHIMNEY REPAIR
4I:W Licensed Professional 201-IIXNIAMPS IMPROVEMENT
Say=; OWNER-BUILDER DECLARATION OVER IIXX)AMPS I]BATH REMODEL/REPAIR C1 DEMOLITION
C Q Ihereby affirm that I am exempt from the Cnmmmor,s me Low fnr the
3 ha.H following reason.(Seniors]011.5,Business and Professions I.Any city or county SIGNS ELECTRICAL El OTHER
m which regmres a permit to causa 1.alteq improve,d ish,or repair any swcmte -
�6 poor to issuance,alw requires the appinam"ur tpermirzp finless sigtmd smmmcm SPECIAL CIRCUIT/MISC.
r— that he is licensed pursuant to the provision a Cnmmmors License Law(Chapter 9
daQ� (commencing with Seccinn]fXNI aonJufthc tlusiness and Professions Code)or TIiMP.MtiIER OR POLE INST. COMMERCIAL:
C.6 o CG that he ix and me basis tie the alleged excmptian.Any violation of E)NEW BLDG/ADDITION ❑DEMOLITION
¢xx, Y• Sect ](131.5 by any applicant for a permit subjects the applicant a civil Penalty of POWER DEVICES
n ❑TENANT ❑FOOD SERVICE
1„•z y not P than Ove hundred dollars(5500).
=Q ❑Last, erofthepropeny.ormyem Inyceswi wogesasthcirsolecompmoilion. SWIMMING POOL ELECTRIC IMPROVEMENT
W!: willdothewo nil the structure isnot ended on feed for sale(See]BW,Business ❑OTHER
L3 m and Professions ate:The Contractor .ic oe docs not apply to m owner of OWLETS-SWITCHES-FIXTURES
property wh bu c or improv ren as o s such work himself m through -
his own crop p a e t al u r I are our intended or offered for NEN'RESIDENTIAL ELECTR SQ FT
Ie..11 however I ng n proveme I I Iwithinon y a n •the SQ.FT.FLOOR AREA 5/SQ.ET.
tar badderw II vn the molenofprovi 6d II 1 ,b Id Invpur-
m.enthate) � 'ps�`J
❑ 1,as owner o pmperlY.am lues`o y raft.��I Imp a TOTAL:
conswct the pro) (See]M4,Bu 1{ofcss, e)The Cr ns Li- -
nseLaw does noapply loanown pony who buil ds m in •es thereon.and QTY. PLUMBING PERMIT FEE
who contracts fors h projects with a commiconno)licensed uanno the Contractor's
License law. PERhfIT ISSUANCE
I am exempt an,er sec. .B& so
P C for this man
Owimr DI ALTER-DRAIN&VEST WATER(EA) - VALUATION
W KI R S PGNSAVON UI CI ARATION BACK FLOW PROTECT DEVICE
Ihereby affirm. pen Icy of peq ry f die following bd f
•I]I have and will maintain a Certificate ofConsion it) elf-hourn mrWarkers Coni DRAINS-FLOOR.ROOF.AREA,COND.
scion,as provided for by Sec Ton 37M of th lab Code,forth performance of the STORIES In TYPE CONSTRUCTION
w rk for which chis permnis issued. FIXTURES-PER TRAP
1 have and will maintain
ains W 1. Cnmpe I I nee q 'red by Section
3 of the b�ony�GsJ th p K ante fth kf h hth Pe it rs issued. GAS LA SYSTEbf-I INC.iOUTLFTS QR jIB, ��� APN.
CmrierJ (:% I I are cam Fahey Nnmid Y €P�1SSS.. GAS I:A SYSTEM-OVER 4IRA), 1/b
CERTIVICATEOPEXEMFUONFROM WORKERS' CI r
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR I
(Thissacion nail dor Lee completed if Ne Lamont I%Future hundred dollms(S1001 g'i VISION FRES
GREASE TRAP PLANCIIRCK FEE
I orless.)
I certify Nal in the perfnceof Ne work far which this permit is issucol.l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any Person in any manner so as to become subject'.fire Workers Compen- ENERGY FEE
Z scion Laws of California.Date WATER HEATER WNENT/ELECTR
12 Applicant GRADING FEE
N NOTICE TO APPLICANT:IL after making this Certificate of Exemptinn,you.should WAFER SYSTENUTREATING SOILS OiE
became subject o the Workers Compcnsminn provisions nl the Labor Code.you na n
forthwith comply with such pro vision,or this penin,shell be dcemedrevoked WATER SERVICE
a �
U0 Cat thenUCBONLENDINCAGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID Dale Recciplp
L7 � Ihereby affirm that them isaconstrvecion lending agency forthe performance of
'he work for which this Permit is issued(Sec.3097,Cie.CJ
l"' Lenders Name TOTAL:
V Lcnda's Address TOTAL: - -
-
F fa 1 certify orllk 'd this application I.c, Ih nh Nov f n, m,s BUILDING FEE
correct.1'% t ply 're If city and entq N d:cl I :rcl l glrr QTY MECHANICAL PERMIT FGF;
Z
Vbuild' g vection..,I hby authorizeraErc,camft,c.,.fni,citylrcnmrupon the SEISMIC hhh
move mens oned property far inspection purposes
PERMIT ISSUANCE ELE
(We)agree m......ndemnify and keep I -mess the City of Cupomen,against IC FEE
liabilicies,judgmenc dexpensssw ' may, aeyway.econtlainur said City AI(DiR OR ADD TO MECH.
inconsequence thegmno Ireton out,
PLUMBING FEE
APPLICAN NDERST D DWI C . P WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURC G 1
/( AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
of Applirun . uvetor �•/ Date F.XHAUS'1'HOOD(W/DUCT) HOUSING MILGATIONFER
HAZARDOUS MATERIALS DISCLOSURE
Will theapplsumorfumre buildo,oce.parn mlc or handle haeunlnu.a mmerin BEATING UNIT CO 100,000 BTU) ,
m ddnsd by tte Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Cade.Sacinn 25532(.)] HEATING UNIT(OVER 100,000 BTU)
LJ Yes C]No - PAID
VENTILATION PAN(SINGLE RESID) - Date RettiplN
Will the applicant or more building mcupeu use equipment or devices which
emit Inclusion,or c runainams as defined by the Ifvy Arco Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL:
District -Yes No BOII.I3R-COMP(OVPR I co,m Itl'PH -
❑
Ihave read Incursion rest ac srequircn•its order Chapter 6,95 nfthe Cali AIR CONDITIONER ISSUANCE DATE
forma Health , afery Code„ R s25505:2553 and 25531.l undcvmnd that if de NEW RESIDENTIAL MECH. SQ.FT. f
of ag me...tly v cnatildratitisin mxponsibilitymnulifythroecupint
n here, n hi met prion is sof nifica n cupancy.
col- - rDmc - TOTAL: ISSUED IIY:
OFFICE