28867 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY •-
CITY OF'CUPERTINO .BUILDING-ELECTRICAL" PERMIT NO
. BUILDING DIVISION APPLICATIOSITERNUT PLUMBING-MECHANICAL 2886 f
TI BUILDING PROJECT'IDRNTINICA'1'1ON
13UILDIN(;AI)/�S:° . � SANITARY NO AI'1I'LICATI(>N SUBMITTAL UAI'L
OWN 2'S NAME; PHONE: CONTRACTOR'S NAME LIC NO
g,� r—I—tD Y k'� A/ • g.�✓ N/C, CONTROL It
4 CIIIT'IiLT/fi fiINHF:R: I' ' T.IC NO A1 KE.S/ ,(rO RLrY�� _`,jY` ❑ ��(�1 .
CONTACT: PHONE: (IL' ' BUILDING PERMIT INF`O-'�
r! _�J O���y /� ❑ Consultant Fees Paid by Applicant(Initial) Fy,D[] ELECT PLUMB MECH
LICENSED CON HAC'IOR'S DECLARATION [� IrLYI`. ll��ajC�" IrRjI` ��LICT'
QTY ELECTRIC PERMIT FEIi
Tnovelty ),I' Thal.tun licensed C Brunderpmvtoan5o n,Coder9aammense I, 406 DESCRIPTION
W"WowC in lht]home]00(hof Drvoron3 of the Business and Profe.von>Cmle,add my h<ervse i> pF.ftMIT ISSUANCE
I-Nn ensiaa la and euecl. - WI. ❑KITCHEN REAfOUEI,
a� Damnu Class C;cn ryc-0-Qr 'T . APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
CHITCCT"S D[CLAR, TON I ❑MULTI-UNIT ❑STRUCT'URAI.
FDA PANHL$
Z02'4 Z4 T ordentand my plan shall he uxJ as MODIFICATION ,
OZtfO / a tll'T0301AMP5 ED INTERIOR [I CHIMNEY REPAIR
6„b'.,;'Licensed Paursauoul E I 201-I1g)BAMPS ` I IMPROVEMENT
OWNER-BUILDER DECLARATION
6 1 h City affirm that I um al l fnttu the Common.Luensc Law bit the I OVER Ig0)AAIPS I BATH RBMODIiUREPAIR DEMOLITION +
O L U following non (Sntion 7031.5,Huntress and Professions O It:Any city orcomay SIGNS ELECTRICAL I ❑OTHER
LL y wh ch req reran peat to construct.alter,improve,demohslt,it repair any structure
an hrtla s 'e.ul>n mymresthe lapphcxm tlr ouch pennnu tilcasrgneA smmmem SPECIALCIRCI)rr/MISC.
y me he n In eased puouanuothe pmvismmofthe Cartmnornl¢c ataw lChaine COMMERCIAL
all :
00 ICa'nmen ng with Becuon]00Bot UmismnJul the 0u>rnessaN l'mlasanm Code)... 'ILb1I'METER OR POLL INST a'
1.0)X 0)X That hen arm,merchant and the basis Inv the alleged ermat :ion Any Callao..of ❑NEW BLDG/ADDITION ❑DEMOLITION
My Section 731.5 by any applicant for a permd subjects the appl¢a it to a civil penaltyol POWER DEVICES + QTENANT ❑FOOD SERVICE
IC,,, } not more hat toc hundred dollars 1 108 _ IMPROVEMENT
2 0 ❑has witrarmepropery,ormy ipl e t we as �lecompenvmmn, SWIMMING('001.ELECTRIC „
2 wdldot ew.,k,endtbestru rei le Jora red a] (Sce.7414,BU>ieass ❑OTHER
tiltse and Pm CSSmn Code:]he ni tors r >,Law not 1,to tin owner oil OVI'LLTS-SWITCHES-FT%TURFS
proper who b ds a t o c t ,and who s such worA7ilI tself or through
his ow empl ,p vide such impmv ens arc not mtendcJ m nflered tar NEW RESIDENTIAL LLECfR SQ FT
val,.IL ow ,1 lit tnmpmsamer "Adxnbal, YCar ol compleuoq the I���A///�yy��� 1/�� SQ.FT,FLOOR ARP !I/SQ.FF,
Jdcr eburden ofp ng the he did not M1UJJ anmpmve(nr par- I�'fty'L� `Q 2LtiC�� ^ aA A}'{y1' -
poxof Ie” : ' 3 +,J`�
T,a. nee of I -par •rt,a xelmrvely Coleman,with hecnsed cmmerator>m r TOTAL:
cad=et c projeC .] ,Bustness land Prnfs.ums Cixle.)'Fhc CCntmnnr's Lt-
cenulaw not apply an owne r at property x hn held.nnmpnrvn lineman,and Q'I'Y. PLUMBING PERMIT FEE I ,.
who LV".I aloe 'Teets with a mntractortsl licensed P Contractors "
a License Law - I PERMIT ISSUAN
❑I am exempt under Sec. ,B&PCfnr thin noon
Owner n.._ ALTER-DRAIN&V -rrW ER(EA)_ f• /^\ VALUATION '
Wm under SCOM of I on DfthepRAr,ing BACK FLOW P_ T/A.DLbft�i,^ \ �O'7
rO 1 hereby ulfirmumn.penaltyof.f Cm era of the fallox rag Jminmuons, `: l
❑Ihaveund will tmimmmla Cendcma of C.nsem In sell-inv met Wader's Crnnpen- O S-1'LOOR,ROOF AREA. ON �\ gTOR11iS I TVPIi CONS'TRUCf10N
salon.as provided for by Section 3700 of the Labor Care,for the performance of the _
ark far which tints pcmm isolated. FIXT OR \ ER'1'I2AP \
❑I have and will maintain Worker's Compensation Insurance,a reyoued by SCa'rm R _ -
s 3](10ufda lads,Code,forhmperfnnnance nflhC link Ra bch this perms i>issued GAS-PA.SYSTF., INC LE"�. OCC GROUP APN
My Wode' n 0)e wlion l ranee Can nand PMtcy numMr y GAS-IiA.SYSTHM OVER A) r flC
Carrter.n Policy No: fed WORKERS'
�j�-- -
CENT CAEO� A YfIINIRANCE RKEkS' GREASIYINDUSTRI.WASTEMTETTT <MPR7 00 ;1619 '/
COMPENSATION INSURANCE
(The secmn neutron,im,nmpkted if the F,nn.(I,f r one hundred dollar,(S 1110)
BUILDING DIVISION EF.E$
or less.) GREASETRAP . .�)t PI,,/sNEHP.1CKEE 11 �O shall Tccmfy that in performance of the wad for which 0opermiO kC,,'C. ,n- r VI\i
SEWER-SANITARY-S'I ONM IiA`200 FF. �,�
nm employ any p,nun m any mdnnenn as lit hacmn,suhjmt 1.the Wnrkeri Cnmpen- I ENERGY FEE
0 z saran laws of C.1 rat.Lie WATER IIEATF.N WNENT/GLECFR I k
Q Apphear ' - _ GRADING FEE 1
M NOTICE FO AP ANtIrk,after nuking this2 nnfcme of Esempnon,you should I Wq}'ER 5YSTF.M/I'BEATING 1
h Mcnme subject m the Woders Compensation pr.visionwf the IaMr CNe,you must SOILS HE
i�. forthwith comply with such provisions or this pernnt shalliedscmed nevoked. ''. WAFER SERVICE. 1
L CONSTRUCTION LENUINGAGENCY NEW RESIUEN I'IAI.PLAIB SQ.ET. (PAID
z
V Ihorebyaffrmthm Ncre is a construction lending agency for the perhmnanceaf I Date Rumpld
H. the work for which this perms o oared(Sec 3197,Qv.C.)
N
U am^ i i
Lenders 'D)TAI.:
Lender's Addrens A)o
Fy ,I candy that 1 have mad this uppheation and state Had the abase intimidation is BUILDING FCL
V) Cancel.I agteee comply with all city and county ordinances and state laws relating in Qpy, MECHANICAL PERMIT FEE.
C.) z hrolE gcunsuuu - SEISMIC FEE
shave-marooned pm,ady for mspectme purpose, PERMIT ISSUANCE
(We)agree 1.see, mni
indety and keep harmless the Cny of Cupertino agaiml I ! ELECTRIC FEE 2`
IiuhiLbn,judgment.,n..b.ad expcnves which may in any way aemeagmmtsml City ALTER OR ADD TO MECH ^
in consequence of the granting ofthis permit. PLUMBING HE /I `
APPLICANT UNDERSTANDS-AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IU,O)O CFNG ,
MECHANICAL SOURCE REGULATIONS. FEE
AIR HANDLING UNIT(OVER 10,000C17M) CONSTRUC9'ION TAX
Stgnamm oMpplicantlCConn~acmr✓ - Day,-13• EXHAUST HOLD(W/DUCT) IHOU(INGAIITIGATION FE,
HAZARDOUS MATERIALS DISCLOSURE `` . , I
Will the spphcunt ortuwre FmlJrngacupam situ,or handle h.nIDrdors mamriel HEATING IIMTfTO 100,0X)BTU)
as defined by the Cupcmn,Municipal Code.Chapter 9.12,add the Health and Safety -
Code,Secuon2553260.1. r '111iATING UNIT(OVER 100.00i BTU)
❑Yea` . . ❑N. I VENTILAT ION FAN(SINGLE RESH)) (PAID Data Receiplk ,
Will the oil amalua furore buildeg by the use Area Ar,QuordManage.nh BOILIiR-COMPI3HP OR IW,g10BTU(
f 1 hnmrdouv av ronleiiindnl.m Aefincd by line bay Arm Av Quality M.anagemea I I '
Dal s - TOTAL.( w
Yes Fl No (BOILER-COMP(OVER 100,001 BTU)
AIR CONOITIONIiR'�
r 1 have read the hazallout rmtenal>rtgmtvttrcms under Chaper 695 of the Cut'. - ,ISSUANCE DATE
lamn Health&Sal ety Cole,Sections 25505,25533 and 25534.1 understand that dthc NI7W RES I DENTIAL M ECI I SQ FT
building doer not currently have a meant,that my respa rialoy to ratify NC occupant +
of ill qunG`nt>which must he met Mar In issuance of a Cani,icv �5/al�/�l '
O�m.int freed ant Dam r - I _ - )d'm ISSUEOBY:Y ?1 •"
OFFICE
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