28486 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO • - BUILDING-ELECTRICAL I PERMIT NO 2 8 4 8 6
BUILDINGDAISION APPLICATIONTERMIT - ^ PLUMBING-MECxgrvlcAl.
1 - BUILDING PROJECT IDENTIFICATION 1
BUILOINGADDRESS: I SANITARY NO APPLICATION SUBMFEPAL DAD
�OWNERS NAME: -v Ac PHONE: I CON] LIC NO.
( � A tA = 1/77 N'xIC
ARCHITECfEN EE LIC NO: ADDRESS: '
CON]ROL#
CONTACT PHONE I ❑ Consultant Fees Paid by Applicant(Initial) I BLDG BUILDER PERMIT INFO
I MECH
El ❑
LICENSED CONTRACTOR S DECLARATION I QTY ELECTRIC PERMIT FEE.
1 hereby affrm that I am licensed muhu provismn,nfchamer 9 mem«ncrms JOB DESCRIPTION
�0"Z Ia nlIotSefi and Pmfemmm Codl.andmylmcnxr` RESIDENTIAL:
0 _ PIiRAfIT ISSUANCE ' ,J .
WF UW Pt Lieem,EDsuadclicct _ lima ❑SFDWL ❑KITCHEN REMODEL
HZH Date Commct` - APPLIANCES=RESIDL'NTIAL ❑ADDITION El PLUMBING RE-PIPE
F,Om ARCHITECES DECLARATION PANELS - ❑MULTI-UNIT ❑STRUCTURAL
z` ,7j- IundetsanJ my plan,shall henscda,public records MODIFICATION
OZ n .. UP ED AMPS El INTERIOR ❑CHIMNEY REPAIR
F4f'� Urmocd l'rofovomul , 201-11M AMPS IMPROVEMENT
Oat I am DECLARATION
Waa Q 1 hereby off nn that 1 am emmpS from the Contractor's License Law for the OVER 10110 AMPS � J/// _ ❑BATH REAfODEL/RBPAIR �DEMOLITION
W O y U fullowmg Season (Section 9 031.5,Business and Profmdom Code:Any city or county SIGNS ELECTRICAL `/ I ❑OTHER
3 LL E' which tegmres a permit m,um m L alter,on, s,d,a fish.ar repmr nny,tim. .
1y�-4
W poor to us issuance,also requires the applicant for such pemih to Bl easrgnedstaworlat ISPECIAI.CIRCUIT/M1IISC that her,licensed pursuant m the or.,isions of the Contraamh License lx(Chapter9
(commencing with Section70(ad of Dnismn 3 ofthe Business and Professions Cade)or TEMP.METeR OR POLE INST. COMMERCIAL s
Shut io a exempt therefmm and the basis for the alleged enempttan.Any vrohmm�of W BLDG/ADDITION ❑DEMOLITION
Se<uon?t)il56y any applicant for a Wood subject,the appbeam m v civil pl :0 f MIWF.R DB\'ICE& r TENANT 0 F60 SERVICE
^Zy (more then fie hundred AUllen 15500). x . PROVEMENT
�=OI]1,ac ownerol'the pmpeny,or my employees,nh xvgesasiheir rule compensaunn, SWIMMING POOL ELECTRIC � •
y xAt do the work,unit the structure is not intended or offered for sale(See T94,Business - - --- ;4�TIJIiR
a 3 and Pmm,smn,GiJe;The Commcmrs License Law Jews act apply to an nine,of OUTLETS-SWITCHES-PIXTUIE9
property who builds or improves Shemom,and whsi Jews such xork himself or thon,
his own employees,provided that such impmxemen i,are not intended of offered for NEW RESIDENTIAL.GLECTR SQ FT
snle.lf,howeveg the hurldmg or rmprnromanis sold wiShin one year nfttnnplemn,R. - SQ Ff.FLOOR AREA s/SQ FE,
owner-builder x dl have She burden of pros ing that be did not huild or improve for pur-
❑Las owner of the Sec 70y,am threes and contracting with licensed C contractors t- TOTAL
mown the pmlect(Stu.9814,Business and Pvdessions EMC)The Contractor's Li-
sclawJ«xnm apply man owner of pmpeny who bnrWsonmprme+thereon,and (QTY. PLUMBING I MIT FEE I PER xuho Imuns,ix for 61h Pmjeec with a contmemm,)licensed part to the Contractor'- _
License Law t PERMIT ISSUANCE -
❑IamexemptunderSee ,B&P C for this icmom
ALTER-DRAIN&VENT-N'ATER(EA)
Owner Date` ' I VALUATION
WORKER'S COMPENSATION DECLARATION' BACK FLOWPROTEM DEVICE -
i I hereby affirm under penalty of perjury one of the M( is ded.uons '
❑I have and sill maintain a Cemfcate of Consent m sel6msumf..Werker'x Compen- DRAINS-FLOOR.ROOF,AREA,CONU . STORIES 'fYl'E CONS'IAUC PION
salmm as provided for by Section 37M oldie Labor Code,for the Pv rfw
nnnce of the -
x uk for which this perms i,t,suul I I I FIXTURES-PER TRAP
❑ i hose and will maintain Worker's Compensation ImUnU e.as regmred by S[elan -I ,
37M of the Labor Code,for theperformove of he work for x rich this North isissued. ( GAS-EA.SYSTEM-I INC.4OUTLETS „OCC CROUP 'AI'N
My Worker,Compensation Inmmnce carer nu
and Policy mber em: I
Carrier I Policy Nn: 11GAS SYSTEM OVER 4(EA)
CERTIFICATE COMPPNSAION INSURANCEORKERS' rs
GRGASFANUUSTRL_WASTF;INTERCEPTOR'
(This waumm d not he the permits fo..mehundrMdnllan(s100)' 1 - BUILDING DIVISION FEES
in 1.s,)• ORGSE TRAP
PLANCH FEEFEE
Iccmfy mm in me anynrnamceof stolorkforwhah this permnsiswed,lshall / T
not employ any person many mannerm usmbecorne subject vnhe Wnrkcrn'Compem SEN'Iik�ANI fARY-511URM EA.200 FT��
_ ENERGY FEE
7) Atli lnws n(Calilamre DUp•
O A'fF:R HEALER WNENT/F:LECI'Ft
z Applicant GRADING FEE
ayy
NOTICE TO APPLICANT If Cmimakingthis Census of of E aborodyoushould WATER SYSTEMITREATINIG
becomeanhucty the Workers Compensationecondir of the Labor Code,it most ' (,SOILS FEE
forthwith comply xnhsuch pmvvanm or this pcmm.boll he JCemed rewkcd WATER SERVICE -
az CONSTRUCTION LENDING AGENCY ' L INEN RESIDENTIAL PLMIL SQ.Up PAID
U O (hereby affirm that them is a cmnswahon lending agency for the Nofotmenceof I Date. Rexeipta
the work for xhteW his Permit is issued(Sec.31199,Cn,C.) '
Wader's Addr,= I
U Lead o',Nam= TOTAL
I certify that I have read this application end score that the¢hove infomimum is BUILDING FEE
1F.t
CO) correct.)agree to comply"bit ill coy and county ordinances and state lows reforms to QTY. MECHANICAL PERMIT PEE
Ua7 bmlJmgcnnamctmm,and hereby andmos,u,nosemnake,ofihrvary memerumm She (SEISMIC FEE
above-menhoned pmpeny for msp som r p."oe,. I PERMIT ISSUANCE
(We)ug oven,snxe,indemnify and keep bamde,+the City of Cu'rom,against (ELECTRIC FEE L
habldlCa)ndgmcnts,costs and expenses which ma)munyway iccmeagunin%md Cn)' I ALTER OR ADD TO MECH. IPLUAtBING FEE :� /�
inconsequence of the granting of tba permit -
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ( AIR HANDLING UNITGO 10,000CFNU MECHANICAL FEE
C �GGis iy 9_5 I rNSTRUCTIONTAX
='x�_/(,.^V,R(,(_'kxI c .x� AIR HANDLING UNIT(OVER 10,"CFM) -----
Signl�rrcid/AppLCeHAZARDOUS MATERIALS DISCLOSURE Date EXHAUST HOODfN'/DUCI'1 -_ _ I HOUSING MITIGATION PEE
1\WII the applicant elfumre building occupannmrcorhandle harardous mmmrnl HEATING ON[](TO l Oay"R]'U)
us dcfned by the Cupertino Municipal Code,Chapter 9.12,and the Hndth and Safety ^^
Code,Suction 255120?' HEATING ONE'f(OVER 100.000 BTU) r V --I
❑Yes EDNo (
M1 I VENTILATION FAN fSINGL PAID{j.�
Will the applicant or fuurre binding«cupam iue egmpmem or Jerices whteh ` Date Recnpr N
nn to'allousmr ronamm.n,as dufmd by She Bay Area Art Quality IsLio,cont BOILER-COMP OFF jf t?W,(MM)BTU) 1$95, I -
�isuict? BOILER-COMP IW.IMN)HT61( ,Cu 7771 J I TOTALL'
❑Yes u ❑No
AIR CONDITIONER P/VU K�
Lhasa red the hozvJous material,rqurremenrt under ChaPterb 9S of the Cali I ISSUANCEDATE
fimie Health Csxle,e a met 2SS115,?5533 and2,x341 to nordmnd thatiiIre NEW RES IDENTIAL MECH. SQ FT. I -
M1mldrngd«sit Safety lyhaveatemwgihanti5533 Cud25541 mnarstand «,if the '
n(Ihe regnrremenls wh¢h muss he moi pnorm rssuence nl'u Cenifcatc if Occupancy. I „ 4. ,(����/
Owner or auihonxed ngcm (lam TOTAL: IISSUED RY: �r{�Y` 1
OFFICE