28988 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OFCUPERTINO - BUILDING--ELECTRICAL PERMITN028988
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L l}Jf {J,/II•J( VX
BUILDING PROJECT IDENTIF'ICA'TION
BUILDINGADDRISS: - SANITARYNO. APPLICATION SUBMI'TI'ALDATt
A003-TY .12-1--%-
OWNER'S NAME: PHONE: CON'fRACTOR:S NAME: LIC NO:
t NIC CONTROL#
SNANGIN ADDRESS
g,4./ 6v yz6 U
��RCHRELT/ENGIN[ER: - LIC NO: ADDRESS:Y 94Szl� ElSo.</Qaofc os LOA Rpt( "alta
CONTACT. PHONE: I BUILDING PERMIT INFU
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB. MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRICPERMIT PEE
^ L hatch,affirm chiltautlicensed,underprometts of Chuptcr 9(commenciug JOB DESCRIPTION
W5 W1Nll Porce ndrth Section f1O� mJoOhe Buslnessen sZI�eY 9do,and my license ie RESIDENTIAL
PENMIT ISSUANCE ---_
�UZ j License Clus Lia# _ CSFDWL O KITCHEN REMODEL
-04 'onua��+ .d - .r APPLIANCES-RESIDENTIAL CADDITION O PLUMBING RE�PIPE
1F-..Dvvii ARCHD'ECTS DECLARATION PANELS
❑MULTI-UNIT El STRUCTURAL
Z8•2z I understand my plans shall he used as public records MODIFICATION
0Z- UP TO 20b AMPS
Ft�ii Licensed Pmfesstonul ❑INTERIOR CI CHIMNEY REPAIR
L$Y ay
OWNER-BUILDER DECLARATION Y(11-IIXMIAMPS IMPROVEMENT
m
^ 1 hereby effinn Ilii m i uexempt from the Contractors License Law fur the OVER I010AMP5 ❑BATH REMODEVREPAIR El DEMOLITION
following reason,(Sntion1111 L1.Business and Profeseions Cele:Any city orceunty SIGNS ELECT RACAL 00'I'HER
Owhich requires a pencil to conW-rt.ulcer.improve,Jenudish,nr repair uny stmcwre _ ����/ �L�J��F�
y Prlortoitsiss......No reluirev tbotWplicaut lorsmh permino filcn.vil nwlement SPECIALCIRCUIT/MISC.
�. tbattle is licensedpursuanl to the provisions ofthe Conticmr'a license Lae,(Counters)
00 (eommencingent Section 70gq of Division 3 ofthe Businessund Professions Code)., TEMP.METER OR POLE INS . COMMERCIAL '
a tY that he is exempt Therefrom wd the beats for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION 0 DEMOLITION
4• Section 7031.5 by any applicant fm a limit subjeem The applicant to a civil penalty of POWER DEVICES OTENANT CFOOD SERVICE
P. not more Nan five hundred dollars($3w).
�Q ❑Lasrovinfofthe properly,or myemployeeswith wages"their.solecompcnsation, SWIMMING POOL ELECTRIC IMPROVEMENT
willdothework,andtheatmcturei...tialendelm.1fiemdfarsalc(Sac.7B14,Business OOTHER
a3 and Professions Code:The Comment's License Law does not apply to an owner of OUT LETS-SWITCHES-=IX URIS
pmpcny who builds or improves thereon;and who does such work himself or through
his own employees,provided That such improvements am nm intended m offered for NEW RESIDL'NTIAL F.LF,CfR SQ[if.-
sale.
.
sale.If,however,the building or improvement is sold within one year of atmpletfo The �- SQ.FT FLOOR AREA $/SQ.PT.
owner-builder will have the harden of proving the,he did not hulld or improve for pur-
pose of all
C I,as owner of the properly,am exclusively enmructing with lice"ed comments to TOTAL:
consumer the project(Sec.7044,Busirness and Professions Code,'Tbe Con.....s Li-
nsetawdoesnotapplytoanownerofPropertywhobuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
who contract,for such pmjacts with a nmmnctods)licensed purmanmo the Co lactoes
License taw. PERMIT'ISSUANCE
Eliler l am exempt mSee. ,B&I'C for This reason
Owner Dam ALTER-GRAIN&VENT-WATER(III VALUATION
WORKER'SCOMPENSATIONDECIANA'CION BACK FLOW PRO1'ECT.DEVICE / (,J
1 hereby affirm under penalty of Perjury one of The following declarations:
C Ihave and will mainmin a Cer ificam of Consent to.velbasure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND. DRIES TYPE CONS'I'HUCTION
sation,as provided for by Section 3700 of the Labor Code,for The perinrmmnce of the - -
work for which this permit is is.ued. FIX,LARHS-PER'I'RAP
0 1 have and will maintain Worker's Compensation Insurance,ns required by Section
37M oftha Labor Cole,fill The pereprourceef the work fur which this permit is issued, GAS-ITA,SYSTEM-1 INC.4 OUTLETS (ICO GROUP
APN
My Worker's C��omppee }yt�� Im��umncc camer and Policy number arc'
Caraiee Q/p (e _Policy No.: YiIS 11'-S.f GAS-EA.SYSTEM OVER 4 EA)
CERTIFICA'TB OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIONDUSTRL WASTE INTERCEPTOR
(This section need not Ise completed ifthe Permit is for ane hundred dol lam 01 W) UUILDING DIVISION TPES
or less.)(This
PLANCHIiCK HE
(certify that indue tiny mnance nerof thework becomr which jelhio thmt orkersued,lshall SEWER-SANITARY-STORM EA.204 PI'.
not employ any person in tiny manncrwazto become subjunothe Workcn..'Compen- ENERGY FEE -
O
sation Laws of California.Date WATER HEAfIiR WNENT/ELECTR
NOTICETO
GRADING FEB
q rA NOTOTICE TO AP.tine 04'1:IC afterCoo nmking This Cen eBete of E idles,Code,
you should WA'11iH SYS I'Elvin REATING
�i become subject to Ilia Worh pro Compensation provi. ns of the reedit Coda you most 5011.9 PEE
131
forthwith comply with such provisions or this permit shall he decreed revoked. WA'I'17R SERVICE
d
CONSTRUCTIONLENDING AGENCY NEW RESIUISNTIAL PLMB. SQ.IT, PAT])
D
I far which
h thi Thi there issued(iee 30lendie.agency for the perfommncc of Dam Receipt as
F-t the work for which This penniT is issued(See.3097,Civ.C.)
;Is Lenders Name- A-, TOTAL:
Lender's Address TOTAL.:
app I certify That I have read this application and site that the above informiion is - BUILDING FEE
p2 concct.Iagree mcomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U buildingconswction,and hereby authorize representativesafthis city toenteruponthe SEISMIC FET
above-mentioned pmpeny for inspection purposes. - .?
,(We)agree to save,indeniody and keep harmless the City or Cupertino against - PERMfC IgSUANCP. 3.2.�'7J f31,f?MRIC FEE
IIuhIIltles,Judgmenev.caste nnA cxpcnaen which may many way uccrucaminst said City AUI'ERORADD'TOMECH. PLUMBING THE
in tisegoenee of the gmnthtg of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1011 CPM)SOUR
:e&Z �,ATIDNS, MECHANICAL F
4EE
`/n .�rwy/per-/ /y�p� TO."HANDLING UNIT(OVER 10, CPM) CONSTRUCTION TAX
Situation,ofApplicarr Conmaior Die EXHAUST FOOD(WMUCq HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicant or future building occupant store or handle hazardous material HEATING ONE-[(TO 100.000 BTU)
"defined by the Capetian Municipal Code,Chapter 9.12,and the health and Safety
Cade,Section 25532m)'1 HRACI NO UNIT(OVER 100,000 BTU)
El Yes C No
VE'NTILA'TION PAN(SINGER RE$ID) PAID
m
Will the air roplitar future building by the nt BuseaA it Quality
Mnawhich BOILER-COMP OR 100.00)BT U) 'I
Dist hazardous air tmntntnitunns in del incl by the Bay Area Air Qu:Jity Management TOTAL:
DiamdO Yes ❑No - BOILER-COMP(OVER IW,OW BT U) 1 nI IIYN 7�a
AIR CONDITIONER
I have read tate hmandme nnormuls penitential,mover Chapter 6.95 of the Cali- ISSUANCE DATE(&
forma Health&Safety Code.Sections 75505.25533 arvJ 23534.1 understand that if The NEW RES IDENT1AL MECH, SQ.14.
building docs amt currently have a tenant,drat it is my respunslbility to notify the occupant
I trireme s ich most be,a pdnno nuance of o Certificate of Oceulare
Owner or authorized agent - Datta TOTAL:Iy3r ISSUED HY: `_—i9��.7JaWeC•
OFFICE