28979APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN;ONLY
CITY OF CUPERTINO e a • , -
I UILDLNG - ELECTRICAL _
PERMIT NO.
BUILDINDIVISION APPLICATIONIPERMIT
G
rLUMBIIs;- MECHANICAL.
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28979
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BUILDING PROIFICT.IDENTIFTCATION
BUILDINGADDRESS:
SANITARYNO,�
APPLICATIONSUBMITTAL DKIF
"a OOHS
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OWNERS NAME: PHONE
CUNT ItACT(]RS NAME: ^LIC NO'.
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C�ySP
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CONTROI:N -
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ARCHI'I'ECTAINGINCER: _ yI TICNO. ,a /
ADDRESS: - .' _ -
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CONTACT:++6-iso"
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BUILD( GPERMIT NFO
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L C(rkV 'B 5 1 Dq46b 4-30cees pi 7
❑ consultant Fees Paid by Applicant (Initial)
.- ' BLDG ELECT PLUMB MECH
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'ORSDCCLA11A1[ON
- -LICENSED CONI
QTY. ELECTRIC PERMIT III,
O fLZ
1 hereby a1Rrn that 1 am I ensed nseJ uionder pnwmons of Clasper 9 (common ing
with Seclon 7000).f Division 3 fthe Busirs,xieJ 11 .. headline, C.dc,.fd my licepeis
JOB DESCRIPTION ' '
RESIDENTIAL: •'i
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and effect.
p
ince.
1'ERMI f ISSUANCE, _
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❑ SFUWL ❑ KD'CHEN REMODEL.
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License Class Lica
a Class
Date Cnmrunor
APPLIANCES - RESIDENTIAL
❑ADDITION C1 PLUMBING RE -PIPE
' F "J to'%s
' +' ,ARCIII DiC S DECLARATION
PANELS " ' '4 h
❑MDLTI-UNIT •. ^; El STRUCTURAL
'..MODIFICATION
ZoOZ
1 understand my plans shall be used as public records 1
.
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UP TO 2W AMPS _
E] INTERIOR • ❑ CHIMNEY REPAIR
777777
Licensed Professional - .n^ a
OWNER -BUILDER DECLARATION
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201-1m)(FAMPS _
'. IMI'kOVI?MENT "
'p�
wi
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OVER Iqp AMPS -
BATH REMODEUREPAIR ❑DEMOLITION
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I hereby affirm that 1 arm exempt from the Commarnr. License Law for the
❑OTHER
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following renin.. (Seed.. 0031 5, 1 inose and Prnfnoionx Code: Any city or coarry
SIGNS I?LBCfI11CAL •
rs1 as O ya
requires
r^ m❑
tWtW��p.
which a permit m cons met, ahee impfovq demolish, or repair any &fracture
priors t also q' 'thapplicantf s ch pe .oil Ile a.'6 ed statement
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SPE CIN.CIRCUIT/MISC.
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tlot, lin islicensed parrita In, p a f he C union', LLaw Clunme, Y
�fcommennngwith
Seco .]0001 fD'vias 3 fthe ❑atmos.. enJ Pn fes:' ns Cnde)x
11: MP. MITER OR POLL INST.
4COMMERCIAL: ,
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that he is exempt themfn m and the basis for me alleged enempr n Any violation of
❑ W BLDG/ADDITION ❑ DEMOLITION
'Is✓-e"'w
Section]0.41.5 by any applicant for n permit subjects the applicant m a civil penalty Zu
POWER DEVICES
NANT ❑FOODSERVICE
F=6
t more hundred
/IMPROVEMENT =A
FO
aswoomfvc
yempl
perry, or-my
yemntended oifffered as their ececompensaiess
❑ Lo the work, the pearmat armature
will do the work, and theswc[ur<is not intended or offered hmaale (Sec. ](W4, Hareiness
SWIMMING POOL ELGCfRIC
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❑OTHER
Land
I'tnfessiom Code: The Contractor's` License Law does not apply,ro an owner of
OUThCI ti -SW I'ICHHS-FIXTURES
prepeny who builds or insproves the¢on, and who does such work himself of through
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his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL ELEcTR= SQ EL
sale. IL however the building or improvement is sold within one year ofcompinlon,the
'`SQ. FEFLOORAREA
$/SQ. ET, ,
wnerbuilder will have the burden of proving that he did not build or improve for par.
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para p 1 ).
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01. as wori.1 the Pn pc LY an xtud'ly comment, wim Lcet.ard,emmoclrsor
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construe the d rt The ConwnoP. Li-
not
-
C_ l
es pl *owner ofwh buildsori
applyrmimpit)
mhosed
who
QTY. PLUMBING PERMIT FEE
rat horn,and
coawdnear suchplytoan thaofpropeny
pursuant
su'
far ouch pmjecli withawmrucmr(sl livens«Ipm antmthe Coufmrm(s
License
License Law.
ow,
'KI amexem,ocra rSea.' .B& P C for this reason
PERMIT ISSUANCE
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s
ALTER - DRAIN & VENT -WA'I'ER(EAI
VAIAA'1'ION
Owner Date
WORKER'S OMPEN TION DECLARATION
BACK FLOW PROTECT. DEVICE^/
s'
Ihereny nRimt under penalty of p yone .hoof llnwing Aeclamfivnr. '.r
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❑ Ihavesndwillmaioneina Cenific' cfC senna sell' -insure for Worker's Cnmpen-
DRAINS- FLOOR. ROOK AREA, GOND. � s
STORIES
TYPE CONSTRUCTION
sation, as provided for by Section of the aba" Code, fur the performance of the_
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work fngwhich k peow, is'iss d.
In
FIXTURES-PERTRAP _
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❑ I have and will maintain rkaA Competitor Ion Insurance, as re,mred by Section
3700oftheLaborCode,fo eperformanceofth work for which this permit is issued.
GAS-I:A.SYSTEM-TNC.40U1'LETS
OCC, GROUT'
APN
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My Workers Dampens a'a..runce currier and nifty number are:
Carrier. ` Policy at
CAS-I:A. SYS'I'EM;OVEIY4 (HAj•
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TIFICATH OF EXEMPTION OMWORKERS'
COMI'IiNSA N 1 U NCI:
GREASMINDUSTRL WASTE INTIiRCEVI'OR
HUILDI DIVISION F[ES
sscction neednothae
a "No's ne hundred dollars Ira
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GREASETRAP
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s) 1
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PLANCHECK PEE
M
Icanifythaliame to
fine work ho hick this Permit is issued, I shall
SEWER -SANITARY -STORM PA. 200 FE "
not
rola
p yany pe in of rsn tax to hoc e.unjen mthe Wnrkeri Cumpero
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ENERGY FEIi' _
C)Z
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satin maws of Calil�mt'
A, ,in
WATER HEIATER WNENT/ELECIR4"S
I NG EEE
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NOT P. TO APP .'IL eller makin tie CeniOcaf of Exentptiarn, yon apoulJ
Wq'1'NR SYSTIiMfIRF.pI'ING
SOI
a^
bacon • subjem m the leer's Cnmpenca sn prn�sioes of a tabu Code, y�L must
G
fonhw hemoply with a Provisi.nsn his tit erred revo e.
WATER SERVICE
].z
CON$TRU ON LEND GENCY
NEW RISIDF.NTIAI, PLMH.
PAID
Receipt is '
'UOtliewnrRl
1 reby affirm that them is carn.n adingagcnf �'c1r Nets, formance of
rwhlch this panniti•s 09],Civ.Cy \ -
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Lendor e
TOTAL:
U
ULender's
Ad
1 taint &frau I Inry mall pllumion m I! At ane above inlnronal— la
HUILDIN PHC Ito
h
mrrcct.I agrees nm whnalc y rid countya .inane. and state lows rtlatins to
QTY MFCFIANICAL I'IiRM
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building constmcti rid hertb�vm teprenenmtira of this city to enter uPun the
SEISMIC '1? '
Ez Lk
ahovcmentidnal property for inspection purpoma - : a.
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P[RMI'II ISSUANCE 'I�
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` 'ELECTRIC -
(We) agree io save, indemnify'und keep harmless the City of Cupeninn against
19:
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liabilities,judgments, costs and expenses which may in anyway warm, against said City
pLTEEORADD1OMI7CH., �•
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indonsCANTeof tha permit., -
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PLUMBING PEE
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NDERSTANDf, A
AND WILL COMPLY WITH ALL NON POINT'
'g1ft HANDLING UNIT (TO IO,gNI CFM)
M[CHANICALFEC
SOURCE REGULATIONS.
SOURCG REGULATIONS. �
AIR HANDLING UNIT (OVER I(h000 CFM) '
CONSTRUCT ION TAX
Signmamof ApplicanVContmcmr�- Data
EXHAUST HOOD(WMUCq
HOUSING MITIGATION
HA7ARDOIIS MATERIALS DISCLOSURE, "
- Will the applicant or future building oecupam store or handle hnmmous mm[erlul
HEA'1'INGUNI'I'fP0100,0N)B'I'U)
as defined by the CupeninoMunicipal Code, Chapter 9.12, and the Health and Safety
Coda, Section 255321v)1.
HEATING UNIT(OVF.R 100,000 BTU)
_ 5
❑Yc _ N . ; 1
VENI'11.ATION ]--AN(SINGLE RESID)
PAID - -
Will the applicant or future building occupant use equipment or devices which
th tosatcommunicators as deposit by the Bay AreuAu Qrrhlt Management
BOILLR- COMP(3HPOR 100,000 BTU)'
•)s! 'x
❑Yex - No
D�
BOILER-COMP(OVF.R 100,N)ORTID'
I have read the hmmdous materials tequircments under Chapter 6.95 of We Cali
AIR CONDITIONER r
ISSUA AT
]
farm. Health & Safety Calve, Sections 25505, 25533 and 25574.1 understand that if [he
_ NEW RESIDENTIAL MIiCH. SQ.
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building dares nose can my havevfcnanL that 116.1)yespnrvlbilitywnotify thcscwpunf
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of the repo' which muif st rat prior enc Ceni&nie of 0ocupan
'Owncror vat emcee igenr "Yeall,
AI.+,
ISSUED BY
L'. OFFICE --