28919 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUDV;NG-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLU\IRNG-MECHANICAL I nO n
BUILDING PROJECT IDENTIFICATION L O J
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAPI
000 WpLa5 Paw 02L+
OWN'.R'$NAME: — ^ PHONE CUp'TRgCfON'S AME: ��Co7' N/C CONTRO
ARCH]"EC/ENGINEER: 1/ Lll/4NO.. ADDRESS: S �f/ ❑
tizl �lS/o83 2Um 9tL6iki D Ave. -IsC `1s
CONTACT. PHONE: BUILDING PERMIT INFO
Bpi �I� 44�- 6466 ❑ Consultant Fees Paid by Applicant(Initial) BLn, PLUMB Ec
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm da 1 am licensed code,Moisture,of Chapter 9(commencing JOB DESCRIPTION
O0Z with Section 7000)uf Division3ofthe Businessand Pndeaions Code.undiry license is RESIDENTIAL'
W 2
{y wt PERMIT ISSUANCE
Ful` faill cffat. 4PI50.7" CSPOWL ❑KITCfiIiN REMODEL
�UV License Class - Li af� �' APPLIANCES-RESIDENTIAL ❑ADDITION [3 PLUMBING RE-PIPE
in 6 a Dae Contra,
ARCHITECTS DECLARATION PANELS
El STRUCTURAL
~anZ 1ununderstand my plass shall be used us public.cards PANELS MODIFICATION
UPT0 2M AMPS
p Z= ❑INTERIOR El CHIMNEY REPAIR
ul Licensed Pndcasianol 20LIOIXIAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IIXp AMPS [I BATH REMODEDREPAIR ❑DEMOLITION
Q I hereby affirm Nat I om exempt Bass the Contraztm's License Law for the
mow, following teams(S¢ Professionsr CT
linn]031.5.Business and Code:Any city s county SIGNS ELECTRICAL
[:]OTHER
LLi 3 R�j which requires a permit to construct,alter,improve,demolish.or repair anystructure
prior to its issuance.also requires the applicant forsuch permitlo file a signed statement SPECIAL CIRCUFUMISC.
ythat he k licensed pursuc.Itnlheprnvisians of the RomrnenKS License Law(Chapters,
C OQ CO (cammencingwils Section 7000)ofDivision 3ofthe Business and PlofCsso os Ccde)ar TEMP.METE RPOLE UeST COMMERCIAL:
6 6 0 that he is exempt therefrom end the basis for me olleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ern Section 9031.5 by any applicant for.perit.bjec¢thc applicant ma civil ponmlty of POWER DEVT IN&ANT ❑FOODSF,RVICE
5Cnot more tban five hundred doll.($500L r 1 ROVEMENT
❑ Lus owner of the propcny.nr my entpinyas with wages as their sole compensation, SN' MI OL EL'CfRIC
will Jo the work,mdthe structure os nal intended or offered far sale(Sec.91W.Business OTHER
el. an and Pmfessions CsJe:The Comrecrors License Law docs no apply t m owner of OUTLBTS S HIiS- XTDRIS
6 3^ property,who builds or improves thereon,and wh)111'
such w k himself or Jtaag
his own employees,provided That such improveto t ndcd or nIf NEW RE91U IA E. SQ FT
sale If.however,thenailJing or improve ncnt is sithh fretmpe' ,u SQ.FI'.FLOOR AREA USQ.FT.
owner-builder will have the burden at provin ' not build p O
pose of sale.). 4
I,as owner of the pnspcn3 < i g wJ'tb tic oncacmrs to •% t ,
Comfier the project(Stt.] and 1Qofcs(inns.CNegThe Comracmrs Li-
c ,e Law dies nm applyman sw r.R property
wit
JJs or iapnnea thereon,and Ql'Y. PLUMBING MIT FEE
who nmtruets for.snch pr ow �I m nmd
trunrOIleenvedpursvanuu lM1e Commctnr'x Iqn
License Law. PERhI1T ISSUANCE `L� ��
❑I.n sempt under Si .B&P C for this reason C, kJ
ALTER-DRAIN&VENT-WATER(EA) 'a VALUATION
Owner Date "x•60 a� _
07
WOR KE ITS COMPENSATION DELLA RATION BACK FLOW PROTECT.DEVICE `�'Y—`y/1 '
—� Ihurcny affirm under Penally9l'Term,one of the Bal lowing declamtior,:
❑ I have and will maintain a Certificate of Consent to sell-insure for Workers Compan- DRAINS-FLUOR.ROOF,AR EA.COND. STORIES TYPBCON5'IRUCIION
salon,or,provided for by Section 37W of the labor Code,for the performance of the f
work for which this permit is ismer, FE TURES-PER TRAP
9 1 hove and will maintain Workers Compensaion Insurance,as required by Section
3]( of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Wor r' Comp -lion Insured,,canner and Policy )rY GAS-EA.SYSTEM OVER 4(EA)
Lamer. Policy No.: bD
CERTIPIC OMPEN ATIONI NFROM WORKERS
' GREASPANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILD )NISI YFEIS
('His section need not b,utmpl9mJ it thearit is Become hundred Jnllars($IW) GREASE'rRAP
9r Icsal I'LANClIIiCK PIiE
is
Icenify that in the ficrfonm9nce ofthe work forwhich this peril is issued,Ishall SEWER-SANITARY-STORM EA.2nd FT.
not employ my loom in any manner so us m become subject m the Workers'Cmnpem ENERGY FEE
Z .tion laws of Catbirds.Date WATER HEATER WNEM/ELECfR GRADING FE
z Applicant
NOTICI7 TO APPLICANT':If.after making'his Certificate of Ese.Puan,you should WATER SYSI EMITREATING
► SOILS Fliii
F north.,subject The Worker's Compensation thin provisions 9I'the Labor Coke,you must
forthwith comply with such provisions or this perit shall M1e decided revoked. WATER SERVICE.
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM1I B. SQ.FT PAID Da Receipts
U 0 l hereby affirm that there is a cnnswction lending ugcncy for the perforanccof
Y+ F. the work lin abidtthis permitis issued(Set.3097,Civ.C.)
O U1<nJet's Name TOTAL:
W Lenders Address
y certify that I have read this application and state that me above information is IT
FEE
V] correct.l agree m comply with all city and county ordinances and state laws mixing m QTY, MECHANICAL PERMIT FEE SEISMIC FEE
U Z banding construction,and hereby immunize representatives of this city m enter upsn me
abrve tncaoned property for m,P,etion purposes. PERMIT'ISSUANCii
(Wo)agree m save,indemnify and keep handless the City of Cupertino ngain.0 ELECTRIC hlil!
liabilities.judgments.cents and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEI
in comequitnce of the granting of this perit.
APPLICA NT UNDERS'TAN DS AND VILL COM PLY WITH ALL NON-POINT A IR HANDLING UNIT LTO 10.000 CFM) MECHANICALS
EE
SOURC' iGULATIONS.
AIR IIANDLING UNIT(OVER 111.(0(1 CFM) CONSTRUC11 AX
mgnawre Dae EXHAUSI'HOOD(W/DUCT) IfOUSING MITIGATI FEE
HA'LARDOr. LS DISCLOSURE
Will the applicant or frme huildingtacupartsmrcor handle haz.doos marenal HEATING UNIT(TO 100,00O BTU)
as defined by the Cuperao Municipal Code,Chapter 9.12,and the Ilcallh and Safely
Code.Si 25532(0)'! HEATING UNIT(OVER 1 W.000 BTU)
❑Vons ❑No VENTILATION FAN(SINGLE RESID) PAID DateRax to
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(RIP OR I E RES BTU)
mil hamrdous air contaminants as detined by the Buy Arca Air Quality Management TAL:
Diuricf! BOILER-COMP(OVER 101,M)BTU)
[3Ycs EJ No
I have read the h.arrous materials requirements under Chapter 6.95 of Jac Cali. AIR CONDITIONER I ISSUANCE:DATE
forms Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.ET.
nullding docs not curmiy have a tense.,that it is my r,sp.dbility,to n lify the occupnnl
of me rcgmienr nmx whish must be mel poor m m tons c of o Cendfieure ofO,capancy.
Owner or authorized agent Dam TOTAL: ISSUED BY:
OFFICE