28509 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL 28509
BUILDING PROJECT mevrIFICAIION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
10,501 N , ANTl s
OWNER'S NAME: FLOES �s CO ' ICIPR'S NAy LIC NO:
L. /V• N/C CONTROLX
•.A ITEC`16NG1 7-7 R. ,LICfJ I&eqq ADDRESS: - ❑ 77 C/6
_
cow&m LC• PHONE:/ BUILDING PERMIT INFO
G, S 1 O'Z2 b'/''') /']O ❑ ColtNltant Fees Paid by Applicant(Initial) BLDG ELECT` PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
hereby I hey afr'm that I ann licensed nyder no,inm or iaChapter 9(emmeceing JOB DESCRIPTION
MW"CZ NSctirn]0001 of DiriaimJrf the Businessand Rofessims Code,.efrd mY hemse,u
�O vI PERMIT ISSUANCE RESIDENTIAL
'
nfullfurceaMeRat. '� ❑SFDWL - ❑KITCHEN REMODEL
aUZ Liccwe Class Can APPLIANCES-RESIDENTIAL .0ADDITION ❑PLUMBINGRF.-PIPE
InQ�. Due COnneclm
FUy ARCHITECT'SDECLARATION PANELS ❑MULTI-OMT ❑STRUCNRAL
Z p 1 IudawM ray plans shall h cod!
i as puhlic records MODIFICATION
pZ p UPTO KU ❑INTERIOR ❑CHIMNEY REPAIR
LLicensedLicensedProfessionalcssional � N11-IB(p AMPSMPS IMPROVEMENT
•J OWNER-BUILDER DECLARATION OVER IWBAh1PS C1 BATH REMODEUREPAIR El DEMOLITION
C 6 1 hereby affirm that 1 am exempt front the Comraclnr's Lice w law for IIIc
O U SIGNS ELECTRICAI. OTHER
3 which ro{uirts a pcnnil Ir¢nslrud,neer ilnpnwe,N:Imlinh,rr rdwirany awaurc
F 0 prionnio ismancr,der rtyuirc the epplkvm fur such pemlitw Ilk a,igrcd uammrnl SPECIAL CIRCIIITIMISC.
<� Rtesmi,nsc¢wed mcRhm lolhcpfDininn.v 30lor BOuna,,,I,iccn,claw(Code)r9 _
Qp (wrmmcming wish Snnion]IXXB of Divlxinn3nl lie Buzino'n end Pm[rn'ims Code)or T13MP.METER OR PULP INS II COMMERCIAL' '
a" thin he in eaempt Ihcrcfmm erd the to i,for the ollegN exempim,Any violaam of ❑NEW BLDG/ADDITION ❑DEMOLITION
yx'gs Section 911313 by my yrlrlicunt Br a PmIP
nll uhjcets c rMlicanm l a Civil DEVICESlty of POWER DEVICES u1^.� p'IMPROV ❑FOOD SERVICE
F�Qwl nate Than Eve hmdred ddhta y crapl.
❑I,urwner ofd¢pmprny,urmy employees with wages ulhcir sole compense0rn, SWIMMING POOL ELECTRIC 'IMPROVEMENT
' 0 will do the wrrk,afd the.nrvcarre is tut imcndcd urnHcfcd for sale(Sec.]014.Business ❑OTHER
W 3$ and Prorrimars Cock:The Conlnclor's Li¢cm,law dnea rw apply In an ownef of OUTLETS-SWITCHES-1'1XTVRIS
aropary who huiWs or imprmen Itlec<rn,and wtlo does such work himself a dueugh
his own employees,pocvidN that such impovemrnla etc not inlendavl or offered for NEW RESIDENTIAL FJ,EC R SQ FT.
sine.If,howevn,the building ur improvement is sold within one yearrfc."herioq the SQ.FTROORAREA ESQ.FT.
rwrer bu icier will love Its hurden of Proving That he did nm build a improve for Pm-
poee of one). 3�
❑I,as owter rf the pmpeny.am excluuvclynarrveting will licensed cmntractm to TOTAL -/ x00
cmSenCl
the project(Sec.]IIIA,Has.and 14ofeasions Code:)The Comramor's Li-
crnscLaw closes lel apply Loanowner at rot'er,w'ho hitch,m imam-e,thereon.said QTY. PLUMBING PERMIT FEE
whocontnactsfursuch Projects wmacon ons)licensed p'naantutde CWvactou,
Literate,hw' PERMIT ISSUANCE
lam e.sempt utx4 Sec.' .B R PC fur Nie realm
ALTER-DRAIN&VENT-WATER(EA) VALUATION.
• Ow v Da
WORKER nderp COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE 7o Qs'�
1 nQebw arfnm under penalty of pafjmy one or the fabling MIMr1m4:
�Inave andwillma by Section 377W of Cse,1uxlr-inswefur Wmkcr'a Gompn- DRAINS-FLOOR,RWEAkEA.GOND. STORIES TYPE CONSTRUCTION
swim,r povidd fm by Section J]00 of Ik IoM Code,M the Peffurrtlmue of the
work f«which this pvnti i is issued. FlNI'URES-PER TRAP
I hove and will mellva r Worte(s Canlpd dr em Insurmcewhich required by Scotian
My WcfNelabatCousilaco.00r Nepc e'arac dwpoli,fmrbare: ttmit is ism GAS-EA.SYSfEM-I INC.i Ol1TLEfS
OCC.GROUP APN
Myier. aCnrtryenwtlao Imurarce cenierrml Policy numhea are:
'
Carrier. Pulley No.: GAS-PA.SYSTEMOVER dEPA)
CERTIFICATE On EXEMPTION FROM WORKERS'
COMPEiNSAnON INSURANCE GREASMIsDU.STRL WASTE INTERCEPTOR
BUILDING DIVISION PEPS
fin,aMiun nttd rut ire arnplcled iflm Fu mrd is fur •bumhal dollars( I u
or lees.) r GREA.SETRAP PLANCHECK FEE / •�
I¢nily that in the prcrfamun¢oflhc work for w 'h s rmil in i.(I�d,JaAlell
tut emplo ,Ni A,`,.,, SBWER-SANITARY
-STORM EA.1OI11T.
y any ptuar in my nwnrcrxowln Mone,h,u 111eW Fen- ENERGY FEE
'C) sudors paws of Culitiamiu.Dom WATER IIHATER WNFNUELECI'N
NOT'IC tel GRADING FEE
NOTICEubj APPLICANT:If,after nmkl hl C a¢n ooh,you duuW Wp'ITiR SYSITiM/TREATING SOILS FEE
F hcavtoe subject n Nc WrNcr'h,Comfunwin itru or Nc Cade.You mon
al f¢NwiN cwnply with such provisionh,ort ' ashall he ds rmokM. WgTFR SERVICE
0
P. CONSTRUCTION corraN GENCY NEW RESIDENTIAL i'I.MH. SOFT. „
rF7 Z PAID��
U 0 Thereby affirm that Sen,is ettrutrvnimlenala agauy fm NepMmmarree,of Date Receipp
Lkl r-s the wart for wbicn Wz Permit i.issued(Sec.3097,Civ.C.)
0 H Lerdv',N. TOTAI.
U Leader's Addteh, TOTAL
00. 1 ccnify not I have read thin argAhcedm and urate that the above infmowim is BUILDING FTE
rte comet lagrte to comply with ell city as mnoty¢dinenc avd nate laxs relatingu Qnl. MECHANICAL PERMIT FEE
U Z building toautrvctirn.aM hcrtbY authvtiu rtptecvtativca of Nis city lr elver rpm the SEISMIC FEE - f
`I above-nrarioted pcoper,f«inape fison purpmm.. PERMIT ISSUANCE
(Way ogre,touve indemnify and keep hafmkss the City N Cupmiw ora aga 32,0-3 FJPCfRIC FEE00
Iiabilitiajudmems.cosuand caleeni which may in any way u'tt.1intw said City ALTER OR ADD TO MECH.
in croseaparce MNe granting of Nu petal. PLUMBING FFP
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Uf000CFM)
SOURCEREGULATIONS. MECHANICAL FIE
AIR HANDLING UNIT(OVER IOBKO CFM) CONS-IRUCTIONTAX
Siglwawe MApplicamlCmaemrr Due, FXHAUFT HOOD(W)DUC17
HOUSING MITIGATION FFP
HAZARDOUS MATERIALS DISCLOSURE n •
Will the epplicantor future building retortion start or handle haaardotu hummed L HEATING UNIT(TO 100,000 BTU)
u clef ned by the Cupertino Municipal Code,Ch,.-9.12,vd the HeulN and Safety
Code.Smtion 255]3(,71 HEATING UNIT(OVER IIXLtXp HIV) 2t-2�
UYes ❑No VENTILATION FAN(SINGLE RESIDE PAID Jr+
Will the Due ReerlpM
pir corinlmntluo building by I the Byrsequipmentord Mamwhich BOILER-COMP PHP OR IOn.01X)BTU)
moil huaNwa air cmmmiMnls w detirN by Ins PeY Area Air Quality Mumge,ttent
Drkrarl
0ye, ❑Nu BOILBR-COMP(OVER Wr(OOBTU)
AIR CONDITIONER .rI / C hl ."„ _
Ihove and 0euaM
hunintoriuln ngoiremenss under Cluper 6.95 of Use Cali IS�UANCfi DAT' V
Ernie Deem&Senn,Cnk,Lection,353(P.2597 odd 2553].1 mrirstrod dust if the, NEW RESIDENTIAL MECH. SQ.FI'.
building ml tet ICI' ,Iharn may lcso.ihilily In m4lfy lherccrpwll
of Ne, u awhieM1m . xofeC i0c o or �
0,nerora cm Dote 'TOTAL:;,Yloo ISSUED BY aSlra-JE4Af70A"-CLI
OFFICE