28739 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELELTRICAL PERMIT NO. 28739•2^ .a a�/N
3NIJA
BUILDING DIVISION APPLICATION/PERMIT PLUMING-MECHANICAL - l8 1/
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DAD
n OWN SNAdgtE PHONE CO SNJ yr LIC NO: NIC / CONTROLY
s7rdou9�� b26✓S5
ARCHITEC'EFNGINIi� LIC NO, ADDRESS: ❑
Zz�-7�/adS /�ue fyleU/Pvl
CN'ACJ: PHONE_ BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Initial) BLDG ELE mu B MCCH
LICENSEDCONfRACIOR;SDECLARATION, QTY ELECTRIC PERMIT FEE
I berthy aft mat 1 sur fumed(under provisions of Cha,ur 9(comnx rcing JOB DESCRIPTION
�d'Z thSeelian 71000).1D,Woo Softhe Ban.and Pwfoaioaw Code.erd my(teem,is
�DO our - PERMIT ISSUANCE RESIDENTIAL
m full rame.ad ertert.
'tF;ZLiecnvc�I lie.» SZ 61SS ❑SIO)WL ❑KITCHEN REMODEL
NQi Ume -/m' Cmmnc,. - P4 APm.IANCES-RENIDFMIAL '0ADDHHON [I PLUMBING RE-PIPE
ARCHEFECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
r,
Z O Z I undeu d my plans Dull be uwd n.public nosh. PANES - MODIFICATION
OZ 1i UP102MAMPS ❑INFERIOR ❑CHIMNEY REPAIR
f-r3 F'u� LlCcoad Pwrnaioaal 2014U100AMPS PROVEMFNT
WYfa OWNERBUIIAEA DECLARATION _ OVER 1000AMPS TH RENODEIIREPAIR ❑DEMOLITION
y 6 I hemby affirm that 1 em exempt from the Comrmnors License Lew for the
x O L U following tenure.(Salim.7071.5,Bmiress mol Profea6ma Calc:Any city a aunty SIGNS ELECTRICAL ❑OTHER
Y7 3 LLF which re tdrn a pefrml to ecUM
LI,shoe impa an
improv[,elmnulinah, opeir y stNCwrt
v-O,} Pr O is mastai elan requm"the'PpBcoR for ouch p 11 w file signed.,¢meati SPECIAL CIRCUHUMISC.
dant Inn u I kvmd punmmno Neprovisions of the Comrter
u 's Liec.m Ltw(Chao,9
dZ�O (comncrcing with Section 7")of Diviemon lot the Basin.,end l'mfeuimne Crook)mr TEMP,METER OR POLE INSC COMMERCIAL
6 a e that he is;exempt therefrom sed the beds for the Alcgd cxcmption,Any Villation Of ❑NEW BLDGIADDITION ❑DEMOLITION
-y Sar 70313byanyaMAinrufmageroilxuhjca%J a ]l tioa6i ilpc yof -� POWER DEVICES �TFNANT ❑FWD SERVICE
G
Z Y not.—them five bumlml doll,,($50T,—Q F-1hmowarm Of the pmP,ny,mmy cmpbym with way.utheh role compensmimn. SWIMMING POOL ELECTRIC IMPROVEMENT
X=0
W1F will&We work.said themnwtw,B not aneaded or Offered foraak(See.70L.Busiress ❑OTHER
usad Pr fiesaimu Code:The Cmtrenoi,License Law docs apply tom Owrun f OUTLETS-SWITCHES-IIXTURfS
63— Mi,erywhit huildr a impmn thereon, M
vend wdw_,srrh oak M1imwlfa 1=loh -
his owe employee,n ovidd their ouch imptove is to mendul a effeml fm NEW RESIDENTIAL ELE= SQ FT
sale If hos'ever.the Wilding mr imptovcmmt is • b m Immplet the SO FT FL�ARREA LSQ PI'.
owrcr-builder will levetk Wrdeo of pmvinyt -dor ins Pur-
ryne ofaeled. ^
❑I,uowno of Be pro ny'moexcw: cl a ing li n¢ m TOTAL: O�� fJ
cmaeuct the Project( 700 .Bu fi.imw Ode:, Cm" ora Li- 30 9g5..
Law does nor apply aeat)w pen amilthiri nesmmmeeod Ql'Y. PLUMBING PERMIT FEE ) 19'57
who,umocorfureu ye. reonow of ensile' smwOecmrmewr's CII Y
Lex"w exLit PERMIT ISSUANCE L• ur car NO
❑ IunnemptadvSex. a&rcraroiwmaw„ $till ,
Owrcr Date. ALTER-DRAIN&VENT-WAFER(HA) VALUATION
WORKERS COMPENSATION DECIAR VHON BACK FLOW PROTECT.DEVICE
I hereby sR oder pumhy of perjury one,a the rdlowing deelowmmns:
❑Ihoemil will madmen a Cenmfcmmf Cmnncnt tool(-insure for%AesGmtPrn- DRAINS-FLUOR.ROOF,AREA,COND.
� wtiun,ss pauvidcd for by lectins 3"Ilyl of the IuM1r Cd,,for the perfmmwrc,of the STORIIS TYIt CY)NS'IRUCTION
woh for which this permit is iasasL Z, FIXTURES-PERTRAP �
1 have said will mtinuin Wotter's Compenutioe Insurance,as resited by Sabo. t
3T30of0e(suns Code,for the pefimmuce.fthn work for whi,h,hi,p[mm,is ksted, GAS-HA.SYS'T'EM-I INC.4 OUTLIi fS
OCC,GROUP APN
My Woheta Compenmtim Insurm¢e cmrim and y onumber ac:
arrico N :
CPolicy No.: GAS-CA.SYSTEM-OVER 4(EA) e
CERTIMCATE OF EXEMPTION FROM WORKERS',
COMPENSATION INSURANC17 I GREASWNDUSTRL WASTE LNTERCEPIDR
('Thi.section ocW not he annplmd ifthepcmut is for ore hundred ddlmx($10)) BUILDING DIVISION FEES
mom) GREASE TRAP PLANCHECK FEE
I anify Nat in the perf.n cOM wok fa whiih,his toom,is isvncd,l shall SEWER-SANITARY-STORM EA.201 FT.
ma employ eery pereon in any man ,{P mix Jn hj5yt Workers Caupan- ENERGY FEE
ZZ amino Laws%$li9^:w e Y a—a3/ c-u 7 WATER HEATER WNEYI'/Ef.ECI'R
Applkmu ^U`-^rw e P H - GRADING FEE
Ter NOTICE TO APPLICANT:If,eller making this Ccnif a aEacmption,you should, WATER SYSTEAdiTRIIATING
5 heatme whjW m the Wakes,Contrc.,mio.pwv,.of the Lahr COtle,you mu.a SOILS WE
� 0 fieehwith comply with such po,,,iox m flux mi,shall W deemed revoked. WATER SERVICE
a
L) Z CONSTRUCTION LENDING AGENCY NEW RCSIDENTIALPLMH. SQ.FT. PAID
.. VQ the Which thithatthc iieuctm,tmm monkrdm agency for the perfomummf Usm, RaciptY
0 the wok fou which this pcmut u issued(Sm.7097.Civ.C.)
UIeMeh Name TOTAL:
I<aaln'e AdrBesa TOTAL:
0. I e,nify the,1 Lia-need this opplienutn a d ame thea rhe aMrve infomrurion i, - - HUILDING FEE �.
y m 1_l epee to comply withal[city and county erihmacc,rod state laws relining an QTY. MECHANICAL PFRMIT FEE
U 2 W"ot crosoucthoa sed hereby wthaixe repserenwi,e,of thu onto ever upo.the SEISMIC FEE
abuve�rrcnthnad pwpeny far inspcctvn parpoe.v PERMIT ISSUANCE 'ELI:CI'RIC PEE _
(We)sgmu to save,iMcmnify and kap hmnticss Me C t upediat eguimu
liabilities,judgmerns.coma and cxpemn which they in anyw yainstssid City ALTER OR ADD TO FIECH. PLUMBING FEE
wvnseWeece ar tde yrwti"y Of thi,Pemdt.
APPLICANT UNDERSTAND AND WILL COMPLY ITO LI.NON-POINT AIR HANDLING UNIT(TO IO,"CIM) MECHANICAL TLB
RCE RI 1
a�IlL AIR HANDLING UNRfOVER IO.IXp CFM) CONSTRUCIONTAX
t,nmrer Appli.VCrmtr;,1rc Dmc EMIAU.STH000(W)DUC-n
X HAZARDOUS MATERIALS DISCLOSURE HOUSINGMTDGMDONFEE
Will theeppliesm orfumre mil 'oecupmu worn mr haardkh vdow materiel HEATING UNIT(TO 100.000 BTU) ,
u defircd by the Cupertino Mutt ipal Cede.Cluper 9,12-and the Hedth sur Safety
Code.Section 25532(¢)1 HEATING UND'(OVER He),01(1 BTU)
C]Taa 7N VENTILATION FAN(SINGLE RESID) - PAID
Will the OFF!i.t ex fawn,building occupant use t a devitta whieh' Dare Receipt Y
emit h
rympQBOILER-COMP LIFE OR I.,"HTU)
nrvdrue air cmnwminwu v
defined by the Rey Arco At, uality Maragnrrnt
axon"? TOTAL:
❑Yes In BOILER-COMP(OVER 100.000 BTU)
I have amd ffi v dei,mnImel,nx.iremeos ado CTwtn 695 Of the Cull- AIR CONDITIONER
P ISSUANCE DATE
forma Heelth&Sarety Code,Swoons 25505,25533 sal 255}1.I undcmwd that if the NEW RESIDENTIAL MECH. SQ,FT.
Wiwi"iredon rentseureendywNeb have•tmivLL dei it i,myce of. enirwnoifythe,naps,$
M de nyu'uenre,ae which must be urn prior rm ixwaree of a Cenifrme of Ocntpsncy.
Cvx a orwthetted egmt Dote TOTAL ISSUED BY:
OFFICE