28541 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. nQ C /I
INILDING PROJECT IDEN'PIFICATION G o 5 4
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
�3S 3D (z(d/� 1 00 �c
OWNER'S PHONE: CONTRIsQ'I'OR',SIA I;: — LIC NO
CC SGS- NIC CONTROL
ARCHITECUI NGINERR: LIC NO: ADDRESS: J r J ❑
PT-
CONEACT.'}�p.I N PHONE:F/ �p - BUILDING PERMIT INFO
.VI\" I D B /-f—011V ❑ Consultant Fees Paid by Applicant(Initlal) ILLr� ELECT PLUMB IIQF.CH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEEI hereby A
afirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
G�z with Seetion]flfg))of Divisinn3nfthe Posiness and Professions Coda and rr,bcrmeie RESIDENTIAL:
m full forcaund effect. I'ERMI'1'ISSUANCE
jut S"J,S�' CSFDWL ❑KITCHEN REMODEL.
F�F..U�j License Class Contact..
ppPLtANCFS-RP_SIDENT1AL DITION 0 PLUMBING RI:PIPE
Vi 64 Date— C7S Dador
ARCf11TECT5 DLCLA ATION PANELS [:1 MULTI-UNIT STRUCTURAL.
z O y Z4 1 understand my plans shall he used as public records MODIFICATION
Oy , UPT020DAMPS ERIOR [3 CHIMNEY REPAIR
r-t:. Licensed Prnfeuiannl 201-IMoAMPS ROVEMENT
Y
OWNER-BUILDER DECLARATION OVER 1000 AMPS TH REMODEUREVAIR [I DEMOLITION
a 1 hereby affirm Ihat 1 am eacmPt from the Contractor's License Law for the
OyU f.h.wingreusnn.Section]I131.5,Business and Wofessiom Code.Any city ser countySIGNS ELECfRICAI. COTHER
which requires a permit to construct,alter,improve,demolish,or repair any someone1pQ'WyOy pdmm its issuance,alsmrer,m.lheapplicant forsuch North 1.file aslgned slmement SPECIAL CIRCUIT/MISC.
W Y
that he is licensed pnommaIn they osmom;of the Contractors License Law(Chapter 9
P� (commencing with Section 7000)of Division J ofthe nosiness and Pratessions Code)or TEMPMEILROR POLEINST. COMMERCIAL
d o eC IXet he is esempi therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION C DEMOLITION
�y Section 7031.5 by any applicant for o permit subjects the applicant m a civil penalty of POWER DEVICES
a more than five bund o (SSW). ❑TENANT ❑FOOD SERVICE
❑Lasownerof,hepr ny,or employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
' willdo Nework.and souvuris o,intended nr offcreA for sale(Sec.]044.Posiness CO'THER
a and Professions C e:The Contract Cs License taw does not apply to an owner of OUTLETS-SWITCHES-PIKE URIS
progeny who bo' s or improves Iter n,and who does such work himself of through
his own emplo es,pmvidcd that sae improvements urs not Intended or offe ! NEW RESIDENTIAL ELECTR SQ FT.
s sale.ILhow er,the building or imbrue entissoldwithinonc year ofcompleti SQ.IT FLOOR ARE $/SQ.FT.
-owner-ba' r will have rhe buNen of pro 'ng Ihm he did not bur r impasse fo u (iiY /VV�I/('!s]J
'so.f le.). I ��
es
s owner of rhe graben, c usnvely nl ting wish li co ton to
c stun the project(Stt.] mess and essions a Cu�llptuuam rat Li-
a Law due net uppl nncr of pup Ywhm builds r 'Iherdm,and Q'I'Y,E
BING PERMIT FEEwho omrndsf 1 with aceto r(s)liEenud ors amuvh C ,mcmrsLicrn. Law. BKPCfor this reason VENT-WATER(PA) VALUATION
Ov mrW EH'SC PPNSAT ON LARA at ECT.UF:VICE Ihrth fEmtunderpc tyofperju fthefoA�•,win declarations:Clhaveamiwi maintain. nificam of Consent ]Toruin Workers Camper- OOF,AREA,C'OND.
radon,as provide or by S tion 3%hl of the l.ubm Cnde,lirz the perfomtance of rhe p�1{p��,S r�r TYPE CONSTRUCTION
p forw""this • i sissued, FIXTURES-PERTRAP �� SE OLg
have and will mat air Wohers Cnmpensution Insurmtt,es require)by Su,ion 1/ 19!Isr
37Ml of the Labor
s C, CCode,forthee Performance of the work for which ttthC 1 a �Fhis permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS CL µOUP APN
C CynW eke/ClI/X�GIICIKm/�l an ales No.:y ^fi(1� r+ GAS-PA.SYSTEM-OVER4 EPA)
CERTIFICATEOP EEMYf10NFROMWORKERS' GRFASFJINDUSTRL WASTE INTIiRCEPTOR
COMPENSATION INSURANCE.
BUILDING DIVISIONJT,
(This section need not be completed if the permit is for one hundred dollars(SI W) GRI3ASE TRAP
or less) PLANCIIECK ME
I cenifythutin the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
not employ any Person in any manner so alto become subject a the Workers Comped- ENERGY FEE
Q z radon Laws of Colitcondo.Date WATER HHATER WNENLULECTR
r� Applicant GRADING PEE
.N.a NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you Should WATER SYS]EIV711 BATING
!� become subjectm the Workers Compensation provisions of the labor Cote,'unions, SOILS FEE
WF.t forthwith comply with suchpmvioomor this pemtitshall be deemed revoked. WATER SERVICE
Q
CONST RUCTION LENDING AGENCY NHW RUST DENI'IAL PLM B. SQ.EL PAID
V p Iherehy affirm that there is a construction lending agency for Performance of Recctpt
,he work for which this Permit is issued(Sec.J(1/],Civ.C.)
V 76
lenders Name a l sA TOTAL:
lenders Addres - T
1 certify that 1 have mad this application and sum 0a the above information is PI111.DING FEE —
:r lam/) comct.Iagae to comply with all city and county o dinunces and state Imn,mia,ing u' QTV MECHANICALPERMIT FEF?
U building conatruction,and hereby authorize representatives ofthir city to enter upon the SEISMIC FEG
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree mav
se,indmn
eity.nd it.,harmless the City of Caperton against ELECTRIC FEF.
Iuhililieajudgmenis,costs and expenses which may In any way accmeagainusud City gLTER 011 ADD TO MECH.ns fthe greening of this Permit. PLUMBING i
APP CANT UNDERSTANf DWI.I COMPLY WIT 4LL NON DINT AIR HANDLING UNIT(1'OIO,IXq CFM)
SO R RE ULATIONg //g 1 / MECHANI ALFEE
��( 1 / //'Q✓ AIR HANDLING UNIT(OVER IOpW CFM) CONSTRUCTIO TAX .
Signe of-fltrtT ApplicuntlCn4nuYwmr i Dlmo��//LLQ)) EXHAUST 11001) W/DUCT) HOUSING MITIG ION FIF
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fenum building occupant store unbundle moudo is material 1IEAI'INC3 UNIT(,to 100.000 BTU)
as defined by the Cupertino Murip pal Code,Chapter 9.12,and,he Health and Softy - -
Code,Section 25532(m? - / HEATING UNIT(OVER 100.00s)BTU)
❑Yea (gD:O PAID
q VENTILATION PAN(SINGLE RISID) Dom eiplN
!
Will the applicant or future building oscupeal use equipment or devices which
emit limitations air comaminams as defined by the Bay Arta Air Quality Managements—iiiii OILER-COMP(3HP OR IW,M)BTU)
District'? 1,r/,]"(/ OTA L:
❑Yes BOILER-COME'(OVER 100.000 FITU)
Q
ard the ha smmMals 9� AIR CONDITIONER
ryry rcmeens undo ChePteT h 95 of the Cad- ISSUANCE,DCAT/./�/�'�/
fetoSafety 5 aiom2 3 f5,$5JJnd 2. j4.1 understood that if,he NEW RESIDEMIAL MfCCH. SQ.buil ,cure I have rerun i6il0no,ify he pomoft nds wl hmus en r or ni....ace eaificu ff -
tuner nr au@nnuJ agent write IL ISSUED BY:
OFFICE