28546 V APPLICANT TO*FILL ION WITHIN RED LINESLINES, LL POINT PEN ONLY' u
p
7 � CITY OF CUPERTINO � t• .�' - '� Pl11LDING-ELECTRICAL r PERMIT NO4
' 'BUILDING )IVISION ; API'I,ICATION/PP:RMIT PLUMBING-MECHANICAL :28546
BUILDING PROJECT IDENTIFICNFION '
;w 11
BUILDING ADDRESS: SANITARY NO. vAPPLICATION SUBMITTAL DATE
. -: _ ti'.
10300';
0 NLRS NAME` ., PHONL CONTRACfORSNAME:~• LICNO:
44 17 NIC CONTROL It
4ARCHITEC`LE?RHNEEFL/ ! .LIC NO: ADDRESS: �u�\' ❑ s
�q Fri \JN
COWACT: PRONE: BUILDING PERMIT INFO
y m,-JQA�.�y,N'V ` "^ ZZOa.' ❑ Consultant Fees Paid M1y,Applicant(Initial) BLDG ELECT v PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECIARA'rION QTY ELECTRIC PERN1IT FEE.
I hereby affirm that 1 licensed u d n of Chapter 9(con namanig - - JOB DESCRIPTION
OOO with Section 9000)of Division 3 of the Business dP fecums Code,and my licemems- R ID NTIAL:^
I ul0 + PHRMI11SSUANCE
� in full tome�a�nd eBecr,a�'1�"f _ `,0/ 6108 ElSFDWL ❑KITCHFN REMODEL
'a ZU Licari Contract ML w�^� .APPLIANCES-RESIDENTIAL n• ,.-OADDITION - [I PLUMPING RE-PIPE
F.O y • ARCHITECTS DECLARATION PANELS q []MULTI-UNIT C1 STRUCTURAL
Z O n K I understand my plans shall be used as public records 9=: (p I MODIFICATION
OZ—, UPTo200AMPS ❑INTERIOR ` OCHIMNF,YREPAIR '
r4tm Licensed Professional - - - 201-I(NNIAMPS IMPROVEMENT '
�Yf;
OWNER BUILDER DECLARATION OV ER IOWAMPS ' ❑BATH REMOUEURC•PAIR El DEMOLITION
a 6 1 hereby affirm that 1 am exempt from the Commmnr's Littnse Lew fur the / -
Lx O d U following reason.(Section 7031.5.Business and Professions Cole.Any city or county SIGNS ELELTRICALL4 ❑OTHER
4131I F which requires a permit to construct.alter,improve,demolish,or repair any saucture r!' 1 TI. •- eems�
E•�'� prior to its issuance,also respire.;the applicant for such Permit to file a signed statement SPECIAL CIRCUit/AfISC. vVrtrL��4•n - -
�'y that he is licensed pursuant to the provisions of the Ciabraors License Law(Chapter 9
y.QfO (commencing with Section 7000)of Division 3 of the BminessenJ Ymfessionx CoiII TEMP.METER OR POLE INST. i COMMERCIAL' '
LLl^
d E o f• that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW,BLDG/ADDITION• 0 DEMOLITION
5� Section 7031.5 by anyhpplicant fora octroi,subjects the applicamma civil penalty nL POWER DEVICES r�i OTENANTIMPROV ❑FOODSERVICE '
f-Z} oat morethan five hundred Jollan(SSW).
=6 0 Lasnw cads, hit prapcny,omy.,mieneeswith wxgesar vas solecompensation, SWIMMING POOL ELECTRIC IMPROVEMENT
%E I„.O will doantacids,nodthe9mmoremanots License Law does
apply to
owner
I ❑OTHER
al and Professions Coley The Contractors License 1<w does not apply m ua owner of 011'1'LFi I'S-SWITCHES=F1%TERES
6 3.. property who builds or improves thereon,and who dues such work himself or through -
his own employees,provided,that such improvements me not intended or offeremi for NEW RESIDENTIAL ELECTR SQ ET. ^
sale.If.however.Ne building or improvement is sold within one yearideampletion,the , "SQ.FT.FLOOR AREA SISQ.FT.
owner-builder will have the burden of proving that he did not build or,improve for pun -
pose of sale.). - -'
❑1,as owner of the property,a .elusiwely Continuingwith licen.+ad contmat m,m 'TOTAL:
construct the prniect(Sea 70l1,Bminec mid Professions Cid.; .. ontmemrs Li"
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE' -'
who contracts for such projects with a contrecmds)licensed pursuant to the Contractors _
Licenselnw. y; - PURMH'ISSUANCE' +
❑I am exempt under Sec.•-' ,11&PC fortbis..an
ALTER1 DRAIN&VENT-WATER(F.A) - VALUATION
Owner - '.0 m _
WORKERS COMP ENSADON DECLARATION BACK PLOW PROTECT DEVICE -
IherebyaMnnutitle,penalty of parpay are(if the following declu't m
I have and will maintain aCertificate- fConsent 11 for Worker's C noire DRAINS FLUOR RODE AREA CHING. STORIES TYPE CONSTRUCTION
woon n as provided for by Section 340(1 f the Labor Code.for the Pert it the A
work for which this parrot is fassued. FI VIC RES-PERTRAP
1 have and will maintain Workers CompensationInsurance, .required by Section •', _
3?OOat'tbe Labor Code,for the performerecof the work for which tM1i.;permit is issuad. GAS-EA.SYSTEM-I INC. OUTLETS OCC,GROUP
My Waists Comppccnsay'a�'Insnra1i �ai�iel and Policy -
Carrieti •TFaTF \Cl�Y�N7 Policy No,: GAS-FA.SYSTEM-OVER 4 CA)
CERTIFICATE OF HXHMPTION FROM WOR BE/dcdolh
- _ .r
+ COMPENSATION INSURANCE GREAS FJI NUUS'I RL WASTE INTERCEPTOR - BUILDING DIVISION FEES
(Thlssectlonneettnm we.ompleted lflhc pnnnitisfnronebntc.($I00) 'GRI3ASE TRAP- - 'arlea ) .PLANCHECKFEE
1 oily tti t th pet -rth kl1' 1 tl PJ InhuOSIEWI?It-SANI9ARY STGRMEA 200ff..*,C ilea- - ENERGY FEC
(Z. scion LawsofCplifm Data I' R HFTEW/V
Applicant AANT/:hECfR
GRADING IEE
:y NOTICE 10 APPLICANT IL ager nuking If,Cyt u m t f x.np k m Y it sbo'Id Ilk SYSTFvfrrRHATING
L•-"L-" Eecoma adput a the Worker's Conpensntiou provisions Ill" a LaMn Cndq you nnisi - - - •SOILS FEE
forth lM1 ply with h p rih s permit she •JeonmeJ revoked RI R SERVICE
Q . .. Y, y _ .. f as
CONSTRUCTION LE GAGENCY NEWRIS1DENTIALPI.MB. "SQ:IT. PAID
U 'Z i le by ff th Tth 'sac atm on lend ng ripen y 1 14 rl Data Race pt 0
V thework f r h bibs;pr 9 ;issued(Sec 9119] Ctv C.
to
O VLenders Name n TOTAL:
Lender's Address•
/ BUILDING FEE if
Icoily that,lh read application ad site ave mfnm rents
^nF•t In cont t 1 agreeto comply with all c ty and c t d' aces pod, lawn relating to TY. MECIIANICAL PERMIT FEE
V
buildingc nsiruction,and hereby mortise pre. tatvesofth s coy to ever upon the SEISMIC ME
amuse-menunned property for inspeninn purposes. PERMIT ISSUANCE .. +
(Wu)more mince,indemnify add keep he xs the Clry of Cupmino against ELECTRIC FEE
liahilides,judgmems,costa nnJ eipensea which may in ny way accrue against said Cit ACTE'R OR ADD TO MECH. - - '
• Consequence of the graining oftho Permit. PLUMBING E
APPLICANT UNDERSTANDS AND WILL COMPT. WITH ALL NON-P01 T AIR HANDLING UNIT(TO Hindu CPM)
SOURCE REGULATIONS. MECHANIC E
-y_ AIR HANDLING UNIT(OVEN 10,000 CFM) - CONSTRUCTIONTAX -
SigaatunofAppcant/ nnuctor D' EXHAUST HOOD(W/DUCT) HOUSING MU16ATI FEE!
HAZARDOUS MATERIAL'DISCLOSURE
Will theapplicant ar Pomrebuilding oecupamuorc or hurdlehmadous material HEATING UNIT TO 100,000 BTU)
'as defined byline CuPer ino Municipal Code,Chapter 9,12,and the Health end Safety
Code.Section 25532(x)? HEATING UNIT(OVER Hil lO BTU)
p Yes - CKNo - VENTILATION FAN.(SINGLE RMID)' t PAID -
r Date I Reipt M
Will the applicant or future building occupant use equipment or devices which
unit harSrdme,air contmmdmnD ns defined by the Boy Area Air Quality Manngeincnt BOILER-COME IMP OR 100,000 BTU) TOTAL:
DonicB HOILER-COST(OVER Uld"BTU) - -
OYes
I have and the hsvmdocls tuatedals requiremenu under Chapter 6.95 of the Cali- ISSUANCE DATE
' forma Health&Safety Covlc)Sections 25505,25533 had 25534.1 undentand that if the NEW R[SIDENTIAL'MECH. SQ.Ff.
annual, '
building does not currently have a tnt,that it is my responsibility to notify the occupant •'
of the regiromentawWch must la, at rim to jact ce of n Certificate of Occupancy. , s
��n agenz3l i } CaM1 TOTAL: ISSUED BY:iY
OFFICE