28907 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I .BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT - PLUMPING-MECHANICAL /� O O
BUILDING PROJECT IDENTIFICATION G o
BUILUINGAUDRE99: 'T'RST'toF , SANITARY NO. APPLICATIONSUBMITTALDATI
'7335 0 1 ,� rsf l Wva �.
CONTRACTOR'S NAME: LIC NO:
IKl F1r71 N T• N/C CONTROL tl
AC'E. /6ITE IJ(�Iry�yHO LIC NO: ADURE95: ❑ �_7
CONT
BUILDING PERMIT INFO
1 t I(►M�IyI(]NV;I 5 s ❑ CongWlant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
_IWN,+YWw
Q I hereby affirm that I on licensed under provisions of Chapter 9(commencing
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
CZp
with Section 7030)of Division 3 ofhe Dushow, nd Pmfcssim,CMaand my license ms 'JOB DESCRIPTION
F n full foreeand efTen. PERMIT ISSUANCE RESIDENTIAL
%Q 1-': License Class Lis,a
N `toss Date ❑SFDWL ❑KITCHEN REMODEL
Con DECLARATION
APPLIANCES-RESIDENTIAL ❑ADDITION ' ❑PLUMBING RE-PIPE
F.Orn ARCHITECTS a DECLARATION PANELS ❑MULTI-UNIT
O,x 4 I understand my plana shall h used as public records ❑STRUCTURAL
UPT020d AMPS �/ MODIFICATION
F 4 L Ucensetl Rofeastonal iINTERIOR ❑CHLNNEY REPAIR
kd OWNER-BUILDER DECLARATION 201-IfX3 AMPS / _IMPROVEMENT
yy o U 1 hereby effnm that I am exempt tram the Contractor's License Law for the - OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
X 3 F following reason(Section lo3 str t,de and Pmfde io demolish
Code:Any city or county OTHEII
LLss77 whiching m s n permit to 033.5,Business sine,improforve,demolish,de re SIGNS ELECTRICAL ,Yg
Oant �Iob pair any mrctorc
m pa,he its ce,almu in
hovisiappo sof,h,Cuama m,,a,file a signed statement PE - IRCUIT/MISC.
hat he is licensed paras.tee rhe provisions of the Cnnwmors license Low(CIm S,r9 I
�+ (Commencing with Section7(XXB Of Division 3 ofhMET
e Business and Professions Code)or Pi ER ORPOLEWST. OMM R fA
4 q e K
that he is exempt therefrom mid he basis for he alleged exemption.Anyviolnim of
Section 7031.5 by any applicant far a Permit subject the applicant to a civil penalty of POE ❑NEW RLDG/ADDTf10N ❑DEMOLITION
nm mom than live hundred dollars($5(9)z OTF.NANT ❑FOOD SERVICE
O F,mownerofthepropedy,or my employees with wages as heir sole compensation. SWIMMDJ CTR IMPROVEMENT
will Jo the work,and the swnam is not intended nroticed for sale(Sec.7044,Ifusiness11 ❑OTHER
3 and Professions Code:The Contractors License Law docs not apply to an owner of OUTLET\'SWI - =FIXTURES ��
Property who builds or improves hms
hereon,and who does such work himself or through " `\
his own employees,provided that such improvements are not intended or Offered for NE IDEN L ELE
sale.IL however,the builJing nr improvement is cold within one year ofcompininn,Ne SQ.PI'.FLOOR AREA",
ownerbuilder will have the burden of Proving that he did not build or improve for pus- 'A ESQ.FT.
se ow do - s ` y
s ofthe ProPeny,sm exclusively contracting with licensed comtractorsm \ I R
construct he project(Sea 2014,Business and Professions CNet)The Contmcmfa Li- 4 g�
sense contorts
ith...ovall ossumswcesedpnrimprovesthem.,anJ QTY PL I P,RMIT FEE APR 1
who ttmuans for such Projects with a contmemrts)licensed pars..,,.the Comonmrs
License law. ` PERMIT 11 CE '�f5lt tiv
lam ee�tPder �_,B&P C for his reason U� VUC
/ I I D ALTER-D At -NT-WATER(EA) C11�
WO KER'SCOMPENSATIONDECLARATION EVALUATION
I hereby (firm under nab of BACK FLOW PROT ICE O/�/�
a M Y perjury ane of the fol lowing declarations: 7 (�,
❑I have and willmaimain aCenificateofConsentioself-in.refor Workers Compen- pRAINS-FLOOR,ROO,AREA,COND.
smtfon,m provided for by Section 37W of he Labor Code,for the Ndomahwe of the STORIES TYPE CONSTRUCTION
work for which this permit is ismed. FIXTURES-PERTRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe Labor CNa for he perfommnceofthe work for which this permit is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS
My Workers Compensation Imumnce carie,and Policy number are: OCG GROUP ppN
Caines Policy No.: GAS-EA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASFANDUSTRL WASTE INTERCEPTOR
(This section need not M completed if the F<mJt is for one bund red dollars($1 a0, BUILDING DIVISION PE&S
or less) GREASETRAP
I certify thatmthe pedoemence ofthe walk for which this Permit is issued,I shall PLANCHECK FEE
not employ any Person in any manner in as to become Subject no'he Workers'Compen- SEWER-SANITARY-STORM EA,21X1 FT. GY FE
0 Z sedan Lows of Cdifomia.Dam ENERE
7 C Applicant WATER HEATER WNENT/ELECTR
NOTICE TO APPLICANT:If.after making his Cenificam of Esemphour.you,,h.ld GRADING FE
FFP••• become subject tothe Workers ComPensmion pronsmns of he Labor CNe,you must WATER SYSTEM/IREATING
Wforthwith comply wih tach provisions or his Permit shall he Deemed revoked. SOILS FEE
l� WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQFT PAID
V O I hereby affirm that there is a consuuminn lending agency for the performance .of ReceiPttl
IL H the work for whish his Permit is issued(Set.3097,Civ.C.) ,
O L) Lenders Name
Lenders Address TOTAL:
0. F certify that I have mail this application.d nam that the above Information is A B 1 1 FEE
VJ connect.I agree m comply with all city and county Ordinances and state laws relatio to r'
U FZ7 building conswetion,and hereby authorize represents ivcs of this city.enter upon QTY. MECHANICAL PERMIT FEE
above-mentioned property for impecmn pa,,wi. S I C FEE
(We)agree in save,indemnify and keep harmless the City of Cu,enin,against PERMIT ISSUANCE EL IC FE.
l imilities,judgments,costs and expenses which may in any way accrue against said City
inconsequence Of the gransing.fthis permit. ALTERORADDTOMECH. PLUMBING eE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT - �^
SOURCE REGULATIONS. AIR HANDLING UNIT(TO 10,1103 CFM) MECHANICAL E
AIR HANDLING UNIT(OVER 10,000,CFM)
gnamm nfApplicanVContractor DamCONSTRUCTION T
HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD(W/DUCT ��
HOUSING MITIGATIO HE
Will
yteCapemnn(Muni building Occupant.Chapter
more or handle Heals anditamnalSafety HEATING UNIT(TO I(NI,IXq BTU)
as de0ned by the Capetian Municipal Code,Chapter 9.12,and the Heath.d Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000,BTLO
❑Yes 0N
VENTILATION PAN(SINGLE RFSID) PAID
Will the applicant Or future building occupant use equipment or devices which Dam Res, t g
'mit beemdam, it emominams as defined by he Bay Area Air Quality Management BOILER-COMP QHP OR 10303 BTU)
District?
❑Yes ❑NO BOILER-COMP(OVER 100.030 BTU) TOTAL:
I have rend the harard.s mmerid-requmrem.n under Chapter 6.95 ofthe Cali- AIR CONDITIONER
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the ISSUANCE DATE
building docs not currently haves mnam,hat it ismy responsibilitymnotify the occupant NEW RESIDENTIAL MECH. SQ.PT.
ofhe rryumare h,which mum he met prior to imumce ora Cenificam of(kcugancy.
Owner or a.hon—agem Dare OT L
ISSUED BY:
OFFICE