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28902 - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 28902,� w`SIJ O w BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING-MECHANICAL. L BUILDING PROJECT IDENTIFICATION WPILDINGADDRESS - SANITARY NO. APPLICATION SUBMITTAL DATE NEg5 * — � PHONE: RACfOR'S LIC NO: NIC E �R , CJS A 0 CONTROL# RCHITELT/ENye%wl—ey: LIC NO, a �el ORCSS: ^^O A ❑ CONTACT. .I' PHONE: 1/O SAO _ - BUILDING PERMIT INFO Q ` ❑ Consultant Fees Paid by Applicant(Initial) BLS HL_ ECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Ory ELECTRIC PERMIT FEE ALT f���[� 1 hereby affirm that I am ll[Cmed under provisions of Chapter 9(commencing JOB DESCRilhTION �Z with Sc0iwr7W).f Divaaon3ofthe Busurawand Profbssioln C.de,and my licenseis RESIDENTIAL a O PERMITISSUANCE m full force and cRcct <UV LicenseCas Lic.# ❑SFDWL ❑PLUM INREMODEL I Zw Date _ Cont�9cta APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE ARCHITECT'S DEC N ❑MULTI-UNIT ❑STRUCNRAL Z O 1 understand my plans shall M1e useJ as public rernNe PANELS ' MODIFICATION n O4P1 UP'IOPIIUAMPS ❑INTERIORf -• "�� ©Cr HIMNEY REPAIR b. Licensed Licensed Professional - 3old(10o AMPS IMPROVE'h�/s{}yE(�.N�rT�,,, JV � a OWNER-BUILDER DECLARATION OVEREQMIAMPS ❑BATH REpYyyyJEPAIR [D DEMOLITION y G I hereby eKw Bad I am exempt from the Contractor's License Low far the ��VY >( aa I 3 4 U following reason.(Section 7031.5,Business and ss s Cade:Any city or county SIGNS ELECTRICAL ❑OTHER Oa which requiets a pewit.construct.ghee imp ve,demo h,or repair any swmure .L//V t y.] prior nu its issuance,also requires the applicant orsuch,mmit file a signed statement SPECIAL CIRCUITIMISC. tWW��} that he is licensed pursuanno Ne'provisions the Convector's cense Law(Chapler9 CQ0q (commencing with Section 700()of Divis3ofthe Buxinessan ofessionsCWe)or TEMP METER OR POLE INST COMMERCIAL: Cp(/Nn that he is exempt therefrom and the s for the alleged exempti .Any violation of ❑NEW BLDG/ADDITION LJ DEMOLITION W Section^ 7031.5 by any applicant for mit subjects the applicant t .civil peaahyof POWER DEVICES,y SRENANT ❑FOOD SERVICE CZ} not more than five hundred doll ern,] IA ROVEMENT FS ❑Lmowner ,and the came employees or enedfrilei(S. compeminess SWIMMING POOL ELECTRIC ❑OTHER CG❑ will Jo the work,anJ the cmre is ma intended or offered for sale(Sec, ,Business and Professions C Contractor's License law does not apply to owner of VfLETs-g WITCHES-FIXTURE Property who but orimproves Nerean,an no does such work himsel or too.mgh his own enipl ex,provided that Sochi., eau ore no in, c'dg or ere4 for NEW RESIDENTIAL ELECTR SQ FT. sale If.how er,are building or imp.. rosy within or r�f ..,I 'on,do, SQ.FL FLOOR AREA ESQ.FT. caner-but er will have the burden of p m i t he did not`vd)i sl`k`L�ufpPro a par. Pose of we said, co I,us r of the pr any, I c ntmnin license ontmctnrs In TOLG construct he Project IS f ode:) ammnor's Li- ceaseLa does not up' a rte`^}a" who builds ori .vex thereon,and QTY, PLUMBINGPERMIT FEE who voter for such pr,le iNe tr}\res icensrd pars ntmthe Camracror's License is PERMIT ISSUANCE ❑ l.mexe #under Sec ,R&PCfo this reason lOwncr I Date ALTER-DRAIN&VENT-WATER IEA) VALUATION \WORKER'S COMP HNSATION CLARATION BACK FLOW PROTECT DEVICE I hereby nder penalty of,erjury eahhefollowio,c],dunuma: III wandwmmitcarificateofC wutmadf-maireforworkehC.mpen- DRAINS-FLOOR,ROOF,AREA,COND.cation,m providy Section 3]W e Inbar Code,for the perfornwnce of NuSTORIES TYPE'CONSTRUCTION work for which sissueJ. FlXTGRES-PER TRAP I have and will maintain r s Compensation Insurance,m reyuircd by Semina - 3700ofthe Labor Code,forthe performance of the work for which this pewit is issued. GAS-EA.SYSTIt-I INC.4 OUTLETS OCC.GROUP APN CCe err v nmpe salon nsm nee conte Polity N'Policyr Lim!; nna6 GAS-FA.SYSTEM OVER 4(EA) - CERTIFICATEOF EMPf1ON FROM WORKERS' COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION ETES (This section neetl and be completed if@epewit is[orooe hundred dollen(S LOB) GREASETRAP or less.) PLANCHECK FEE Loy any that peram in performancany sm as tohe which this theins issued,I shall C..pr- SEWER-SANITARY_STORM EA.200 FT. nm employ any person in atuy manner m m m become snbjauo the Workers'Compen- ENERGY FEE L satim Laws of California.Date WATER HEATER WNENTMLECR Applicant GRADING FEE � flT NOTICE TO APPLICANT.IL after making this Certificate of Hwaramr,you should WATER SYSTEMR'REATING ' abecome subject,.the Worker's Compensation provisions of the Lnhor Cade,you must SOILS FEE W forthwith comply with...h provisions or this pewit shot]be deemed revoked. WATER SERVICE a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FII PAID V Q I hereby affirm that there is a construction lending agency for afommnce of One R We work for which this permit is issued(Sec.3097,Civ,C.) - V.(~ LendeYS Name TAE: WLender's Address TO AL 1 verify that 1 have read this application unit state that he above information is ' BUILDING FEE F.i V] correct.1 agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE LJ Z building construction,and hereby amhrrize representatives of this city to enter upon the SEISMIC FEE above-mentioned property lot inspection purposes. PERMIT ISSUANCE (We)agree.lave,indemnify lad keep hatml.x the City of Cupeninoagins et 0— [HOUSING ECTRIC liebilities,jvdgments,csts and expenses which may in any way accrue against said City ALTER OR ADDTO MECH. in asequence of the graming of this permit. �^ UMBING FEE APPLIC INDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT D 010,"CFM) • SOURC.REG TION CHANICAL FEE AIR HANDLING UNIT(OVER 10,003,CFM) NSTRUCTTONTAX Sig are of ApplicandConrac.r Dat EXHAUST FOOD(WMUCT) MpDGATICfI FEE HAZARDOU MAT R LS DISCLOSURE Will the applicant or future building occupant score or handle hazardous material HEATING UNIT(T0100,000 BTU) u defined by We Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety Curie,Section 25532(al] HEATING UNIT(OVER IOQIIOo 9'N) - ❑Yea C]No PAID VENTILATION PAN(SINGLE RESID) Dnm Recdpt Will Ne applicant or furore building occupant use equipment or devices which emit bazardons air contaminants as defined by the Bay Area Air Quality Mara gemepl BOILER-COMP(3HP OR 100,00 RTU) - District? El Yes ❑No BOILER-COMP(OVER Iffy"BTU) I have read We hawdous materials requirement under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE torch Health&Safety Code,Secdons 25505.25533 and 25531 I understand Wan if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently have a tenant.that it is my responsibility to notify We occupant of We requirements which must be met prior to ixwence of.Certificate of Occupancy. ` r Owner or authorized agent Date ] - ISSUEDBY: OFFICE