28639 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPRRTINO BUILDING-ELECTRICAL - "PERMIT NO.
UU,DINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL nO Q
BUILDING PROJECT LLIENTI FICAT
BION Lo 9
BUILDING ADDRESS: _ SANITARY NO, APPLICATION SUBMITTAL DATI
ME Gt'rmrniro �s
OWNERSNAME'
f, HONG: /� � CO��g(pCfOR'S NAME LIC NOS:/�!
JII �ir'J/i KJ� CSN Y.�J NIC
RCHITECf/ENGINEER: LIC NO: ADDRESS: ;(y�+ ❑
CONTACT: PHONE: ,. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
• •' LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
a z w I hereby off that I nm licensed under provisions of Chapter 9(commencing '^ -JOB DESCRIPTION
N Section 700(0 of Division J of the Business and Prdemlons Code,and my license is RESIDENTIAL,
OO PERMIT ISSUANCE
�� as fuuforee mid eDe ❑ADWL ❑KITCHEN REMODEL
�UU License sten Lic.p APPLIANCES—RESIDENTIAL ❑ADDITION []PLUMBING RE-PIPE
�U Dem Comnaor
Fly ARCHITECTS DECLA I N - PANELS ❑MULTI-DNR []STRUCTURAL
z O m z 1 undersand my plans shall he used as public records - MODIFICATION
Oz4- UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional - 201-IIXOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 10110 AMPS ❑BATH RE!J�EUREPAIR ODEMOLITION
a 1 hereby affirm that 1 nm exempt from the Comactar's License Law for the �) _
yd3SV following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELI:CTRICAh [3 OTHER
�� _
u7 O fy.. which requires u permit to construct,alter,improve,demolish,or repair any structure
��7
4 prior its issuance,also requires the applicant for such permit m rile a signed statement SPECIAL CIRCUITNISC.
v��---iii that he is licensed punuanl to the provisions of the Contractors License Law(Chapter 9
C00 (OOmmencing with SeminaTf00)of Division 3 of the Business and Proressions Codfor TEMP.METER OR POLE INST. COMMERCIAL:
L e C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^,y Smile.7031.5 by anyapplimm fora permiasuhjects theapplicam be.civil Penalty of POWER DEVICES "' []TENANT ❑FOOD SERVICE
y not more than five hundred dollars($500). IMPROVEMENT
F1 I.as ownerofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
€'O []OTHERwill do the ww
ork,nnd the is not inandralm.ffered formle(Sm.7044,Business
Fall
a and Profusions Cole:The Committers Litems law does nm apply to an owner of &, —OUTLETS—SWITCH -1 RES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided Nat such improvements are not burgled or offered for NEW RESIDENTIAL.E
sale.If,however.the building or improvement is sold within one yearof completion,the
SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- pp
pmeofmleJ. ,� Lm7 D
❑1.as owner of the property,arr exclusively contracting with licensed convectors to TAL: -
construct the project(Sec.7(LW,Business and Professions Code:)The Contractor's Li- ell
Q �1g.v� ��
c se Law does of apply to on owner,of property who hands or improves thereon,and T'Y, PLUMBING P FEE S 1995
who contracts for such projects with a conte mr(s)licensed pursmnuo the Commcwrs y kJ
License law. PERMIT ISSUANCE CSI f
❑ I am exempt under Sec. ,B&P C for this reason VC L jr
Owner Dae ALTER—DRAIN&VENT—WATER IEA) VALUATION]
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty o(perjury one of the following decorations: m '
❑(have end will maintain uCertiricam of Consenun selGinsurefm Workers Compen- DRAINS—FLOOR,ROOF.AREA,COND. r. STORIES - TYPE CONSTRUCTION
salon.as pmvlded for by Section 37M of the Labor Cade,Am the performance of the
work for which this permit is issued FIXTURES—PER TRAP -
❑ 1 have and will maintain Workers Compensation Insurance,a examined by Section
370X1 ofthe Labor Code.for the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-I INC.40UTLETS OCCGROUP AM
My Workers Competwmjon Insurance carrier and Policy number are:
Cartier: Policy N., - GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRBASFIINDUSTRL WASTE INTERCEPTOR
(D
BUTGONi ION PEES
ais ceche.readmit be completed Lathe permit is boron,hundred dollars IW) GREASE TRAP
or less.) - PIANCHEC Alli
I ttnifythem in she perfomuntt nfthe work for which Ibis permit is issued,)shall
SEWER—SANITARY—STORM PA.400 FT.
not employ any person in any manner so as m become subject the Workers'Compen- - ENERG
,Z mum laws of Califomia.Date WATER HEATER WNENT/ELECfR
7�7 O Applicant 1 G
G r~�i NOTTCB TOAPPLICANT:If,mf r,making this Certificate of Exemption,you should WATER SYSTEMaREATING
abecome subject to the Workers Compensation provisions of the Labor Cade,you must
UJG forthwith comply with such provisions car this pemmim shall he leaned revoked. WATER SERVICE
ps Q PAID
U O . CONSTRUCTION LENDLNGAGENCY NEW RCSIDEN'f1AL PLMB. SQ.IT, Dame Receipt#
1 hereby which
thi that Chert is o c0nmru.0m lending bgetay far the performance of
the work for which this permit is ixsveJ(Sea.Jl197,Civ.CJ
0 U Lenders Name s TOTAL:
�w Lender's Address - TOTAL: -
I�,Irr. 1 certify that L hive read this application and at that the above information is BUILDING .E �-
4y corect.l agree to comply with all city and county ordinances and state laws relating um QTY. MECHANICAL PERMIT FEE •-
U Z building construction,and hereby authodu representatives of this city to enter upon the SEISMIC :E
above-mentioned Property for inspection purposes. PERMIT ISSUANCE: -
(We)agree to save,indemnify and keep hatless the City of Cupertino against ELECT C FEE
liabilities,judgments,corms and expenses which may in any way starve against said City
AFTER OR ADD TO MF.CH.
in conquenc,of the gzaaling of his Permit. PL
uUM ING FEE
APPLICANT DERSTANDS AND WILL OMPLY WITH ALL NON-POINT AIR HANDLIty'G UNIT(TO 10,000 CFM) MEC MCAL FEE
SOURCE . U ATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRU(MTAX
Sig t imnUConmmer Da EXHAUST HOOD(W(QULT)
HAZARD S h T AIS DISCLOSURE HOU GA N FEE
I
ill the applicant or future building occupant store or handle hazardous material HEATING UNIT MO 100,000 BTU)
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety - f
Code,Serum 25532(a)? HGTING UNIT(OVER 100,000 BTU)
❑Yes - ' ❑No VENTILATION FAN(SINGLE RESID) PAID
Will Nes iwarl or future building occupant use equipment or devices which Dam Roc a p
pp gby a quiprQ BOILER—COMP I3HPOR 100,000 BTU)
it havrdous air romaminana as defined by the Bay Area Air Quality Mamgement TAL:
Dinner? - pOILER—COMP(OVER 100.FXGBTU)
❑Yes Fl No '
I have rem the hazardous meiedalarcyuiremena under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCEDAT
noun Health&Safely Cole,Seat.ns 25505,25577 and 25534.1 undersand that if Ne NEW RESIDENTIAL MECH. SQ.FT.
building does nahmarrany have a anneal,(ham it is my responsibility to notify Use occupant
of the requirements which must be mea prior to issuance of a CeNficme of Occupancy. ;1 -
Ovarro,infli ized again Date - TOTAL ISSUED BY:
OFFICE