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28592 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL: PERMIT NO. BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL28592 BUILDING PROJECT IDENTIFICATION BUILDING [DRESS: SANITARY NO. APPLICATION SUBMITTAL DAD �.JRO 2 O CS AM C PHONE: ^ CONTRACTOR'S NAME: LIC NO: S L NIC CONTROL# ARCHITECDENGINEF.R: LIC NO: ADDRESS: ❑ CONTACT. PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT U MECH ❑ ❑ ❑ LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE I hertby affirm Net 1 am IiunsW under proonsvisiof Chapter m 9(commencing QTY DESCRIPTION qaZ withSecdon 700n.f Division 34flic Bomdocssand Professions Code and my license is RESIDENTIAL: O PERMIT ISSUANCE v L full sforce ld affect. Lit # rd0 g OsFDw ❑ CHEM REMODEL m Date Crntacmr APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE ARCHITECT'S DECLARATION ❑MULTI-UNIT S RUCTURAL F 7 4 1 understand my plans shall ha used as public records PANELS MODIFICATION OZ a UPTO2MAMPS [3 INTERIOR ❑CHIMNEY REPAIR Licensed Professional 2014000 AMPS IMPROVEMENT OWNER-BUILDERDECLARATION OVER IOW AMPS ❑BATH REMODEIJREPAIR ❑DEMOLITION yy I Q I hereby affirm that I am exempt from the Contractors License Law for the 5d 3 d U following meson.(Section 703 L5,Business and Professions Code:Any it,or countySIGNS ELECTRICAL ❑OTHER 44Fi7 WO[_' which requires a permit to construct.alter,improve,demolish,or repair any structures X71 prior to its issuance,also requirts me applicant for such permit o file u signed statement SPECIAL CIRCUIT/MISC. ythat he is licensed pursuant o the provisions of Ne Contractors License Law(Chapter9 ^q�q (commencing with Section]000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: 6 o LL.that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Section 7031.5 by any applicant for.permit subjects the applicant m a civil penalty of POWER DEVICES []TENANT FOOD SERVICE y, not more than rive hundred dollars l$50).� IMPROVEMENT Q ❑I.as owner of the property,or my employees with wages as their role compensation, SWIMMING POOL ELECTRIC []OTHERwill do the work,and the structure is not intended rroffemd for sale(Sec.7(M,Business and Professions Code:The Contactors License law does not only to an owner M OUTLETS-SWITCHES-FIXTURES proper who hullda or improves thereon,and who does such work himself or through his own employees,provided Nat such improvements am not intended or offered for NEW RESIDENTIAL ELECTS SQ FT. sale If,however.the building or improvement is sold within one year mfcompinion,the SQ.F'L'FLb);1R°AR,Ff USQ.PT. owne-builder will have the burden of pmving that he did not build or improve for pur- ❑F11,as le,. SEP 12 C I,as owwr of the property.an exclusively contracting with licensed convectors m TOTAL' ��J construct the project(Sec.0044,Business and Professions Code:)The Contractor's Li- causes Law does not apply to an owner of property who builds or improves Merton,and QTY, PLUMBING PERMIT FEE ho comntra racis for such projects with a coctors)licensed pursuam to the Contractor's V Ur t'Llq ff`` License Law' PERMIT ISSUANCE COY WNV I in exempt under Sec. ,B&P C for this reason Owner ~ Data ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby union under penalty of pe jury one of the following declarations: ❑I have and will maintain a Certificate of Consenuo self-iname for Workers Compan- DRAINS-FLOOR,ROOF.AREA,COND. section,as provided for by Section 37W of the labor Cade,far Ne performance of the STORIES TYPE CONSTRUCTION work for which this permit is issue, FIXTURES-PER TRAP ❑I have and will rommuin Workers Compensation Insurance,as required by Section 30M or the Labor Cale,for the perfoommen of the work for which this permit is issued. GAS-CA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AM My Worker' Coqpc ti rsince carrier and Policy nu brare: GAS-PA.SYSTEM OVER4(FA) Carrier: 5�rE__ .�N 0 Policy No.:� CERTIFICATE OF EXEMPTION FROM RI COMPENSATION INSURANCE GREASFANDUSTIR WASTEI BURRING DIVISION FEES I/l (Thiswcdnnt dwtWcompletedifthepermit is foronehumbaddnilsoX811#) GREASETRAP ur less.) PLANCNECK FEE L certify that in thepedMormanccofthe wortk fo which Nis permit is issued,Ishall SEWER-SANITARY-STORM kIPT not employ any permm in any manner as as In freeman subject to me Workers'Crimper. ENERGY FEE O ,'Z sation Laws of Celifornsm Date WATER HEATER WNENT/ELECTR z Applicant GRADING FEE VVVJJJ NOTICE TO APPLICANT:If,after making this Camficom of Exemption,you should WATER SYSTEM/IREATING a bm ecoe subject[.,he Workre cea Compensation pinvisiorf the Labor Code,you must SOILS FEE {iI forthwith comply win such provisions or this pewit shall be domed revoked. WATER SERVICE aQ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. .FL PAID UO • Ibereby elfrm rat here isecrnstmdion lending agency fnnhe perronnan.of Dole Receipt W. the work for which his permit is issued(Sec.30TT,Co,C.) U Landers Name TOTAL: , Lender's Address 1 unify that I hove reed this.,plication and sore Nat as BUILDING FEE U ta/1 correct.t agree to comply with all city and county ordinances no laws relating to QTY, MECHANICAL PERMIT FEE L) z building construction,and herebythommic reprammUdivesof this city to emitter.rte SEISMIC FEE above-mentioned Property for inspection purposes. (We)eg.to save,in emnify and keep handless Ne City of Cuperdaoagainst PERMIT ISSUANCE ELECTRIC FEE �APPLICA litia/Y2 snwbiNmoyinanyway...me.,rumt said City ALTERORADDTO 'CH. PLUMBING FEE nsethis Fc - ILL COMPLY WITH ALL NON OI T AIR HANDL SNIT TO 10,OW M) MECHANICAL FEE RC /2AI DLING UNIT(OVER IQ(p0 ) CONSTRUCIONTAX nam o HAZARDOUS MATER Applicaor SDstCLOSURE Data EXHAUST HOOD(WMUCI) HOUSING MITIGATION FEE HAZARD Will theaCupertor nofumrc building occupantChapter 9,12, handle Health if is] HEATING UNIT(TOIW,000 BTU) 1 as defined io the Cupertino Municipal Code.Cheprcr 9.12,erd rte Health a afdy ` Code.Section 255J21a)! HEATING.UNIT(OV IXI,aW DTII) ❑Yes ❑No VENTILATIO ERESLDI PAID Will the applicant or future building cecupanr use equipment or devie s which Data Receipt 0 �i earth hazardous air commit...m as dented by the Bay Are.Air Quality Man gcmem BOILER- 3HP OR IM, is Di.trict7 O - MP(OV ,t)1I9TJ) [3 Yes ❑No I have reel the haardous tmuriels fwircmenu under Chaptu fi.95 of rte all- ONDIT R40 ISSUANCE DA front Health&Safety Cala,Sectirre 25505,25533 and 25534.1 understood that i NEW ESIDENTI MECH, SQ.FT. WitWngdeesnotcu ntlyhovea Rnmi.thatitismyresponsibility to notify Ne occu of the mqunements which must he met prior to issuance of a Certificate of Occupancy. Onme,m unmlzed agent Dom TOTAL ISSUED BY: CE