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28648 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT N`28648 .^^ ^ /1 /1 4.8 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L Y6 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE ea PHONE CAC ONTRACTOR'S CONTRACTOR'S N, AME: ' LIC NO; "�� ) 3735 sNIC CONTROL# O4RCHITECT/ENGINE LIC# ; ADDRESS: (^ ,J I G ejLl❑' CONTACT: PHONE: BUILDING PERMIT INFO 7l�_�8a I ❑ Consultant Fees Pald by Applicant(Initial) B G ELECT❑ PLUMB MECH ❑ ❑ LICENSEDCONTRACTOR'Snsedunderp DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby affirm that 1 nm licensed under Prevision of Chapter 9(commencing JOB DESCRIPTION �� with Section dde ect. sionlofthe Business and Professions Code,and m li<enu is O ) � � y PERMIT ISSUANCE _ RFSIDENTIAI: I n full force enJ effect. 1.icens Class Li<.p -�❑SFDWL [I KITCHEN REMODEL NGY Beo Commctor APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMBING RE-PIPE E.pV, ARCHITECTS DECLARATION PANELS [I MULTI-UNIT []STRUCTURAL OZ S g 1 understand my plana shall be used ns public records MODIFICATION - Jpp UP9'021MAMPS [I INTERIOR C1 CHIMNEY REPAIR ru&"W.4 Licensed Prefrcssi...I ., 201-1000AMPS IMPROVEMENT PE .6 OWNER�BUILDER DECLARATION y� 1 herchy affirm that I um exempt from the Cantrucrors License Low for the OVER 1000AMPS ❑BATH REMO l/I;EPA R 0 DE 3 L U following teams.(Section 7031.5,Bvionew and Profession.Cade:Any city or county SIGNS ELECTRICAL ❑OTHER {@] tt7 O which requires a permit to construct,Wme improve,demolish,or repair any structure prior to its issuance,also requires the applicant for such Permit o file a signed seamen SPECIAL CIRCUGUMISC. ythat he is limnsed moment o the provisions of the Contractors License Law(Chapar9 00 (commencing with Section 7110E)of Division3.f Ne Bisinessand Profession Coaled., TEMP.METER OR POLE LNST COMMERCIAL: p, a that he is exempt therefrom and the basis for she alleged csemgion,Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION iC {� Section 7031.5 by any epplicare for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT- ❑FOOD SERVICE not mom than five hundred dollars($500). �CI,ex owncrof Ne properly.or my empl�yms with wagesn their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT will do the work,and the awnuro is not intended oroffemd for sale(Sec.704,1,Business ❑OTHER end Profession.Code:The Committees License I<w does not apply to nn owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL ELECTR SQ PT. We.If,however,the building.,improvement is sold within one year ofcompletien,the - - t SQ.FT.FLUOR AREA VSQ.FT. owner-builder will have the burden of proving that he did not build or improve for par- pone of sal.). ❑1,as owner of the property,an exclusively contracting with licensed contractors to TOTAL construct the praiser(Ste.704,1,Business and Professions Code:)The Comment's Li- censeLawdoesnotapplytoanownerofpmpertywhobuildsorimprovesthemon.and QTY, PLUMBING PERMIT FEE who contracts for such projects with a cnnmctons)licensed pursuant to the Contncmrs ' License how. PERMIT ISSUANCE ❑1emuemptunder Sec. ,B&PCorlhisreason Ownu ALTER-DRAIN&VENT-WATER(E)d �(aLDAT1ON Dee /&K/ WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.D I heacbyeRrmunder penalty of perjury one of the following declarations: ClI �, I have and will maintain a Certifivie ofConscnt to self-insure far Worker's Compere- DRAINS-FLOOR,5905EAEEA,COND. STORE (z T ONSTRUCTION sation,as provided for by Section 37M of the Lehn Labor Code,for the perfottnce of the (/ work for which this pcnalt is issued. P)XTU R ES-P546TRAP rQ ❑1 have and will maintainWnfkee$Compensation Insutnnce,as squired by Section 37M ofthe Labor Code.fmthePerfomunce ofthe work for which this permit is issued. GAS-FA. STENIA INC. O OCG GROUP - APN My Workers Compensation Insurance carrier and Policy number ore: Cartier, Policy No.: GAS .SYSTEM-OVE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE OR ASMND TRL S INTERC /t (ThissmdonneednNbecomplctedift pemdtistmonehundra{dolim(SIW) BUILDING DIVISION IBES or less.) ^ ORETR. , PLANCMECK FEE I certify that in the perfotmattce ofthe work for which this permitisisaucd.lahall sr.wm ANITA I/2 PI'. not employ any person in any manner sec an tghcnryrpyhim(.p tpfW ker%Compen- ENERGY FEE z cation L. of It iu.Date - �[—�I 1 `L f� nr WATER HPA RWNENEl O 0 A licant 4 - GRADING FEE PP NOTICE TO A o me Work 1, ommakin this visa teem of Labe tion,you should y 8 P WATER SYST� ?REATING a become subject to Ne Worker's Coons in this provisions oftheVodr Code,you must SOILS FEE LTI forthwith comply with such previsions m this penndt shall be decmed revoked. WATER SERVICE Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIA LMB, SQ.FT. PAID V I hembyofleandiat then isaconeuctionlending agency for Ne performance of Data It Rae' # L F the work for which this permit is issued(See.3007,Civ,C.) 0 U Leader Name TOTAL: 1,17 Lenders Address TOTAL: I cenify that I have rtad thio application and.tae that the above information is BUILDING FE L Ln correct.l agree to comply with all city and county ordinances and.see laws relating to QTY, MECHANICAL PERMIT FEE V building construction,and hereby authorim representatives ofthis city to enter upon the SEISMICF above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE ' (We)agree m save,indemnify and keep harmless the City of Cupertino against ELECff1 E liabiliticajudgmcns,it to and e.pe"' which ma inan way accrue against said Ciry ALTER OR AORTO SUCH.in corA ucnee m the Bmntin8 of this pe - PLUMBING FEE APN #DERDSA WILL COMPLY WITH ON- HANDLING UNIT(TO III,gp CFM) MECHANICAL ILAT10 AIR HANDLING UNIT(OVER 10,1000 CFM) CONSTRUCTIO AX of ApplieanVCotar Date EXHAUST HOOD(WIDUCI) AZ US MATERIALS DISCLOSURE ' HOUSING MITI ATION FEE Will theapplicant.,future building mcupan stosof handle hospices material HEATING UNIT(TO 100,0100 BTU) in defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety .. Code,S, tE..2553200? HEATING UNIT(OVER 100,000 BTU) ❑Yu [3 No VENTILATION FAN(SINGLE RESID) PAID Will the applicant or fuem building mcupnnt use equipment or devices which - Date Rmeipt p :mit hassamoses air contaminants m defined by the Bay.Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) District? NOTAL: ❑Yea No BOILER-COMP(OVER 100,000 BTU) I lave most the Kverdous mammals regoircmcnts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE D190=;-`N format Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIi. SQ.FT., building does not currently have a aunt,that it is my responsibility m notify the occupmt of the n comments which must be me pfi.no issuance oft Cenifica c i f Occupancy. - - Owner or authorized agent Dee TOTAL: ISSUED BY: OFFICE ,