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28746 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELF,CTRICAL PERMIT NO. ^ a.a BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28774 {6 BUILDING PROJECT IDENTIFICATION B LDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT qq5a r)4-r. Ju, Ln - � rw lbw S UW - ;S NAME: l 1PHONE: NTRACI'OR'S NAME: LIC NO: HQ A-L, -_L,ckj �#k/�` O(,k/T�,C-I NIC CONTROL# rqw ARCIHTECl/ENGINEER: ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Feca Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ $ LICENSED In.,I CDMRd TORmile,S DECLARATION QTY ELECTRIC PERMIT FEE 1ho«by0)of That1 ant OheBdandernr provisions Chapter9 my lirandng JOR DESCRIPTION �� with S«rceanp0)of Divisiun3ofthe Boniness and Professions Csde,and tiny licennc is PERMIT ISSUANCE R - IDENTIA F F. in fall forces e1T«t. a�U ❑SFDWL QKITCHEN REMODEL aU D.tense Clm. Cmde ❑ADDITION El PLUMBING RE-PIPE rFaa Date Commnor APPLIANCES-RESIDENTIAL ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURALO Z n z 1 understand my plana shall be used ns Public f«vrv, PANELS MODIFICATION UPT02WAMPS ❑INTERIOR ❑CHIMNEY REPAIR Licensed P..I,xomral 201-I000AMPS IMPROVEMENT Y •.I OWNER-BUILDER DECLARATION SCC< 1 hereby affirm that 1 am exempt from the Camrracim''s License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION Ffconstruct,following reason.(Section 7031.5,Business and Profesvions Calc:Any city or county SIGNS ELECTRICAL. []OTHER I, IL which requires a Permit construct,alter,improve,demolish or repair any%tmewre . �� prior to am issuance.also requires the applicant(orsuch Permit o file a signed statement SPF,CIALCIRCLIFUNUSC. Q� that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 _ �b (commencing with Section 700C)of Division 3 afore Business and Professions Code)or TEMP.M ETER OR POLE INST. COMMERCIAL a D LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION _ Section703 IS by any applicant for a pcmnit sahjects the applicant to a civil penalty of POWER DEVICES I.-Z} on more than five hundred dollars S500). ❑TENANT ❑FOOD SERVICE " 'i ❑Locownertt the property,or myemployeas with woopsn theirwlecompcnsation. SWIMMING POOL ELECTRIC IMPROVEMENT will do the work,and the,structure is not intended oroffercd forsale(Sea 7044.Business ❑OTHER W 3 m said Rofessionx Code:The Commoners License Law does nor apply to as owner of OUTLETS-SWITCHES-FI%TURES property who builds nr improves thereon,and who does such work himself or through his own nnployeas,provided that such improvements arc not intended or offered lin NEW RESIDENTIAL ELECTS SQ FE sale.If.however.the building or improvement is sold within am year ofcompletinn.the SQ,Fr.FLOOR AREA $1my Er. owner will have the burden ofpnry log that he did not build or improve far pur- pow of amen. ❑ 1,as owner of the property,war, usinessi and Professions with licensed contractors - TOTAL: construct the pmjeet(Sec.]044.Business and Pndensions Gmep'Che Contractors Ll- _ cause law does not apply to an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE who contracts for such projects with a contractor(a)licensed pursuant to the Contractors License law. PERMIT ISSUANCE ❑Iamexcmptunder Sec. ,B&PCfonhisreason —'Owmar "t Date y t ALTER-DRAIN&VEN'T-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 1 hereby affirm under penalty of perjury,tine of the following declarmiom: ❑I haveand will mvintaina Cenificacof Consent toselbimure fm Workers Camper. DRAINS-FLOOR.ROOF,AREA.COND. cation,as Provide l for by Section 37W of the Labor Code,for the performance of the STORIES TYPE CONST RUCCIOt work for which this permit is issued. FIM ORES-PER TRAP El 1 have and will maintain Workers Compensation Insurance,as required by Section 3](Mtofthe Wlmr Code.for rhe performance ofthe work for whicht 's per mit,,issued. GAS-EA.SYSTEM-]INC.4 OUTLETS My Worker's Compensation Insurance cave,and Polic,ommh. OCC.GROUP APN Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(GA) CERTIFICATE OF EXEMPTION FRO DRKERS COMPENSATION INSU CF GREASEINDUSTRL WAS TE INTERCEPTOR (This section need not becam"'a',if the nit is 'ma hand reddollm ($1100) BUILDING DIVISION FEES er lens) 'I GREASE'IRAP PLANCHECK FEE Loy.,pera the myPeran nm to orkbee for wMchtho permit the Woners'Crpper. SEWER-SANITARY-STORM EA.200 FE nut cmLaw any person any m r se m to become subject to the Workers'Crupper. ENERGY FEE Z svoinn Laws of Califf in a 1 0 0 Applicant I WATER HF,ATF.R WNENTELECTR Z GRADING FEE NOTICE TOA LICAMI':If,uRer making this Certificate of Exemption.you sh uIJ WATER SYSTH 01REATING a , become subje to the Workers Compensmion prov inns of the Labor Conic,you must SOILS FEE ❑ fuMwith co ply withsuch provision arth permi hall he earned revoke). WATER SERVICE r Uz CON. U, I 1 AGEN}'Y NEW RESNENTIALPLMB. SQ.Ff. PAID Lt. 0 the th,miffiwhich hithers endin r1. tit a rfa Mu Raeiptp 0(.:, the work h which this c C ` Y Lender's Ni e r is us c 0 V Lendcr' y TOTAL: V) 1 cc ifthat1hove« 1./nom TAL: tris y andatian ands the.rhe salve information is BUILDINGFEE Gull -1,r mnect l reg m campnd here withall city and roan rudivio es and state leace,i acing m QTY. MECHANICAL PERMIT h/.r.. L) z huildi on iedimsvnd herby amhnriu muntaoives of this city to enter upon the FEE SEISMIC FEE rsaV tbovcmcnsi edproperty(brute, ter purposes. ` PERMIT ISSUANCE (We)a rtetosave,Inde and keep which hayin any he Cityru Cupertino against ELECTRIC ME IiaM1ilities.juu1c tits.ten mi of this permit ALTER may in any way accrue against said Cloy ALTER OR ADD TO ME CH. APPLICANT ming oft his permit - PLUMBING FEE' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT qIS HANDLING UNIT('f01(1.000 CPM) UR .E REGULATIONS. MECHANICAL FEE a-A_q-A,-A sx. •ti� +� lo/ /4s- AIR HANDLING UNIT(OVER 10,000 CFM) Signoutre of ApphcanmComracmr �! Das EXHAUST HOOD(W/DUCp COM1'ST'RUCf10N TA% HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE Will the applicant or future building occupantsm¢or handle haamdom material HEATING UNIT(TO 100,hod BTU' 1� an de0ncd by the Cupertino Municipal Cade,Chapter 9.12.and the Ilealth and Safety Cade,Section 25532(.)] HEATING UNIT(OVER 100,0')BTU) ❑Yes 0 N VENTILATION PAN(SINGLE RESID) PAID Will the applicant or future building resonant use equipment or devices which Date Receipt# emit hvallous air ro mminams us defined by the Bay Area Air Quality Management BOILER-CO.MP(3HP OR 100,000 BTU) District? ❑Yes F1 No BOILER-COMP(OVER 100,000 BTU' TOTAL: I have mad the h adcd Sections 503,2 tcmcns under Chapter 6 rand that Cuh- AIR CONDITIONER forma Health&Safety Cede,S«dom 23505,25533 arm 25534.1 understand that if the ISSUANCE DATE building rites not currently have menant,rbm it is my rcspsnsibilitytunotify Nc occupant NEW RESIDENTIAL MECH. SQ.Fr. , ofthe requirements which mus be met prior to issuance oft CeniGade of Occupancy. Owner ser aathoneed agent Date ISSUED BY: OFFICE