28894 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ ^ ^ ^ ar
BUILDING DIVISION APPLICATION/PERMPP PLUMBING-MECHANICAL. L l}!( yV( 5�1J 4
BUILDING PROJECT IDENTIFICATION
RUILD�INGAUURFS IV\V� � Or Iaf'T� <a ��a^.!\ SANITARY NO. APPLICATION SUBMITTAL DAFT
OWNER'S NAME
.:IIxs1I'" PHONE: "-, CO RACTOR'S NAME: D U NO::
yZ . 1 si c�oI NEC CONTROL#
H HITECT NGyN .
mill
+ LIC NO -1Z Q ADQRk 61140� Ll -I*
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ACC M ,Nl ONE: J LI 3 BUILDING PERMIT INFO
kALI (a��u>JINT, 1—(031
❑ Consultant F<es Paid by Applicant(Initial) B� ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARA'T'ION . 'tl�Cg 1
I hereby affirm Nat 1 am licensed underQTYELECTRIC PERMIT PEE
previsions of Chapter 9(commencing JOB DESCRIPTION
O«Z with Section 8100)of Division 3 oflhe Business and Peomsxions Cade,and my license is RESIDENTIAL,
�00 PERMIT ISSUANCE
C knF- in lull foreeant effect. ❑SFDWL ❑KITCHEN REMODEL
U License Class Lic.p RESIDENTIAL
6 U APPLIANCES []ADDITION ❑PLUM BING RF.-PIPE
Gi nate Canvacmr
FOq ARCHITECT'S DECLARATION PANELS ❑MUCH-UNIT ❑STRUCTURAL
z O 7J. 1 understand my plans shall he used its public records MODIFICATION
OZ-0�r UPI'0 200 AMPS
F`4. - Licensed YmPossional INTERIOR [D CHIMNEY REPAIR
p 201-10100AMPS IMPROVEMENT
j OWNIiR-BUILDER DECfARA'1'ION AVER EMAMPS ❑ENT'H REM( REAR�I_DEMOLITION
Q 1 hereby affirm that I am exempt form the Contractors License Law for the \b qV
as U following reason.(Section 81)15,business and Professions Code.Any cantor county SIGNS ELECTRICAL. ❑OTHER ir
.��
a] MW y which requites a permit to construct,alter,improve,demolish or repair any structure
P
rimp,its issmnce.00homoluires thcupplicant formeh pamwo file toatimdsmmmem SPECIAL CIRCUITIMISC. AlC
that he is licensed pursuantn the provisions ofthe Contractor's license Law(Chapter 9
C�QE mommen,ingwith Section 81f1(gof Divisim 3ofthe B.mirosand Professions Code)m TENIP.METER OR POLE INST. COMMERCIAL:
a'a 2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
c p ❑NEW BLDG/ADDITION [:1 DEMOLITION
X"" Section]031.5 by y applicant for a permit subjects Ne applicant to a civil penahy of POWER DEVICES
tel^fin an ❑TENANT [I FOOD SERVICE
n mare than live hundred pmpcdotlms y employee,W T.
F Z> IMPROVEMENT
=60Lashewor of the,ormthropetly.ormyntendd oithwagesaz their sole c0m.Businessor. SWIMMING POOL I1.ECfRIC
will do the work,and Thestrvcwreis notice ice. orowercdforsale(Sec.7044. wma,of DOTTER
I�il m and P.. vause Come:L e Connote,,hiccnne law JOev nal apply 10 an nwmr M OUTLIiTS-SWITCHES-FIXTURES
pmpeny who builds or improves thereon,and who does such work himself or Through
his own employees,provided That.such improvements are non intended or offered for NEW RESIDENTIAL ELECTR S
sale.If.however.the building or improvement is sold within one yearafcompletion,the SQ.F1'.FLOG VSQ.IT.
caner-heikka will have The burden of pmving that he did not build or improve To,par- I�-/J♦a A
pose of sole.). 'f{9�..A�r((''/^JJVi�'
1,as owner of the property,am exclusively contracting with licensed wourec ms,to
construct the project(Seo.0044.Business and Pme,,mons Cale:)The Contractor's U-
cense law does not apply roan owner ofpropcny who builds or improves Thereon.and QTY. LUMBIN ERMIT FEE
who contracts far such projects with it comraemgs)licensed pursuart to the Convectors O !'
License law. IT ISSUANCE CT
1 am exempt under Sec. .B&Y C far This m mm 1
LTE & r-W 'I ER IEA) r/.� 4. bUAT10N
Owner 1—
WOR
_ WOR KE R'S COMPENS ATION DECLARATION 1A PRO TF .DEV 'E {�
G Iherchy nffinnuoder Penalty of perjury one of the following tied a'on, L( `
I have and will maintain a Cenificam of Concent to self-insum for Work 's Compen- AINS-5edR ROOF.AREA,COND. STORBS aV TYPECONSTRUCfION
sation,as provided fart by Section 38q of the Lobe Cale,1'ar the Ferfor rocculhe
cam tmoshich Thispermitoissucd —R -PERTRAP
❑ 1 have and will anderam Worker's Cornpemntlon Insurance,as required h Section
J]UO of rhe WbnrCode,for The perfamlancc of The work forwhich Thio permiti 'stood. S-EA.SYSTEM-II.NC.4OUTLE'TS
"`7P
P APN
My Wnry}��yaj(''yyynnlpy no 1 and Polio
Cam'm `I+v nv Policy No.Yn a Z 2 GAS-L'A.SVSTP.M-OVIiR4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WA. INTERCEPTOR
AL�1111M,DIVISION ''ES
(This section need not bernmpldW permit is piz for one hundredd011ats(SIWJ GREASETRAP
or tela.) PfANCqu
l anify that in N<performance of The work forwhich Nis pemtit is itsuod.l shall SEWER-SANIT Y .T EA.- FT.
ma
employ any person In any munne`so as rat hcrome subje'TO
m The Wn kers Comyyy- EN Fl
O Z scion Luw:'Iy�alil a WATER HEATER LECTR
O Applicant ,/ G IN
TV) NOTICE TO AI'PLICANII ll:aIle,m1A Nix Canil'mme of Exunption,you should W IiR SY BEATING
E' become mbject m The Workers Comps-- n provisions of Nc Lahr Code.you must 1'E
rt
Ya] •,••I forthwith comply with.such provisions or this permit.shall bedeemed revoked WATE F.R CB
a �
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPf.MO. SQ,FT. PAID prem Rceciptp
L)0 1 hereby aBinn that there is o construction lending agency for the performance of
P the work for which this perait is ismed(See.3097.Civ.CJ
u'' Lcnder'.v Nutnc TAL:
LJ lendds Adcums 'T'O'TAL.:
,Y W BUILDING PEE r'
k.. I certify that 1 have read this application and%rate That the aMve information is 1
L Val comet.I agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT EEE
U Z buildingconamction.and herehyauNoize representatives of Niv city tommrupon the SEISMIC FEE
above-mentioned property aur inspection purrovex' PERMIT ISSUANCE
(We)a,.m some,indemnify end keep h:gankst the City of Captain.against ELECTRIC PIiE `
liabd tics.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit. PLUMBING FEE
APP)ICAN'f tNDI. STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
MECHANICAL F; t
5 C CEREI 'LA'1'IONS.
AIR HANDLING UNIT(OVER 10.00(1 CFM) CONSTRUCTION AX
/ O
'ignawreof ArldersnUContrecter Dat EXHAUSI'HOOD(W/DUCT) HOUSING MITIG TION HE
HAZARDOUS 'ERIALS DISCLOSURE
Will the applicant or fuwre hui goccupam.une or handle hccondus mmerol HEATING UNIT(TO 100,000 B'1 U)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and to Health and Safety
Cale.Section 25512(.)? HEATING UNIT(OVER 100,000 BTU)
0 Yet ❑Nn PAID
VENTILATION FAN(SINGLE RFSID) Date Receiptn
Will the applicant or future re building recupause equipment or devices which
t hazardous air contaminants as defined by the Buy Arta Air Quality Management❑Vcs ❑No BOILER-CONP(3HPOR 100.(100 BTU) "TOT,
District? BOILER-COM('(OVER 100,000 BTU)
I have read The Examims malemoto arbarerumty ureter Chapter 6.95 of Ne Cali- AIR CON DI'TIONER ISS ANCE DATE
Leman Health&Safety Cale,Sections 25505,2.5533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.nbuilding docs ant,currently have a tenant,that it is my rearytmibility m nnt
otify the occupa
of Ne requirements which mus,be mer Micron)iouanee of a Certificate of Ocemo ney.
Owner or authorized agent Dare TOTAL: ISSUED BY:
OFFICE