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28881 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MFICIIANICAL ILI)ING PRO.IEC'1'IDI4N'I'IF'ICATION 28881 BUILDINGADDRISS: , I - SANITARY NO. APPLICATION SUBMITTAL DATI OWNIiR'S NAME: PHONE COM 'OR", II: � LIC NO: �� NIC CO ROhM '•,\RCHITECT/HNGINEER: - LIC NO: ADDRISS: I p n, - ❑ CONTACT. - PHONE: VJ f/"/'•V✓`— BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) B .LE PLO MECH LICENSED CONTRAC OR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hemby affirm ma I oro licensed under provivinnx of Chapter 9(commencing JOB DESCRIPTION "Z with Section 7011olof Division Sof the Bmi.essamd Professions Cade,snd my license is 00 full force and effect PERMIT ISSUANCE �LL1 SFDWL ❑KITCHCN REMODEL 1.V5j License Clesx LIL.M gPPL1ANCBS-RESNEM'IAL ❑AUDITION ❑PLUMBINGR&PIPE NQS Dae Convector ARCHITECTS DECLARATION .OMULTI-UNIT ❑STRUCTURAL I-Dot, 1 understand my plans shall he used us public records PANELS MODIFICATION O Z:lpp UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR (rte W Licensed Professional - 201-1IXXIAMPS IMPROVEMENT .•33 OWNER-BUILDER DECLARATION OVER IfAM1AMP5 ❑BATH REMODEUREPAIR DEMOLITION yah 6 I =so .(Sect that 1 1m exempt from the Conaacmh License Law for the ippiS5,�OyV following reason(Section]0115,Business and Profesxionv Code:Any oily or county SIGNS E1AiCTRIGAL ❑OTHER which requires u permit to construct,alter,improve,demolish,or repair any stucarc prionoirs issuance,Wso requlrcalhe applicant for such pc.niuo Ele exigned smmmem SI'ECIALCIRCUIT/MISC. } that he is licensW pursuant to the provisions fthe Commune,Licema Laos(Chapter 9 OC (commencing with Section 70(10)of Division 3 oflhe Business and Professions Code)or T'Eb1P.METER OR POLE INST. COMMERCIAL: 6 c e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION res Section 7011,1 by any applicant Iia a permit snhjecm the upplicant a u civil P=nalty of POWER DEVICES El TENANT ❑FOOD SERVICE: pZ0not more man five hundred dollars($500)' IMPROVEMENT I,as owner Mlhe propeny,mmy employees win wages as Meir uJe cumpensmion, SWIMMING POOL ELECTRIC will do thewolk,and Nesnatme isnot intendedoroffere)bargain(See.7044.Business ❑OTHER 0.a� and Profession Cade:The Contractor's License Law dons not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Ff. sale.If,however the building or improvement is sold within one year ofcomplelion,the O SQ.FT.FLOOR AREA SISQ.Ff. cr-builder will have the burden of proving that he did not build or improve for put- �w �// poseofsale.), - rL i`j ❑I,as owner of the property,am exclusively contracting with licensed contractors a T constrict one project(Sec.7044.Business and Professions Code:)The Contramo's I.i. LI yk lotOannex,law does not apply to an owner of progeny who builds or booming thereon,and QTY PLUMBING PERMIT FEF, who contracts for each pmjecd with a continuants)licensed pursuant[(,,he Commear's License law. PERMIT ISSUANCE ❑1 am exempt under Sec. .B d P C for Nis reason n� Owner Dale ALTER-DRAIN&VENT ATT: FA) / �;� —VALUATTON WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT U, G 2�J. C*IQ� I herchy af0rm mnJer penally of perjury ane of Nc following Julamtions: 1 ��` 1 ❑Iheve end will maintains Ce.ificam of Cnnaem to self-insure for Workers Compcn- DRAINS-FLOOR.ROO EA. 1 ration as provided for by Section 3700 of the Labor Code,far the peR nuance of the STORK o 'TYPE CO STRUCTION work for which this permit is issued. FIXTURES-PER TRAP ❑ 1 have and will maintain Worker's Congensutian Insurance,us required by Section 3700rdf Ne Labor Cede.fu In Perfoms ace ofthe work lit which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OC P APN My Work a P if.. matt mier and Policy no are Carnee Policy No.: GAS-EA.SYSTEM OVER 4(E ) -\ CERTIFIC T170FB EMPTIONFROM ORKERS C_1 Of curt COMPENSATION INSURANCE GREASFJINO .WASTIi INTER BUILDING DIVISIa I'll[+S (This[eclion need not he completed if the permit is Tanana hundred dollars(SI W7 GREASETRAP or Ices.) PLANCHECK FEF. Icenify Auris the perfor. ae, n(thework for which this Kind.iixecolsho. SEWER-SANITARY-STOR 'A.200 FT. not employ any penton in any manner so ns m hcmme subject m the Workers'Cnmpen- ENERGY FEE Z smion laws of California.Date WATER HEATER WNHNT/ELECTR 0 Appliance, ITS, FEE NOTICE C 1, mrmemg ertifieam of Exemption,you should WATER SYSTEM/IREATING SOUS FEE become sides ante urkere Compensation provisions of the Labor Cook,you must fonbwilh comply with such provisions or this permit shall he deemed revoked. WATER SERVICE Q CONSTRUCTION is.emoN LENDING AGENCY NF.W RLsSIDENTIAL PLMB. SQ.ET PAID V � thereby s(Hnn manherc is econswction lending agency for the perfommnce of Dam a �ipp V4 L~-' the work for which this Perini[is issued(See,7097,Civ.C.) 0 U Lender's Name TOTAL: H.l Lenders Address TOTAL: 1 certify that 1 have read this...limliam and atom maube above information is BUILDIN I M6 �• N7 correct.l agree to comply with all city and countyominances and state laws relining to QTY. MECHANICAL PERMIT FEE U G building construction,and hereby amhorizc represemmnlvesoflhis city aenterupon the SEISM cn eMve-mentioned progeny for inapaclio.purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupenino against ELF. IC habilities.judgmenu.costs and expenses which may in my way acerae against said City ALTERORADDTOMECH. in consvqueaue of the grunting of this perinit PLUMBING PEC It APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT To Ud,000 CPM) SOURCE REGULgTTONS. MECHANICAL E AIR HANDLING UNIT(OVER 10,IX0 CFM) CONSTRUCTIO. TAX 0,6 Sig of AppLuen Comrucmr C Data EX HA U91'I IOOD(W/DUCT) HOUSING MITI ATION FEE HAZARDOUS MATERIALS DISCLOSURE. Will the applicant m Faure building osculating go,.or handle Numerous memrid HEATING UNIT(TO 100.000 BTU) as defined by the Cupenino Municipal Code,Chapter 9.[2.and the Iimah and Safety Code,Section 25532001 HEATING UNIT(OVER 10090W BTU) ❑Yes No VENTILATION FAN(SINGLE RESID) PAID Dam Rece M 18, Wll ein air comntorfuturentsa building occupby nt Buy Area Air Qualitnt or y vicca which nagemnt BOILER-COMP'CHP OR 100,000 BTU) Dist District, us air contaminema as defined by the Boy Arca Ain Quality Management TO L: District? _ ❑Yes ONO 1 BOILER-DGMP(DVER I00,f100 BTU) I have mid the humorous mammils rvquircments under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE brain Health&Safety Coale,Sections 25511.5,25533 anti 23534.1 undcrsmnd that if the NEW RpSIDENTIAL MF,CH, SQ.FF building does not currently have a mora,that it is my mvpomsibilily to notify the occupant of The requirerrmnn which must be mel Prior cc)nostrum of a Certificate of Occupancy. � '^ �� Owner or awhorized agent Date TOTAL: Y; ✓YY OFFICE