28470 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 28470^ 4 7 O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. L�XJ 1/
- BUILDING PROJECT IDEN'PIFLCATION
BUILIIINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
110Q 541eh
c. AS Ln! �1 l��
OWyf-.g'S NAME: PHONE CppN'I'�AC'fOR:S NAMII: LIC NO: 1{
KA. Aon m 2vI ZSZ- lyp Wein Cr �k,G3b . 3`�1Z5 N/c CONTROL.
•ARCHITECTIENGINEER: LIC NO, ADDRESS: - ❑
11 z Flore',.x ex Lit )
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEF.
he
1 mby aRrtn that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�z with Section 11100)of Division 3 of the Business and Professions Cade,and my license is
�O Y PERMITISSUANCE RESIDENTIAL:
n full force and effect
elf t - S ❑SFDWL [I KITCHEN REMODEL.
aVl LicenseL N APPLIANCES-RESIDENTIAL
FFZ``bila'' Date G,moaor ❑ADDITION C�<GMBING RE-PIPE.
F=y ARCHITECT'S DECLARATION J PANELS 'OMULTI-UNIT ❑STRUCTURAL,
Z O J Z I understand my plans shall be used as public recoNx - MODIFICATION
pZ Cl - UP TO 2W AMPS El INTERIOR ❑CHIMNEY REPAIR
I:�H, Licensed Professional - 201-10MAMPS IMPROVEMENT
,ej p4m OWNER-BUILDERexemptOE DECLARATION OVER 10110 AMPS ❑BATH REMODELiREPAIR 0DEMOLITION
pG,G I hereby allium that 1 am exempt(mm the Contractor's License law for the
34 F.Vfollowing reason.(Section 9031.5,Business and Professions Gyle:Any city or roam, SIGNS ELECTRICAL. ❑OTIII?R
Ovj which requires a genNt m Curr muct,ehcr,improve,demolish.or repairany strvcmre
gprior to its issuance,als)requires the applicant for such permit to me a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the prmisions of the Centimeters License Law(Chapter 9
(commencing with Section 7")of Division 3 ofthe Business and Professi.m Code)or TEMP.METER OR POLE INST. COMMERCIAL:
0,p,M C that he is exempt therefrom and the basis for me alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
i� o,, Section 1031.5 by avy upplicam Cara permit subjects me applicant to u civil penalty of POWER DEVICES
H9 not mote man five hundred dollars fS500). ❑TENANT ❑FOODSERVICE
Z6 I,as owner of the property, employees with wa es as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
0 ❑ Petr Y Y8 P
II dome work,and the he Car t is not intended a Law
do fm sale EF,7044,a....,,at ❑OTI IHR
and Professions Code:The Contractors License taw does not apply to if owner of OUTLETS-SWITCHES-FIXTURES
6'3 hPropertyis own who builds or improves thereon,and who nts such work himself or through _
his own employees,building thin such improvements ora not intended or nl7ered for NEW RESIDENTIAL ELECT'R SQ Ff.
sate.
er-howevwll the have
bur impmvemcm issoldhe id noneild or
improve
SQ.FT.I.100R AREA 5/SQ,PI'.
wnerbuilder will have the burden of proving that he did not build or improve for pur-
posenfsaleJ.
❑ I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
ommum the projcet(Sae.16$4,Bvaineas and Professions Coale:)The Co....Our's Li-
cense law than mlapply man carer.f,mmery who build,or improves thereon,sena QTY, PLUMBING P13RMIT FEE
who contracts for such projects with a commodore)licensed pursuant o the Convectors
License Law. PERMIT ISSUANCE
El Item exempt under Sec. ,B&P C for this reason
Owner Date I ALTER-DRAIN&VIEW-WATER U3A) VALUATION
WOR KBITS COMPENSATION DECLA RAT ION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compcn DRAINS-FLOOR,ROOF,AREA,CONED STONIIS TYPI?CONSTRUCTION
sail..,as provided for by Section 31110 of the labor Code for me pnfommmor of the
nark for which this permit is issued. gj FIXTURES-PER TRAP O�q
have and will maintain Workers Compensation Insurance,as required by Section
3100 oC the Luton Care,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM.I I NC.4 OUTLETS OCC CROUP APN
My Walk '�Crmpe ,ion ln3y�Ce anter and Policy nyu�bc yam,
Carrier. ��'nVLdt( 9.l' �i Policy No.:,I-Cr`i"t '&'o GAS-EA.SYSTEM OVER 4(FA)
rCERTIFICATE OF EXEMPTION FROM WORK17RS'
COMPENSATION INSURANCE GRFASWINDUSTRI,WASTE INTERCEPTOR
(This section need probe completed if the Permit is furnace hundred dollars(SIM) BUILDING DIVISION PL'I15
or less) GREASE.TRAP PhANCHIiCK FEE
Loy any than inthe inmymannigeo as t work for whish this per Workers CaIsbell SEWER-SANITARY-STORM EA.201 Fir.of employ any person in any munne(so as to become sulSecr to t 7 Workers C.mpen- ENERGY TEE '
,$ sari..Laws of C.lifnrnin Date
- ' WAI'IiR HEATER WIVENT/ELF.Cf
Z2 Applicant R GRADING IEE
fq NOTICE TO APPLICANT:If,after inking this Ce fico I r,prion,you should WpIMRSYSTEMOMEATING
h 5 becomewhijeet within Workers C nmtmn r e Lain G you n - SOILS PL'B
L forthwith comply with such pmvisian r t�s IM E; deemep re you WATER SERVICE
Q 2
CONSTRUCTI CNDINGA Y/ NEW RESIDENTIAL PLMB, SQ.FT. PAID
`7z I hereby omrm that isacon cion lending., ymrm perm ance of Date Receip,M
the wink for which this permit is issued(Sec.ENI,Civ,C.)
Lenders Name
TOTAL:
IV Lenders Address r'
I certify that 1 have rwJ this application and time that the.bole information is - BUILDING FEE
ZI comet.I agree to comply with all city and county announces and state laws miming to QTY. MECHANICAL PERMIT FEE
U - building contraction,and hereby authorize representatives of this city to enter uponthe SEISMIC FEE '
above-mentioned property for inspection puryosea.
(We)u,me to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
Iiabildics,jodgments,costs and expenses which may many way acemeagaim,said City ALTER OR ADD TO h1ECH.
in comequence of the grunting of this permii PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT .AIR HANDLING UNI'1'(TO ItI,IpO ChM)' MECHANICAL FEE
SODR(1E R[GULATIONS.
,� L, —1-I - AIR HANDLING UNIT(OVER IO,OQI CFM) CONSTRUCTION TAX
SignatummApplieaMC n nor Dam EXHAUST HOOD DODUCI) HOUSING MITIGATION FEE
HA \R OUS MATERIALS DISCLOSURE
Willbrit,liamnn mrohuilJing occupum store nr hovAlohazwd.ux malcriul HEATING UNIT(TO Ui BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? / HEATING UNIT(OVER 100,000 BTU)
❑Yes T,aN YEN1'ILATION PAN ISINGLE RESID) PAID �
Will the applicant or future building occupant use equipment or devices which Date a" Teo,,M
emit hazmdcux air conmmiv.nts u,J cd by the Rey Area Air Quali,y Mm ogement BOILER-COMP(3HP OR 110,000 BTU)
District? BOILER-COMP(OVER 100,000,1BTU) TOTAL:
C Yes No
1 have read the hommost,materials AIR CONDITIONER ,
requimmcnts under Chapter 6.95 of the Cali- rUl- ISSUqAUNC TE
foods Health&Safety Code,Sections 25505.M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does am uurently have a tenant,that it is my axlnmsibility to runty the Lc afpmm Q
of the nqu meats which most the met prior t.issuance of.Certificate of Occup /N
Circulatory. NO
Owner or outhorieed ugcn, Mule TO'T'AL: ISSUED it,
OFFICE