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28768 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO I BUILDING J RLRCTRICAL PERMITNO BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION 28768 BUILDING ADDRESS: SANITARY NO. APPLI�NSURM.•�F '295 ..►.�s OW kRS NAME: PHONE: CON'I'1AC'I OR'S NA LIC NO: 11 ` NAC CONTROL# �A TE / NGILI' O: ADDRESS: ❑ L.NF : •7Z� CON/T�)I' PHON ILDING PERMIT INFO , ❑ Consultant Fees Paid by Applicant(Initial) BLDQ ELl= PLUM MECH 11 LICENSEDCONTRACTOR;SDRCLARAGON ` /�QW' OX 1 hereh Pone Ilial 1 em licensed under signs of Cha ter 9(atmmencin QTY. ELECTRIC PERMIT FEE ' Ya pmol P B JOB DESCRIPTION 000 with SeorcendaffecDivision 3ilthe Business and Professimw Centered m licenseris �I W r y PERMIT ISSUANCE RESIDENTIAL FWD Lemafulfoes and effort ❑SFDWL ❑KITCHCN REMODEL �(„) License ClaI Lica APPLIANCES-RESIDENTIAL - []ADDITION El PLUMBING RE-PIPE N QZ a Dele `pS DECLARATION u ANCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL F D m PAN fiLS OZ— ns shall be used as public records / _ MODIFICATION pZ^ a -P T02IX1AMP5 ❑INTERIOR ❑CHIMNEY REPAIR �h., Licensed PlF'msRonul' 2UI-(MAMPS IMPROVEMENT 4......111 OWNER-BUILDERexemptDECe Contr ON OVER IOW AMPS ❑RATH REMODEUREPAIR DDEMOLITION ©a 1 hossio affirm tial 1 um exempt Dann the Conine Co License law for the O y U following reason.(Section]U3L5,Business and Professions Cade:Any city or rounrr SIGNS ELECTRICAL ❑OTHER which requires a permit m construct,alter,improve,demolish,or repair uny sweture pdormilsissoarm.0sbrean.lhehyplicanl fursieh permillo file a signed stolen at SPECIAL CIRCUIT/MISC.} that he is licensed pursuant the provisions ofthe Contractors License Law(Copa,9 00 (commencing arm Seadin7010)if Division Sof the Husinessand PoLowioms Code)nr TEMP.METER OR POLE ST. CDMMERGIAL: ^n p that he is exempt Nemfrom end the basis for no alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Y• Sectimt]031..5 by any vpplicum for a permit xuhjeclx the applicant m v civil penally of POWER DI!VTCE ^'/1 `� I'ENAMf m m ❑FOODSERVICE FZ} nore Nan five hundred dollars(SS W). / IMPKOVEMENT ' C� D1,esowner efthe propnr,or my employees with wages as their sole compensation, SWIMMING ELS \ FG` will do the work,and the structure Isnot intended material l'orsale ISn"70,14,Business ❑OTHER W a^m and Professions Code:The Contractors License Law does ten apply to ua owner of O TLGTS-SWIT HFS-EI P � 6 property who builds it improves thefion,and who dews such work himself or through his an employees,provided that such improvements are i..intended it offecd for NEW RE fl)fi]IA R ". 'pl'. sale+If,howeved the building or improvement i.sodd within one year ofcomplmien,the s\ ass / SQ.FT.FLOOR AREA $/S FT. (sated. wmerbrael.will have the burden of proving that he did not r- buildorimpnrve for pa pose - Jv_ as owner of Ne property,am exclusively contracting with licensed Commences t. % Dost cI Ne pm" Sec.]049,Business and 1lvfessinns Code:)The Comracmrs Li - nseLawd of 0 man ownendprolnny who builds or internees thcon,and Q'T'Y. PLUMDINO 'SMT-� —N` PEE. who con sin h ejects with a cormorants)licensed pursuant to the Contractor's ""� a-i Licen a Ll sPERMIT ISSUANCE Diem Indo ,B&PCir ralwirra CfER-DRAIN&VEND-WATER(EAI VALUATION )RKER'SCOMPENS TIO CLA A ON BACK FLOW PROTECT.DEVICE I hereby of irin under penally of perjury one of the following declamdons: ❑l have and will maintain a Certificate ofConentto elf-insure for Worker's Comped- DRAINS-I'LOON,RODF,AREA,COND. STONIES TYPE CONSTRUCfION ..tion,as provided for by Snation 3701 of the Labor Code,for the perferreance of the work for which this portal is lamed. FIXTURES-PER TRAP •tea D I have end will maintain Workers Compensation In s required by Section 37W of the labor Code,for the performance of the w for wh ch this penal is issued GAS-P.A.SYSTEM-1 INC.4 OUTLETS �/� OCC.OROUI' APN MyW.umex Compensation Instruntt canceled olicy num arm Cartier: ' my No.: .GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF G%L' PION FROM WOR ERS' COMPS ION INSURANCE GREASFIINDUSTRLWASTElNr..RCEPDOR abis section need not ompletedifthepcnnitisforooe nJteddollars(SIME 6 II +DIVISION FEES or less) GREASE.TRAP - PLANCHIiCK In Ne performance of a fir Which Nis pn it is issueJ.l shell SEWER- notemloyanyperseoiaady mer ebjccnothe Wirkcrs'Compeo SANITARY-STORM EA.2W IT. Z otionl ws nl CaliG ria.Doe ENERGY OO all. I < co WATER HLIATHR W/VENT/BLECTIR /' GRAD] G NOTICE APPLI T: making this C Icac of Exem t o h Id y �p tote y u s onion,y u s oo WATER SYSTfiM/TREATING SOILS FIkV['! ti become subj I rs 'ompenon tions ofthe labor Cede,you most WC, forthwith con ly withse provisions nr�tshell be deemed revrkd. WATER SERVICE Q �z C STRU A NLENDING AGENCY NEW RESIDENTIAL PCMB, SQ.FL PAID C.)Q Ihenh ffirmthm the mstrution lending agency for We peffamrmce of Dole Deceip ry F the work for wi tell this pe a issued(Sec.3(97,Civ.CJ , O U Leadcr'x Namt Lenders Andre OT' �}at � (certify have read this application and ammo that the above information is BUILDING FEE• ^� it N7 ro(rerl.l agree m comply with all city and court ru ly omlinances ani ,are lows relating m QTY, MECHANICAL PERMIT FEE SEISMIC FEE U G building construction,and hereby authorize representatives of Nis city to enter upon the above-mend.und property far inspect purple. PERMIT ISSUANCE (We)agree to save,indemnify and keep hamtless the City of Capella against ELECTRIC FEE liabdo., mrrs,costs and expenses which may in uny way uccrve against said City ALTERORADDTOMECH. / PLUMBING FGE ,..^ do., fthe tingofthm ispcdl. PPLIC ) NDS AND WILL COMPLY WITH ALL NON-POINT WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10/000 CFM) MECHANICAL PEE 'O' '':REG I SI S. AIR HANDLING UNIT(OVER IO.oligh U CONSTRUCTION TAX St of Applicenl/Convac'o I Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DI CLOSURC Will the applicant or future building occupant s morhandichancedouematerial HEATING UNIT CPD 100.001 BTU) (� p as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety 11 Code,Section 25532(a)'! HEATING UNIT(OVER 100,000 111 U) //��} q u Yes 0N VENTILATION PAN(SINGLE:RESID) PAI Will the applicant or fmurc building ewcupam use equipmentor devices which ni , 79Wpt# .,nil hazardous air conmoinants as defined by the Buy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) h cl? TOTAL: ❑Yee No BOILER-COMP(OVER 100.000 BTU) f I have read the hazardous materials acquirements under Chapter 6,95 of the Cali AIR CONDITIONER ISSUANCE DAIP---, fomin Health&Safety Coda Sections 25505,25533 ani 25534.1 understand that if me NEW RESIDENTIAL MECH. SQ.ET. Is does not constantly have a tenant,Nat it is my onponsibiliay ro notify the oceapam of NO cquicmeats which m all he mel prior to wasocofu Ceriisawof Occomincy. Owner it authorized agent Data T ISSUED BY: OFFICE