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28562 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT,PEN ONLY ' CITY OF CUPERTINTO BUILDING_-ELECTRICAL PERMITNO. 28562 BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL. BUILDING PROJECT IDENTIFICATION - BUILDING ADDRESS:. - - y- SANI'1'ARYNO. APPLICATION SUBMITTAL DATE OWNER' ME: L �� 1'HON i:- !4 -6 CO f ACI'OR'S,NAMIi:. OL . LIC/O:L 6 �. NIC CO 01. ARCHITECT/ENGINEERi LIC NO ADDRESS: CONTACT: PHONE: ' HUILDING PERMIT INFO ' ' - ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT . PLUMB MECIi / LICENSE:DCONTRACTOR'SDECLARATION - QTY ELECTRIC PERMIT ' ITC ❑ ❑ 1 nanny affirm that I art,ucantad ander provkirm of chapter 9(commencing` JOB DESCRIPTION wo, withSwtion 70001 of Division3ofNe Business and Professions Code.and mylicense is, d RESIDENTIAL: F in full force and effect. t PERMIT ISSUANCE .W r Licenu Class_ 'hlc.p _ C SFD W L ❑KITCHEN REMODEL HG6 Date ,,. Contractor APPLIANCES-R[SIDHNTIAL ❑ADDITION T [I PLUMBING RP.-PIPIT pm ARCH]rEC'I"S DFCLARATION t ❑MULTI-UNIT [I STRUCTURAL Z0Zj - I understand my plans shall Med as uspublic records 1'ANL'LS MODIFICATION'. OZ O UPT02NAMPS CINTIiRIOR .a C CHIMN17Y REPAIR 'rt,,F-M Licenud Professional 201-1000AMPS IMPROVEMENT ' g�ji OWNER-BUILDER DECLARATION OVER IOW AMPS' -- C BATH REMODEUREPAIR El DEMOLITION aMpa5a :I"'a I hereby affirm that 1 am exempt from the Contmnm's License Law for the x+34 .. (allowing rensan:(Section 70ll s,Business and Prufessinre CW nyti coSIGNS ELECTRICAL ❑OTHER . whit eq p 't tcrammer.'alt mipm a dent I'. pe y� etunty re �� pnarl t '. I y the applicant h to rile signed nt SPECIAL CINCUIT/MING - `gY that(commencing licensed pursuant t N provisions Ill t sl L (Cb tr9 �00a (coat sc.co,o iSectn71and tof he vtsin the Businesstend Professions¢ Tor TEMP.METER OR POLE(NST COMMERCIAL: 6—o W That he is exempt Iherefront mA the fit,Ihe.nllegeJ cxertnion.'Any vinlmibu of C NEW BLDG/ADDITION C DEMOLITION px, W Swoon 7071.5 by any applicant a permit subjects the applicant to a civil penal) of POWERDEVICHS L+l^m ❑TENANT FOODSERVICE .F. P not more Non 0vehandrulJ m . .IMPROVEMENT fC ElI,os owner of the prop y,or my yempemployees with wages us th' sole compensatit SWIMMING POOL ELECTRIC 4' C y� willdnthewmk,andlh fracture is not intended oroffered for sale .sa,71,Rusincs a 19 OTHER ul and Rofesslnns Code c Contractors License Law oc not y to an owner f OUTLHTS-SWITCHES-FIXTURES; 6 3— proper who builds impmvex thereon,and who J ,it) self or Ih his own employees, rovided that such impnrvements d f� the�H NEW RESIDENTIAL HLECTR SQ F1'. cmI,1fhowever.th Inildingorimpmvementi. wit ' neyearoyfa��'jtfyrbJtlQQ/v(�IIff3��Jth ,SQ.IT.FLOOR AREA $1SQ.FII owner-builder will methdbu ofpn t u Bol o Jo - n Iwsaofiale.). 1h/s o`/ - C'I,as owner of he pntpen' t vcly co a tag 'NyVn,ad con cats In TOTAL: cerse Lo the pro•a tits ]M4� r�J The C- maters Li- c1mccorwdoes otapply w an ow fpr y ea dpsusumpn aComustors, QTY. PLUMBING PERMIT FEF- whocontmcwf such,rojenswM amtmcpitt�i s) sed pursuer Babe Cnnuanure - License Law. PERMIT ISSUANCE ❑'Iain exam, under Sea. ,13&P C for this reason - ALTER-DRAIN&VENT-WATER(EA) VALUATION rd Owner - .. Date /��(q. .� WORKER'S COMPENSATE)O 'Cafolim ON BACK FLOW PROTECT.DEVICE //J/ A Ih..d affnn nndar penalty of perjn uofihe following declarations ;c/" tritium, as and amaimain eCenificate of num msdf-ins.rc for Worker's Compcn DRAINS-1100R,R001'.AREA,GOND' S7Y) 15 TYPECONSTRUCTION workr pvwl ed fnr•by Seniors 37q the LaMar Code,for aM1a perfomtance of the wink fnr which i¢permi(is issu - ITX'1'ORES-PF.1t'1 RAP , 1 hove and wt maimm.W ccs Compensation Insurance,as rtyuired by Section 9700of Ne labra e,I a armormace iifthe work to, huh this permit is issued. CAS-EA.SYSTEM-I NC.40ULXTS. 4' OCC.GR0UP APN Mynotrkern Compcnsauo n rend Policy nu in a OOH GAS-EA.SYSTEM-OVER4(EA) Carrier.� (Zr l'oliay Nu:�.,�{.fcat _ , C:RTIF ATF.OFHXEMPIONFROM WO KERS' I- .COMI'I:NSATIONINSURANCE GRIiASUINDUSTRL WASTE INTERCEPTOR •'(Thisixtinn Bad nmhecompleted if Ne tisforonehundr dolls (SIM) _ - BUILDING DIVISION FEES pemtt G or 1<DaJ REASETRAP PLANCIIECK FEP. Icymythatint irony onnmwofNewbuckrta,mlchlhisparmifisiss-Cmech SEWER-SANITARY-STORM P.2W FT. not employ any person irony manner xo as m bsotne subject m IM1e Workers Compen- - O ,z xzdon Laws of Celifnmia:Date - - WATER HEATER WNENT/ELECTR °' `_ ENERGY MH A"hassm - - GRADING FEE y NOTICE TO APPLICANT:If,tiller making Ods Cedifnnc of liump(mn,you should, - /." Wxt ER Sys mohTREATING bccome subject to the Workers Compensation provisions of the labor Code,you must _ - SOILS FEE 0. forthwithcomply with such provisionsor this permit shall he deemed revoked. WATER SERVICE., t Q 5z CONSTRUCTION LENDING AGENCY NEW RESIDEN9'IALPLMB.' SQ.IT. PAID IV t1 Ihertby teff nnlhm there isaronsWction lending agency fnnhe perfnrmancu of Data Receipt# Ir^•t the work for which this permit is issued(Sec.3097,Civ,C.) t - Q Lender's Nana t TOTAL: Lenders Address - TOTAL: �.a I certify that I have read(his upplicol lnn and swat,that she aMrve information is BUILDING PEE i... (4 correct.l agree to comply with all city and county ordinances and state laws relining m QTY. MECHANICAL PERMIT FEE SEIS �/ MIC HE'V G' mildin,,, stmnion,mod herebymuhoriee rtepmummivesoffhlsally loader upon the above-mend bad Pmpeny for inxpedion phopo cs. • V (We)agree to save,indemnify and keep harmless the City of Cttpeni m against HERMIT ISSUANCE ELECTRIC FEE liabilum.judgmems,costs and expense¢which may in any way ammo against said City ALTER OR ADD TO MECH. inennsequencebuflhegmmingof this permit - PLUMBING FEE APPLICANTUNDENSTANDS-AND•WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) ' MECHANICALMH ' SOURCE REGULATIONS, _ - AIR HANDLING UNIT(OVER 10A.,CPM) CONSTRUCIIONTAX' Signamteof Allorm VConanmor a Date EXHAUST HOOD(W/DUCT) - HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE , Willtheapplicant or fuwrcbuilJing nreup:uv nnrc nr hnnJle haaurdous material HEATINGUNIT(TO I(l0"HTU) r' as defined by the Cupertino Municipal Col Chapter 9.12, it the Health and Safety - Collo,Section 25512D)? , HEATING UNIT(OVER 100,000 BTU) ❑Yes CNo t. - PAID , VENTILATION PAN(SINGLE RESID) Dam Receipt# Will the applicant or future building occupant use equipment or devices which - ,3 emit hmafdous air contaminants as defined by the Bay Arca AirQmlity Management BOILER-COMP GHP OR 100,000 BTU) - , TOTAL: District', BOILER-❑OMI'(OVER 1 W,IXq BTU) ❑Yes Nu - - ' - , i 1 1't AIR CONDITIONER I have bod she nominalism,mmenme( als da,mocns under Chapter 6.95 of the Cali- - -ISSUANCF DATE hernia Health&Surety Code,Sections 25505,25.533 and 25534,I undsswnd that if the NEW RESIDE1,H]AL MECIL SQ.FR building does be,contend,has,.iemtm,that it ism,resforannlity to notify aheoacupam of the fequitemenw which must be met prior m lssuanw of a Cenificme of Occupancy. Ownerorumhorisdagent Darr TOTAL: X0(9 ISSUED — OFFICE