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28728 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITN028728 . ^ a�a�N -tUILDINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L VX I 'LJ.�M! BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE OW R' NAME: Pf{ONE: CppN'TRA :S NAM LIC NO: Z �- S d W ( N/C CONTROL N CHITECI'/ENGINES LIC NO: i RES S: WIT'" ' J (/Z ❑ CONTACT. PHONE: J BUILDING PERMIT INFO Z a\ ED Consultant Fees Paid by Applicant(initial) BO ELECT PLUMB MOH LICENSEDCONTRACTOR'S under SDEOons of CON QTY ELECTRIC PERMIT FEE 1 hereby )of that 1 am licensed under and Proons of Chapter 9(commencing JOB DESCRIPTION CIYZ wimSeniors]000)of Division Sof the Business and Professions Code and mylicenuis RESIDENTIAL, UW O PERMIT ISSUANCE W in forceandGal.G ff� see / ❑$FOWL 11 KITCHEN REMODEL �U�j License Class Cmi pppLIANCF.S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE <i Date Contmcor ARCHITECTS DECLARATION CI MULTI-UNIT [I STRUCTURAL Z O v Z 1 nw understand my plans shall be used es public records PANELS MODIFICATION :7 UP TO 200 AMPS I ❑INTERIOR C1 CHIMNEY REPAIR Licensed P..I ...I 201-10BOAMPS - IMPROVEMENT O'44 11 OWNER-BUILDER DECLARATION OVER IIMIOAMPS ❑BATH REMODEUREPAIR DDEMOLITION yOy W 1 hereby afrom that 1 am exempt from the Contractor's License Law.for the p(36U following rewon.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER IaD7^O which requires a permit m conswm,ober,improve,Demolish,m repair any stmcwm - Prior coits issuance,also requires the applicant for such permit to file a signed statement SPEC]AL,Cl RCUIT/MISC. yNat he is linnsed pursmm mthe provisions of the Cnnwcor's License Low(Chapter9 p0 (commencing wit Section]Oro)of Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INST. q m pC mat he is exempt therefrom and to basis for to alleged exemption,Any violation of ❑NEW BLDG/AD MON ❑DEMOLITION iWC V. Section 7031S by any applicant for a permit subjects the appliesmw o civil penalty of POWER DEVICES C3TENANT CFOOD SERVICE not more than five hundred dollars($500). a, IMPROVEMENT < p hos owner of the prnpeny,or my employees with wages ns rM1eir axle compensation. SWIMMING POOL ELECTRIC Q and dm Tenn. a,and r:no antra es,License does a.,.1Sec.o an Business ❑O R and Profwsiom Cade:The Conuamor's License law data nm apply s if owner of OUTLETS-SWITCHES-FIXTURES n' his o property who builds or improves t such i and who docs such work himself or through his own employeese building that such improvement a2 not intended year efc m offend for NEW RESIDENTIAL ELECfR SQ FT. f 7F sale,lh however,me building or improvement is sold within one year of cnmpinioo,me SQ,FT FLOOR AREA SISQ.FT. ner-builder will have the burden of proving that he did not build or impose for our- you of sale.). 1,a owner of the property,am exclusively connecting with licensed communities to TOTAL: ��j �'\ construct the pro44.project(Sec.]0Business and Professions Code:)The Contractors Li- i VJC EI 1J cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE who comma for such projens with a conorecmrts)licensed pursuant to the Contracmr's License Law. PERMD'ISSUANCE 0 O 11997 1 am exempt under Sec. .B&P C for this reason Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION T�'��J WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE BY: I hereby affirm under Penalty of pe jury'ono of the following declarations: I have and will maintain a Certificate ofConsent to self-insure for Worker's Comocn- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION tion,se provided for by Secuon 3700 of the Labor Code,for the Performance of the W. Tei whichmis peunioisiswed. FIXTURES-PERTRAP have and will maintain Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance ofthe work for which this Permit is issued. GAS-EA,SYSTEM-]INC.4 OUTLETS OCC.GROUP, APN My Workcr ompenmf Incur ce carric Polly NoPolic,:noCAM 1OD � GAS-EA.SYSTEM-OVER 4(EA) / RTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (Thissection nod not be completed Will Permit is fnrone hundred dollars(S100) GREASE TRAP - orl<sxJ PLANCHECK FEE I cen]fy thin in the performance of the work for which obis permit is issued,I shall SEWER-SANITARY-STORM EA.200 PT. not employ any person in any manner w as no become subject o to Workeri Compete - ENERGY HE.. OZ cation laws of California.Dae WATER HEATER W/VENT/ELECTRDO 0 Applicant GRADING FEE [[[.�....J NOTICE.TO APPLICANT:IL after making this Cenifcam of Exemption,you should WATER SYSTEMTREATING a become uncina, be Worker's Comoemminn pmvisimnof the Lubar Code,you..at SOILS FEE W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE 0. Q UO CONSTRUCHONLENDING AGENCY agency NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receipt# Ihereby ichaffirm that then iso issued i30lending agency for me Performance.f LLI L-n the wok for which this permit is issued(Sec.309],Civ.CJ 1-" Leader's Noma Lenders Address TOTAL: 1 certify that I have read this application and state mm the above infomauon ie BUILDING FEC r7A correct.l agree to comply with all city and county ordinances and Stam laws relining to QTY. MECHANICAL PERMIT FEE U G building construction,and hereby aumorize representatives of this city to enter again the SEISMIC FEE above-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep hamlcse the City of Cupertino against ELECTRIC FEE ]iabiliues,judgmenoa,costs and expenses which mayinanywayaccmeagaimtsa]d City ALTER ORADDTOMECEL in emancipationof me granting ofmis permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000 CFM) MECHANICAL FEE SOURCE REGULATIONS, AIR HANDLING UNIT(OVER 10,001)CFM) - CONSTRUCTION TAX Signaturcof Appl{canoContmcuir Dae EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE 1 HAZARDOUS MATERIALS DISCLOSURE W]Ilme applinm urfame building occupant some orlorale huuNuus material HEATING UNIT CFO 100,000 BTU) os defined by the Cmpenino Municipal Gale,Chapter 9,12,and the Health and Safety Code.Section 25532m)7 HEATING UNIT(OVER Ilk,"BTU)- ❑Yes ❑No PAID , VENTILATION FAN]SINGLE RESID) pate t RecciptN Will the applicant or future building occupant use equipment or devices which BOILERCOMP(JHP OR 100,000 BTU) l haaatdous air contaminants as defined by the Buy Arc - Area Air Quality Management 1 tricr:r ! TOTAL. ❑Yea (]No BOILER-COMP(OVER 100,000 RTU) I have and the herardous materials rcquireari under Chapter 6.95 of to Cali. AIR CONDITIONER ISSUANCE DATE Bond.Health&Safety Code,Sections 25505,25533 and 25534.I undersmnd that if me NEW RESIDENTIAL MECH. SQ.PT. � '^ building l../ >rs naesa� M1 amnank thin it is my rcspmsibilioy mnmify the occupant _ ll of me be no w h must be - r prior to pamnce of a Co fcaI 1'�cu racy. ter or eumotizM agentme TOTAL ISSUED BY: OFFICE /