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28553 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, BUILDING DIVISIQN APPLICATION/PERMIT PLUMBING-MECHANICAL ' BUILDING PROJECT IDENTIFICATION 28553 BUILDINGADDRESS: - 4SANITARYNO. APPLICATION SUBMITTALDATE 2 llt � SOWN 'S AME: PHp4ry\E: .CONTRA OR'S NAME: LIC NO:O b V xN/C NTROLRCHITECT/E GINEM: LlCbbbbNO: ADDRES CONTACT: PHONE: '- BUILDING PERMIT INFO Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MECH ED El ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby arm 1 am bcemea under provisions of chapter 9(commencing t JOB DESCRIPTION r �0o�z with Section70pfficuf Division 3ofthe AusinessandProfessionaCede,andimylicense is RESIDENTIAL: 0 PERMIT ISSUANCE - m full force and effect ElSFDWL ❑KITCHEN REMODEL FDz%U License Class Lic.# APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE Dale Contractor Y ARCHITECTS DECLARATION PANELS - []MULTI-UNIT []STRUCTURAL z O m C 1 understand my plans shall be used as public records - MODIFICATION O z ccc4c....,CCCCIII1 UP TO 200 AMPS * ❑INTERIOR ❑CHIMNEY REPAIR F4 l+; Licensed Professional 201-11XKAMPS IMPROVEMENT ' 3a OWNER-BUILDER DECLARATION OVER IOW AMPS El BATH REM DEVREPAIR DEMOLITION ' 1 thereby affirm that I am exempt from the Contractors License Law for the U following reason.(Section 7031.5,Business and Professions Cole:Any city or countySIGNS ELF.CTRICAI. �. El su WO ,which requires a Permit to construct,alcor,improve,demolish,or or repair any sure prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. r than he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9 Yom. aIr (commencing with Section 7")of Division 3 ofthe Business and Professions Circle, TEMP.METER OR POLE(NST. 'COMMERCIAL, mq IMC mm he is exempt merefrom and me basis far me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION p�m IL Section 7031.5 by any applicant for a Is, it snbj rs the epplicam to a civil penalty of, POWER DEVICES IIkYY...11,, El FOOD SERVICE >. (c noturemanfivehundreddollars(83 J. IMPROVEMENT q 6 ❑1,as owner of t property,or my if ve th wages as their sale compensation, SWIMMING POOL ELECTRIC wdldothewmkan theswctur sit 'n offVvcUharsale(Sec.7044,Busimca []OTHER �m and Profession t e ata does not apply to an owner of OUTLETS—SWITCHES•—FIXTURES popeny wno to t cation,and who does such w e f or through his own employeea vided Net such improvements are not r a''ered for NEW RESIDENTIAL ELECTR SQ FT. _ sale.If,however th bo lding iprove eye`ofc pletion,the SQ.FT.FLOORAREA t,t VSQ.FT owner-builder will av the bu de f pro a di in buil prove for put. se of sale.). r� TOTAL: ^ ❑I,tia the rrJec,lf IS coy, exaively contracting Code:) hliceno Contractors �, consortia the project(Sec.7 ,Business end ny who ds or i The Conaetmn',Li- woscLawdoes notchapply to rojean owner ofproperty who buildsorimproves thereon,and QTY PLUMBING PERMIT FEE ,. who contraeanfori such projects with acrmramnr(s)licensed pursuant to the Cnntmemrs License Law. PERMIT ISSUANCE 1 am exempt under Sec. ,B&P C fortis reason Owner Dam ALTER—DRAIN&VENT—WATER(EA) - VALUATIO� WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby,affirm under Penalty of perjury ane of the following deelar tions: F1I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION satlon,as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this permit is issued. FIXTURES—PER TRAP „ El I have and will maintain Worker's Compensation Insurance,as required by Section 37M of be LuberCode.for the Performance of the work for which this Permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP - APN My Wu,ke mpey5 not�Insurnnce corset and Policy number are: - Cartier: Y,rf<(,1tn� Policy No.: 114, 460 9 GAS-EA.SYSTEM-OVER4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISIONFERS ('(Lie taction need not becomplued ifthe permlais forum huntlred dollars($1W) GREASE TRAP or less) - PLANCHECK FEE' I trolly that in me performance of the work for which this Permit is issued,I shall SEWER—SANITARY—STORM EA.200 F1. not employ any person in any manner so as to becomesubject subjeco the Workers'Contain- ENERGY FEE z cation Laws of California.Dine WATER HEATER WNENT/ELECTR Applicant GRADING FEE • Fi y NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMO REATING , abecome subjeet to the Workers Compensation praccu ns of me Labor Code,you must. SOUS FEE W forthwith comply with such provisions in this permit shall M deemedrevoked. WATER SERVICE a Q 'Z - CONSTRUCTION acwONLENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID - � (hereby affirm mat there isonsetion lending agency for the performance of Date Receipt# the weak for which this Permit is issued(See.3097,Civ.C.) Lender's Name - _ TOTAL: W Leader's Address TOTAL: l}, I certify that Union read this application and smte Inside above information is BUILDING FEE u&n correct.I agree to'comply with all city ad county ordinances and can laws relining to QTY. MECHANICAL PERMIT FEE V 4 building construction,and hereby authorize representatives of this city to enter opium the SEISMIC FEL• above-mentioned property for inspection purposes, PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. nsequenaUE e ming of mss permit PLUMBING FEE APPLICAN' TANDSANDWII COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)' MECHANICAL FEE SOURCE RIIO. '. 11``� K j�� C AIR HANDLING UNIT(OVER I0JXk CFM) CONSTRUCTION TAX Signatures AppLcarmCon ^ ✓✓" ` Date LJ EXHAUST HOOD OMMUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I W.tH"BTU) as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health end Safety Code,Section 25532(a)? _ HEATING UNIT(OVER 100,000 BTU) ❑Yea ❑No ' - PAID " VENTILATION FAN(SINGLE RESID) Dam Receipt If Will the applicant or future building occupant use equipment or devices which - - emit hicandeas air contaminants as defeed by the Bay Area Air Quality Management BOILER—COME CHP OR IOf,"BTU) TOTAL: District' ❑Yes [IN. BOILER COME(OVER 100,000 BTU) ^ - � ,-' I have read the limitations materials requirements under Chapter 6.93 of the AIR CONDITIONER Celi- /ry ISSlffAAATF • foods Health&Safety Code,Sections 25505,25533 end 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.FT. building does oratorically have a tenant,that it is my responsibility to notify the occupant. i f me requireme ata which most he inn prior to irw ante of a Cetifiate of Occupancy. Owner or authorized agent Date, TGTnI: ISSUED OFFICE _ --1. 'may-.��•�� •� ♦_� i � ♦ ��`/�� /� _ C ti �~� r�+� `�� t ` � /�Ar����Y[ � � i .�. �:� © - �%; i ��;�� _ � � �... , , � � a _ . ..A .� ��� � I �7' ���.ai � I �j' r _ � S � ' C- - �� � - ■� ' -=�/ � A , , d �si ��,_d► N _ __ . �'.l�l �-,3,Q'� - � �� � � � pier='e � .� Z � .I r� � � �_ LL A � � m �` �� .���, 0 v v� � �� ti � 70 y !v X o 0 o c G Pi Z `l x 6 �fGSv JrC �rrc4t-Si, .[ d Q Q •pr G .. '`� •f` o Co e e .e �o . � coo pec n • o e e o e c ' 1 - S A • T oO�pO�oa�CfnG I o0 0 oQc� ecr.�� 1 I 00 i K . p ira �2 Q J Z � fai