28976 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PBRMITNO. w
CITYBUILDING
CUPVISION I PLUMBING-MECHANICAL l89 16
puILDING nIVIS1oN APPI,ICATJON/PERMIT
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:S � G,� 6 z
9 � 125q.s
WN R'SNA F,: PHO .. CO C OO'S NAME ^L'C NO
Ni I CONTROL p
R ITECDENGWEE LIC NO: - AUDR 5:
r „62 ( S-
CONTACT; - 'PHONE: - _ BUILDING PERMIT INFO
EDConsultant Fees Paid by Applicant(Initial) - BLDG ELECT PLUMB h1E❑CH
L7 E:l El Ej
LICENSEDCONTRA o 'SDECLARATION QTY. ELECPRICPHRMIT FEE - JOB DESCRIPTION.
1 henhy affrot that I am license oder provisions of Chapmr 9(commencing
CXO
with Section 7000)af Division 3ofshe Business and Professions Code,and my license isPL'RMIT ISSUANCE - RESIDENTIAL:
W— m full foree end effect. ❑SFDWI. ❑KITCHEN REMODEL
�UIU License Class Lic.MAPPLIANCES-RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPE
�;QL Data Contracmr ❑MULTI-UNIT [:1 STRUCTURAL
Flv2y ARCHITECTS DECLARATION PANELS DEFECATION
SW,
X%4 I undersmntl my Plans shell be used as public recoNs
:.1Q UPTo?OU AMPS ❑INTERIOR HIMNEY REPAIR
LicensedProfesomal 201-1000AMPS IMPROVEMENT
GY ..•.]]]]l OWNER-BUILDER DECLARATION OVER IOWAMPS ❑BATH REMODEUREPAIR 0DEMOLITION
affirm C Q 1 hereby arm Nut I am exempt from the Contractor's License Law for the ❑OTHER
a 6 U following bacon.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL -
LL7 W which requires a permit to construct,alter,improve,demolish,or regain ony structure
EEO prior to its issuance,also uquircs the applicant for such perniuo rile v signed statement SPECIAL CIRCUIT/MISC.
ypN.. Nat he is licenud pvrsuanIto the provisions of the Contractors License Law(Chapter 9 OMMFR EAI:
Q<'E ourmnencingwith Section 7000)of Division ofthe Busineesand Pmfessions Csd0or TEMP.METER OR POLE INST.
yy M I that he is exempt therefrom and the basis for Nex
e alleged emption.Any smittinn of - El NEW BLDG/ADDITION ❑DEMOLITION
X` LE4 Section 7031.5 by any applicant for is pedgm subjects the-'Pliant t.is civil"try of POWER DEVICES ❑TENANT 0FOOD SERVICE
YFXy not more than five hundred dollars($50(o. SWIMMING POOL ELECTRIC IMPROVEMENT
F� ❑1,as owns,of the properly,or my employees with wages as their sole compensation, ❑OTHER
will do the work,and the immune is not intended or offered far sale(Sec.7044,Business OUTLETS-SWITCHES-FIXTURES
^ and Professions Code:The Commator s License Law does nos.,Ply in an owner of
G 3^ prelacy who builds in improves Hereon,aad who does such work himself or through NEW RESIDENTIAL ELECTR SQ ff..
his own however,
the
Provided that such mens is sold w ore tont intended or offered for S AREA SISQ.FT.
hese.w hemploy the building tat such imps is sold within one year de co r offered
the
mamm-builder will have the burden of proving that he did not build or improve for pur-
. TOTAL:,
01,as owner a
of the properly,.B exclusively contracting with licensed canueca s to
earswn the Project(Sec.V(M4,Business and rty ah.so,build,
Ctde:)The improve,
domed.
and
ecu Low does nmapply seen ith.re pmpeny wcenseddaeaimproves Hereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects wiNvcantrecwr(s)Iiceraed pursuwt.the Contractors
License Law. PERMIT ISSUANCE .
I am exempt made,Sec. .R&P C far this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION„
Owner poor—
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE SQ`
I hereby anion under penalty of perjury one of the following dec imitians:
l have and will meinin a CrAflaam of Consent.self-insure for Work,,',Croupier- _DRAINS-FLOOR,ROOF AREA,GOND. STORIES TY PE CONN I KUCTIOt
stub r,as Provided for by Section 3700 of the Lulxe Gate,fm the performance of the
weak far which this Permit is fssaed. FIXTURES-PIER TRAP f ,
I have end will maintain Worker's Compensation Inmmnce.as required by Sechom GAS-EA.SYSTEM-1 INC. 0IlTL. S
3700ofthe Lahm Coln forthe performvncenfthe work for which Nis permit is issued. OCC GROUP APN
My Worker's Campensidal lnaurence currier and Policy number are: GAS-EA.SYSTEM-OVE114(EA)
Carrier: Policy No.:
CERTIFICATE OP EXEMPTION PROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
or le J
(Thissecsionnecdnotbecompletedifthe Nn lisfor nnehundcd lI. SHID) GREASETRAP PLANCHECK ME
Icenifyihatin Neperformanceofth2lwrk fy lch shisp�i'tor i sued,l shot]' SEWER-SANITARY-STORM EA.200 FT, ENERGY FEE
nonemploy any Person in any manner sec at to' c ti ,bjecno thM1, ,%Compact- _
"Z train.Laws of California.Date WATER HEATER WNENTBLECfit GRADING FEE -
0 O Applicant
Z" p1 NOTICE TO APPLICANT.If Ber coif o Exemption,you should WATER SYSTEMOHIEATING SOILS ME
f-� become subject to the Worker. m tn s i n my the Labor Code,you must
Zs foohwith comply with such p oda shell he demand revoked. - WATER SERVICE //aa.
p' 0 CONSTR CI N LENDING AGENCY NEW RESIDENTIAL PLMB. 4�� Vf'le AID Dau ReceiptM -
IherebyuffinnNassherel sumetion lending agency for she perfornwnce of
IJ the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL:
Q U Lenders Name TOTAL:
Leader's Address - BUILDING FEE
a 1 certify that 1 have cad this application and state that the abuse information is
rah ca,rtctlegrcemcomply with all city and county ordinances and sum laws mlating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building consmuctomand hereby authorize representatives.fshis city to enter upon the
sh.vcm rtiened properly for inspection Purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree it save,indemnify and keep harmless the City
of Cupccino ng-inst
Iiabilitics,judgmems,costs and expenses which may,irony way accrue again I said City ALTER OR ADI]10 MECH. PLUMBING FEES
in consequence of the gunting.faux permit '
I 'APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL MON-PO T AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFEE
5 CE REGULA NS
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Sign reef ApplieenVCono tea
Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS D CLOSURE
Wdt the applicant or fuwre building swcupam seam.,handle hamNous materiel HEATING UNIT DO IW,"BTU)
'as defined by Be Cupertino Municipal Code.Chapter 9.12,and she Health and Safety HEATING UNIT(OVER 100,000 BTU)-
Cade,Session 2553200? PAID
❑Yes . ON. VFNTILATION FAN(SINGLE RESED)
Date Receipsp
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHPOR 100,000 BTU)
mit haaardaiu it eontaminums as&foal by the Bay Area Air Quality Management' TO
District? - - BOILER-COMP(OVER 100.000 BTU)
Dyes ON. ,
AIR CONDITIONER ISSUANC
1 have mad Ne M1auNom mmeri 55 5,2553 ane under .I and rmo t that
Coli- '
funds gdoes&Safetyt;uum Cafe.Stationsea mor Ends is my aM 255]4.1 on
Henri the NEW RESIDENTIAL MECH. SQ.PT.
building does mn is whk.y have a tenant,that n is- ms of Comfim notify the osculum
of @e sequiremenm whicM1 must be tun Prion.issuena of a Cmifcem of Omupancy.
Owner or authorized agent - Dam s TOTAL: ISSUED BY:
OFFICE