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28994 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /1 f1 (�/N /I BUILDING DIVISION APPI.ICA•I'ION/PERMIT PLUMB N;-MECHANICAL 2 8 9 9.1 4 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE Dee lws oni OWNER'S NAME: PHONE: CON" CI' JG LIC NO. O®ANCHIT[CfIENGINEIiR: LIC NO: ADDRESS: N/C CONTROL#❑ .. CONTACT: PHONE: // / BUILDING PERMIT INFO Y.C� _/�`SC� ❑ Consultant Fees Paid by Applicant(Initial) B,L,D_,G/ [CECT' PLUMB MECH �!`�'1). 777 U V R2 ❑ ❑ ❑ LICENSED COST RACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE 1 hereby error,that].at Eccnad ander pow,f,e..of chapter 9(cammencmg JOB DESCRIPTION wOZ withlical r70W) fDivision 3 0111 liusinus and ProfessinnsC ,nnJ my license es E D I �uu1-u u in full force nn ae I'IiNMIT ISSUANCE. FDWI. ❑KITCHEN REMODEL .19 . o2Gs3a P z w License I' p ❑ADDITION ❑PLUMBING RE-PIPE FZ41 Uatc swCanvacto APPLIANCES-RESIDENTIAL IN,apy ARCfIITECPS DEC RATION t /nla an PANELS El MULTI-UNIT ❑STRUCTURAL Z p h Z I understand my plans shall be used az public records MODIFICATION O Z- UPTO 200 AMPS ,� F 4 f'w Licensed Professional ❑INTERIOR jrpi HIMNEY REPAIR aia: OWNER-BUILDER DECLARATION 201-IIX11)AMPS IMPROVEMENT 6 I hereby affirm that 1 am exempt from the Commanr's License Law for the OVER I000AMPS ❑BATH REMODEL/REPAIR DEMOLITION 3 LLF following reason.(Statin.7031.5,13almaol and Pndessions CMc:Any city or county SIGNS ELECTRICAL ❑OTHER which regmms a permit m ainsfruet,alive impmvc,demolish,or repair any structure ���� pnorro its Alone,al xo relaias the applad,fnrcuch permiun file asigneal statement SPECIAL CIRCUIT/M1SC. ppgg rLL1�i1�Y than he is licensed......intame pro,....Ovofthe Contmemrs Licence Law(Chapter 9 (yC�� (commencing with Section 9(KKI)ot'Division 3 ofthe Business and Professions Codt)m TENURMEfERORPOLEINST. OMM RCI E E:c m that he is exempt therefrom and the basis for the allege)exemption.Any violation of ❑NEW BLDG/ADDITION tea• Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑DEMOLITION at more than Five hundred dollari S500j. ❑TENANT ❑FOOD SERVICE �Sp ❑ Las ownerofrhe property,tem myemployces arm wagesar their.decompensaion SWIMMING POOL ELECTRIC IMPROVEMENT tl•p.o will dothework,and mestmcma is not intended oroffered for sale(Sec.THO,Business ❑OTHER Wand Professions Code:'File Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES IL properly who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC'IR SQ LT. ,.Its If.however,he buildingnr improvement issold witbin o.nyetraf mmplcuon,the SQ.FT.FLOOR AREA $/SQ.FF, cr-builder will have flit harden of proving that he did not indoor improve fuaar- p ons samawe.) . - ❑1,as owner of the progeny,am exclusively contracting with licensed contractors to TOTAL: AI�p 2 2 1996 amnhual rhe project(Sec.70,14. Professions 14.Business and Cale:)The Cantrettnr's Li- APR cease law does not apply to an ons of property who builds or improvesrhemon.and QTY. PLUMBING PERMI PE wn who<onhazufor such pmjecss wimamnuacmrts)licensed pursuant to the Cnntmctors License Law. C'N1 of uu iCnIIIs`V \ 1 C]1 am exempt under Sec. ,R&P C for oris reason RMIT ISSUANCE Owner Dec ALTER-DRAIN&VENT-WIT E (FA VALUATION WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICIi � ('% -� I hereby alBnn under pmarlty of perjury one of the fallowing drularmiod.s J LJ ❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compact- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONS'I'RUCI'ION satioo,as provided for by Section 371X1 of the Labor Gds for the Performance of the work far Lh this permit is issued. IEX'I'URES-PER TRAP I o e lord will moiaminWorker's Compensation Insurance,as required by Section fthe Labor Code,far t'he�jo6rownce of rhe work for which this pemtitgis issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN My---xrkf111prtlppaiat�pr ncc carrier and Policy Mmhetnd33/a� Carrier:' O Policyolicy k•�xe GAS-EA.SYSTEM-OVER 4(Eq) CERTIFICATE OP EXEMPTION MGM WORKERS' COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION LTi&S (This section need not be can.Orlard inhe permif is ounce hundred dollars S1NP - orlese:) GREASE TRAP PLANCIIECK PEE Loy mymntinthe perfonnne,an t bework became subject bjech thiI Permitisissuca, per- SEWER-SANITARY-STORM EA.NX)FT. nm employ any person in any senses m m m become subject m the Workers Comped- ENERGY FEE Z sation laws of California.Dec Z O A licant WATER HEATER WNFiNT/ELECfR PP GRADING FEE NOTICE TO APPLICANT. rvatommaking this Certificate of Exemption,yen should WATER SYSTEMlIREATING becomes comp y the worker's Compton this provisions of the lafvt Gde,you must SOILS FEE forthwith comply with such provisions or permit shall he JeenaJ rcvokcd. WATER SERVICE as Q CONS'I'RUCI]ON LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.ET PAID U 0 thereby alEnn that there is a consouetian landing agency far the pedimnance of Date Receipt# the work It,,which his permit Ix moral(Sea 3091,Civ.C.) '] Lender's Name TOTAL: LJ Lando,Addcss TOTAL: I}" a 1 certify has 1 have read this application and eta¢that he above information is BUILDING FEE Z? correct.I agree to comply with all city and county andinances and state laws relating to QTY. MECHANICAL PERMIT FEE ZZ0 L) Z building information.and hereby authorize represcounives ofthis city to contraband the SEISMIC FEE aboveomemiand property for inspection purposes. a) Wc ( goes to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FF;F. liah#IR Igmena,costs and expenses which may in anyway acerae againslood City ALTERORADDTOMECIF r in cfrhe gramingo this permit. PLUMBING FEE A I' T ON .1' A W OMP LTH ALi,NON-POINT AIR HANDLING UNIT(TO IONX)CFM) SO T�,A'T S MECHANICAL Fiil$ /-.??-76 AIR HANDLING UNIT(OVER 10,M)CFM) CONSTRUCTION TAX Signature of Applican/Contwtor / Dam EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE, Will the applicant or future building occupant sore or handle hinumbus material HEATING UNIT CFO 100,000 BTU) as defined by he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532FIF1HEATING UNIT(OVER 1100.1000 BTU) ❑Yes kevd/ PAID VENTILATION FAN(SINGLE RESID) Data Receipt It Will he an comm Or ratan h.ifi 1, he B use equipment tem devices which Di"n"mrtlnm'air mmaminanlx ax Jctinnl by slit Hay Acott Air Onulhy Management BOILER-COME(JHP OR I(X),fXXI IF]GO DistricYl TOTAL'. ❑Vas NO' BOILER-COME(OVER IWJNI)BTU) 1 have read he hazudous materials requiamems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE forma Heal 4 Safety Calc,Sanious 25505.25533 mJ SSR.1 undermad Onto if me NEW RESIDENTIAL MECH. SQ.ET. brig nm curtendy havcarcwnt,than. ponsibilisymnmifyheoccuital of he nus w) u�lur (pm/mi- sofa Ccrtiftc •y[( upaagv� Owner or nuhnntad agent // 77 dd Dam// TOTAL: ISSUED BY: OFFICE