28548 (2) r APPLICANT,TOFFILL IN INFORMATION WITHINIRED LINES-USE BALL POINT PEN ONLY t. -
iJ CITY OF CUPERTINO t " BUILDING.ELECTRICAL,
,. - Y PMMrr NO.
APPLICATION/PERMIT PLUMBING.MECHANICALBUILDINGDIVISION BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS SANITARY NO, APPLICATION O,^L
N SUBMITTAL DVaXA,aT
E
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O OR5mNAME: `�S b_NAME. gU v CONTRACTOR O I S NAME: L_rt•rw'� LIC NO:.. .
' ARCHITECT/ENGINEER:, -LIC NO C11V 1/ S s NTRO
N/C CO L q
•,
CONTACT l PHONE - BUILDING PERMIT INFO
E] Consultant Consultant Fees Paid by Applicant(Initiap BLDG ELECT PLUMB MECH
^^- LICENSEDCONTRACTORSDECLARATION - - QTY. ELECTRIC PERMIT PEE
I hereby affirm Net 1 am licensed unit Provisions of Chapter 9(ommenc ng. JOB DESCRIPTION
oZwithSection7")ofDivismn3oftheBusnessandProfessionCdcandefyfoa i RFSIDFNTIAC•
f••, O PERMIT ISSUANCE 1. - •�
U0 mfallf and ott
UZ S: Line a �+ Lu:'x e' ,`Lo.CIOP7 ❑SFDWL ❑KITCHEN REMODEL
,�Q Dete Contmat -y3ftHL '� •APPLIANCES, RESIDENTTAL; - 11,ADDITION - 11 PLUMBING RE-PIPE'
g,D rn ARCHITECTS DECLARATION PANELS 0 MULTI UNIT ❑STRUCTURAL
OZ n 4 I l lad y plass shall be used as public records - ' � • MODIFICATION '
�F.,�.�j LOi] LKe dPrre6sa I • UPT0200AMP5 ❑INTERIOR ' CHIMNEY REPAIR
DI?Cgj,CY C2G!a•1
OWNER-BUILDER DECLARATION 201=1(100AMP5 a IMPROVEMENT: '
41 O V I hereby firm that 1 am exempt from the Can matters Lice a Law f the OVER 10(10 AMPS ❑BATH REMODEVREPAIR U DEMOLITION:
tL falli mg re (Scamp 7031 3 Business and Pr f Cade Any city or county
SIGNS ELECTRICAL ❑OTHER
WO Iya'•' which req permit m criminal.slur imP demolish,lish o repairyshowman, _ ,.n H ^ ^ A
y.] priorro[ ce,also req N applicant for hPermit t fide signed tat nt ,A SPECIAL CIRCUIT/,MISC
Nat he is licensed pursuant tthe pro i.ionm ofth Contractor's License Law(Chapter 9
�sN pO (commencing wit Section 7000)of Division 3 of the Business and Professions Code) r s TEMP.METER OR POLE INST. ' - vCOMMERCIALC -
L e Nat he is exempt Nerefro and are basis for the alleged exempt on Any vmlation of
B
Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVI - D NEW BLDG/ADDITION [I DEMOLITION 4"
[[t[rimr yyyy�. not mare than five hundred dollars(S5 W) ❑TENANT i Cl FOOD SERVICE
Q ❑I,ea owner of the property,or my employe th wageaasN l compensation, SWIMMING CTRIG.; " - IMPROVEMENT 'r •,
will do the worUand the structure is mainte ded oroffered for side(Sec 70,k Bus ss h ❑OTHER
and Professions Code The Commerce.License Law does not apply to an owner of OUTLETS-SIH URPS
Property who builds or improves Nereow,and who does such work himself or through TC _his own employees,provided Nm such improvements are not intended or offered for .NEW RESIDENTIA ECT 'ISQ FT. -< -
sale.If.however the building crimpravernent is sold within..- roof completion,the ,. SQ.FT.FLOOR AREA 1 $/SQ.IT.
owner-builder will have the burden of proving that he did not build a improve for par- '
pose of sale.). ' 1 -TWA .
❑L as owner of the property,sm eeclueively comraming wiN licensed convecrors to a
oustmct the,project(Sec.7044,Business and Professions Code:)The Contractor's Li-
r
ir cense Law does not apply to an owner of property who builds or improves thereon,and QTy. PLUMBING PERMIT FEE
who coumacu for such Projects with a conractor(s)licensed purmaauothe Conusmors
" License Law., L -PERMIT ISSUANCE
I am exempt under Sec.' ,B&P C for this reason, `y
Owner Oa¢ ALTER-GRAIN&VFW-WATER(EA) ~ 'VALUATIONS.
tt
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE t
I hereby affirm under penalty of perjory one of the following orker'tmns - . !•J _
• ❑Ihave and willfor by
neCion ficide370 ofComent to Labor Cod msarefar Workersce of the
' " DRAINS-FLOOR,ROOP,AREA,COND. ^
setion was Provided for 6 Section JIDO of the Labor Code,for the STORIES TYPE CONSTRUCTION
prove y performance of the
work for which this pennn is issued '' :. i FIXTURES=PER TRAP
have and will maintain Worker's Compensation Ins ranee as required by Sectio
n *'
3] of the tabor Code,fonhe performanc fthe work for wh hN' permit is Issued. GAS EA.SYSTEM-I INC4OUT1LETS OCC GROUP . .APN .
My War s m e emon umnce tamer and Policy p�iube -
Cemer�
Policy No.:TO 300IX'�A�L _ GAS-EA.SYSTEM-OVER 4(EA) ^^
CE IFICATE OF EXEMPTIONFROM WORKERS' " ^ ' '
t l COMPENSATION INSURANCE,: GREASE/INDUSTRL_WASTE INTERCEPTOR' BUILDING DIVISION FEES
(Thio section need not be completed lfibe permit is for one hundred dollars I$Hall pRBASE TRAP -
orlessJ 1' PLANCHECK FEE
I certify that in the performancu of Ne work for which this permit is issued Ishall -
nitsem to an SEWER-SANITARY-STORM EA.200 FT.,
p y y person m any manna so as to become suhjecuo Ne Workers Compen - ENERGY FEE
sntion Laws of California Data
. O�Z' Applicant - � WATER HEATER WNENT/ELECfR � � -
. O NOTICiii •• GRADING PEE." ,
NOTICE bj APPLICANT rs-after making n p v Certificate f Exemption,you should WATER SYSTEM/fREATTNG.'
become subject oro it Workers Compensation p ov ons of Ne meed,Code,you most IFEE
,
fix y
forthwith comply with such provisions or this pemdl shall he deemed revoked. x v WpTFR SERVICE
W
Q
J
z' S by CONSTRUCTION LENDING AGENCY , NEW R65IDENTIAL PCMB';, ` SQ.FT.
VQ. I fWwhafRrm lhenhere ssnmsvucmnlendmg agency fonhe Performance f - Receep[x
0 N Nowork for wh ch Nisp 't issued(So..3097Co,C) - r`JLender Name _ ors ., .,. TOTAL
Le d Add - + i '.TOTAL:I n fy Nat I ha e e d N applic t and tate Nat Ne above int rmat y commas.l agrc t c ply ith 11 ity and act,aril r ces d t t I olei ng m QTY. MECHANICAL PERMIT tI V build gconstruction,and hereby authorize repres tatives of Nes city ro enter upon Ne above-memioned property for impaction purposes. + - PERMIT ISSUANCE(We)agree to save,indemnify and keep hemdess Ne City of Cupertino'micat lisbiliticajudgments,costs and expanses which may in any way accoeagainss said City' ALTER OR ADDTO MECH,in consequence of the granting ofIbis permit.'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) - MECHANICAL
SOI
UE EGULA'I mse
_ AIR HANDLING UNIT(OVER 10.00)CFM) ;
1(��µJ. CONSTRUCTION TA
SignaturemApplicantaCongractin -'• �D�Ie EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future balding occupant store orhandle hazardous maort.11. T HEATING UNIT(TO I0g000 BTU) Ti(
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code Section 255J2piEJJ �• HEATING UNIT(OVER,100,000 BTU) t
❑Yes- �Nri . ..rc.
VENTLLATLONFAN(SINGLE RESLD)- I PAID'
„ Will the applicant or faun building occupant use equipment or devices which - Date Receipt is
emit hazardous air consam'nants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HPOR 100,(100 BTU) ,
District ' - ,x TOTAL:
BT
BOILER-COMP(OVER 100,000 U
C1 Ye a a No -
_ I have read the lainadmas mammals - AIR CONDITIONER
req re t d Chapter fi 95 of Cal ISSUANCE DATE
forma HealN&Safety Cod Sections 25505 25513 d 25534 I ndmtand that
f N - NEW RESIDENTIALMECH { SQ4 FT -
buildfic,drasiot comeraW have.owns,that it is my.,asibilily to notify the occupant,
of requ m h ust met prloru s eo_fa Cemflcaf PancIf
y, ( B
411 o r,
' at
mautharizN agent
Data TOTAL:, Q• , - ISSUED BY:
OFFICE
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