28912 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY
BUILDING DIVISION AIPLICATIONPERMIf PLUMBING-MECHANICAL
PERMR NO.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICA'T'ION SUBMITTAL PATH
rritila /Z 1-0-Z$�?
OWNER'. NAM PHONE: CONTRACTOR'S NAME: ''II LIC NO:
O fj6xNt x✓Cf O A I!✓Mslk,s?y NIC CONTROL
ARCHITECT/E11INEEH: LIC NO: AUUNE55, ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) Be ELECT L Me MECl1
LICENSED CONTRACT OR'S DECLARATION QTY. ELECTRIC PERMIT TLE ElPF ❑
I hereby afar that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
WON with Salirn7W0)PTDivisinn 3nRhe Busines�oml Pmressions Cole.vnd mylicense6 RESIDENTIAL:
WON p PLRMIT ISSUANCE
go IyF arifirliforceiLicense
deflect. ❑SFDWL ❑KITCHEN REMODEL
<—U Liunu Clva Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGR&PIPE
FF Z m Date Commcmr
N6a gµCII1T1iCT5 DECLARATION, ❑MULTI-UNIT ❑STRUCTURAL
y PANELS
Z v�Z 1 endcrnand my plans shall be used as public recallsx� MODIFICATION
Oz—p UP T0210 AMPS �J INTERIOR ❑CHIMNEY REPAIR
(=�2LM Licensed Professional 201-110UAMPS IMPROVEMENT
OWNER BUILDER DECLARATION Cl RATE REMODEIIREPAIR El DEMOLITION
C M 6I hereby affirm Thal I am exempt from the Contractors License Law for the OVER IWOAMPS
i❑ e.U following reavm.(Seeman 703 1.5,Business Cad P...fi iana Code:Any oily Or county SIGNS Ii1ECIRICAL ❑OTHERR .���
IB 3 p•NQ which tegmina a permit ,,cun.aruii,cher,Improve,demolish,or repair any siructure 0 J+C�CJC/t/ (.L/�-_In_1 L
priors,its issuance,alsorepaires the applicant for.such Permit to do u signed statement SPECIALCIRCUIT/MISC.
Ey }•.1 @athe is licensed larsu rd m the premans ofthe Contracmr's License law(Chapter9
I+1�C0� nmmencing with Section BX(Bof Division 3u fine BmineOrmal Pndessiors Code)Or TEMP.METER OR POLE INST COMMERCIAL:
a a p¢ that he is exempt mereftvm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W N Section 7031.5 by any applicant for a permit subjects the applicant s,a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t mare man Ere hundred dollars(3500). IMPROVEMENT
C�Q I,as owner ofthe normemployees with wu es as their sole compensation, SWIMMING POO[.ELECTRIC
❑ prose Y Y6 .coca
W�G wdldmhewons Codec intended License La dos or apply
Bunions ❑OTHER
W m ell Professions Code:no Contractors License Law Joos oat apply m an owner of OUTLETS-SWITCHES-FIXTURES
d 3 property who builds or improves thereon,and who does such work himself or through
his own employees.provided that such improvements no not intended or offered for NEW RESIDENTIAL ELECTR SO FT.
sale.IL however,the building or improvement is sold within ane yearof completian,the SQ.FT.FLOOR AREA VSQ.Pf.
er-bullde,will have the harden of proving that he did not build or improve for per-
posr of'.1c.).
C]L
Las owner of the property,am exclusively contracting with licensed cnmrrs 1.acmTOTAL:
construct the project(Sec.7044.Business and Professions Code:)no Comerears Li.
Often,law does not apply to an owner of property,who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contractors)licensed pursuant o the Contractor's
License Law. PERMG'ISSUANCE 3Z, 0
❑Iain exempt under Sea ,B&PC foss
mhisreon
ALTER-DRAIN&VENT-WATER ESA) qs VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ' i
1 hereby affirm under Penalty of perjury one ofthe following declarations: J
❑ [have and will maintain a Certificate of Consent toself-insure for Worker's Confer- DRAINS-FLOOR.BOOR AREA.GOND. S'1'ON1E5 TYPE CONSTRUCTION
smion,to Provided for by Seaton 3700 Of the Labor Code,for the perl'enearoc of the
rk for which this peril is issued. FIXTURES-PER TRAP I
I have and will maintain Workers Compensation Insurance,as required by Section
37M of the labor Code,for the perbamatice of the work for which this pormit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APES
My Win ix C' pensauon ln_ance comer and Policy C
Cartier: Policy No.:to f'$/D/ /5l6 GAS-EA.SYSTEM-OVF:H 4IEA)
CEI I KATE OF EXEMPT ION FROM WORKERS' GRIiASI%INUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ITES
(This section need not be romplarA if the porn is nehundmd tllso(slyn GREASE?TRAP
m less.) PIANCHECK FEE
Icertifymminmrpetforanceo ark Rn wh,ehthis Peritisi sue4lsM1all SEWER-SANITARY-STORM EA.200 FT.
not employ any Pe sat as ro become nubjen as IM1e Nark rs'Co.,... ENERGY FEE
zz cation Laws Of C domia.Dwa WATER IH:AMR WNENT/ELEC`M
� Applicant GRADING PEE
y NOTICE'IO PLICANT.IL'from making Ills Ctmilleme of Exempt m,you should WATER SYSTEM/IREATING
?
tor
subj tome Worker's Compensation Provisions of me Lahr ale,You must SOILS ITE
CX (it Our on i plywie such pmsisionsmthis peril shall be deemed voked. WATER SERVICE
5z CONSI RU ION Lft4DING AGENCY NEW RESIDENTIAL TEND. SQ.FT. PAID
Ih els, irthathereisns s lion lending agency for eperforancoul' Date Receipt#
U the work) rwhi I this r is ec 097,Civ
P 1 )
It' I"' Lender's.as TOTAL:
]0 U Lender's dl' 111wTOTAL: ^•��
p 1 xnify t 1 have is plieamu rad stat v ave informto.is ��, BUILDING FEE 7
faA cortex. agree tae -ply wi IC andco nances and nam lawsrelatingw QTY MECHANICAL PERMIT FEF. SEISMIC FEE
J Z mildin corms n and he sumo epreunntmives afthis city to enter upon the SO
above-t colioned property lbr ins , na purposes. PIiRMI'f ISSUANCE
We)agree to save,i mify and keep hamdess the City of Cupertino against ELECTRIC FEE
Imbiliti s,judgments, undexpenses which may inmyway.enroagvnn said City ALTERORADDTOMECIL
PLUMBING FEE
in con 0 a granting of this Permit. s !J
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL HON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
02OULATIDNS. MECHANICAL FEE
SOUR
w� / Dald� EXHAUST HOOD(W/DUCTAIR HANDLING UNI'l ) IgIKKI CFM) CONS'I'RUMIONTAX
Si nature of AP nVCommctor HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WI the applicant or future building accupint store or handle hemNous mutual HEATING UNIT(TO 100,00 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)^ HEATING UNIT(OVER 100 000 BTU)
[-1 Yet No VENTILATION FAN(SINGLE RESID) PAID bovoil3�
Will the dpplicanl or fmure building occupant me egoipmem or devices whichOCT 2 e9 TA95
•emit hatumbous air comamon - (3
inls as defined by the Bay Area Air Quality Management BOILER COMP HP OR 100,000 BTU) TOTAL:
District? / os
BOILER-COMP(OVER IIO.(MM)BTU)
❑Yes No �r .... ..� I...�i
I have read the Intonations materials requirements under Chapter 6,95 of the Cali- AIR Cl1NUi'1'IONF.R ISSUANCEDATI? {/^x
forma Ileahh&Safety Cook.Sections 25505,M533 and 8534.I undcumn l that if the NEW RESIDENTIAL MECH. SQ.FT.
building does nor urrently have a serum,and it is my rnpomibility to ratify the occupant
of do,requlmtoems which must be inn prior to issuance of a Certificate of Occupancy. )012-
-
Owner or aumoried agent Date TOTAL: ISSUED BY.1 RJP I�/A.TeA+I�CCr
OFFICE