28735 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. .,
BUILDING PROJECT IDENTIFICATION 28735
BUILDING ADDRESS: _ SANITARY NO. APPLICA11ON SUBMITTAL DATE
OW R'S NAME: I'HO CDNTRACL�lxE: LI ANO.
�/.J-Lt 1 T-L NIC CONTROLp
on ❑
ARCHITELTIENGINIiUR: LIC NO. ADDRESS:.J ' W zl 57,a n Aaz, O Ql�`I
CONTACT': PHONE: •J BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPL MB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby animation I an,licensed carer provision.of Chapter 9(eca meacmg JOB DESCRIPTION
w0Z with Section]IX)0)o(Division3nfNe Business antl Professions Crater and my license is RESIDENTIAL
F�� in PollforeeandeQem. PER ISSUANCE —�—�
Leense Class Lic.N ❑SFDWL ❑KITCHEN REMODEL
APTLIANC.. -RESiDEN'I'IA1.
Qa Dme Contractor ❑ADDITION ]0 STRUCTURAL L PIPE„
F-7tyn ARCHITECTS DECLARATION PANELS ❑MUI.I'I-UNIT ❑STRUCTURAL
Z O sn C [understood an, 1..,,h.11 he used us public records MODIFICATION
oz—, I DPT0200AMPS ' El INTERIOR [I CHIMNEY REPAIR
rawFCm licensed Preficasonul 20LI(XIOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
1 hereby affirm that 1 am exempt from the Contractors License aw for the
ippi5$,�O y U fallowing reason.(Sa,inn 9031.5,❑usinea and Professions Gde:Any ty nr cdumy SIGNS ELECTRICAL ❑OTHER
us'3 d'E' which rcqulrcs a permit to cnnnma alma improve,demolish.or rep r any stmewre
F'�O prior to its issuance,also«quires the applicant for such Permian fil- signedsmament SE'1:914 CIRCUIT
mm he is licensed pursuant to the provisions of the Contractors C core Law(Chapter 9
00 (m,mmenaing with Section]OfNO of Division7ofrhe Businass an ProaWons Codaca- TCM . 7R OR .til T 'COMMERCIAL:
a e C
that he is exempt therefrom and the basis for the alleged extra ion,Any violation of ❑NEW BLDG/ADDITION ❑DP.MOLMON
Section 7031.5 by any apploom for o permit suhjttu the applied l to a civil penalty of PO ER EVICES
—Y ❑TENANT ❑FOOD SERVICE
not moa than five hundred dollars($500). IMPROVEMENT
i*I do has cawnm of the property,rr my empinycu wim wages as that salecotnpmmmion, MI OO.P.LF.CI'kl
Sf. and do fie sions Code
d e The ont is tors License La does n,a 'm or
whereof ❑OTHER
W and Professions Code:The Contractors License Law dos no,ep man owner of 'I TS�SWITCHILS-P URES
6 3^ property who builds or'unprows thrown,and who docs such work It nself or through
his own employees,pnrvidM Ilial such improvements me not intende or otTercd for )UN'I'IAl.Ii1,13CT SQ FT,
w1e.If,however.me building or improvement is sold within am ple,ian,the SQ.FI'.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or imp ve for pur-
poseofeulcJ.
❑ I,asowneroftheproperty,.Bexclusively Profession,
with licensed cool cratem TOTAL:
' answer the project(Sec.]f44,Business add Professions CadcJ The Conwc rk Li�
cense law does not apply to an owner of property,who builds orimpmvea. -a and Q1 Y. PLUMB! GPERMIT FEE NOV
who wormers for such projects with.wmanor(s)Ilcen.od purwunuolhe Gniwc rs LOY
License Lew. PERM IT ISS UANCE t X995
El Iameumptoader Sec. ,B&PCfonhisraeVr
Owner Dam ALTER-DRAIN VENT-WATER(EA) kill ( lir VALUATION
WORKER'S COMPENSATION DUACK FLOWOTECT,DEVICE
CI.ARATION �UT'Cn I inn
1 hereby affimt under penally of perjury one of the following de Worker's
or
❑!have and will maintainaction 37Mficau,of Consenter self-in sure for Worker'sce of the
DRAINS-FLOOR,R001',AREA,COND. STORIIS, TYPE CONS]'RUCTION
woirk for
whichthis
for mi Section 3700 of the Laker Cale,for the performance of the
work far which tiispintain issues, 9 FIXTURES-1'F3R TRAP
❑I have and will maintain Workers amcc ofthe w Insurance,as required by Section
- 3700of the labor Cade,for the performance of ran work far which this permit is issued, GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP APN
My Wmkcde Corypenawian hour n n carrier and Policy9.5
Cartier, l3*��±_ � Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASMNDUSTRL WASTE INTERCEPTOR BUHrUING DIVISION FEES r
(This scclimroced not be completed i l'me permit is for one hundred dollncs(S 100) GREASETRAP
nr less.7 PLANCI3ECK FEE
I certify that in the Performance ofthe work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so ars m become subject to the Workeri Cmnpen- ENERGY FEE
7i salon L.wsof Callfnrnia Data
ZO Applicant WKfCRHEATCR W/VRN1'/ GC R GRADING FEE
.Ni NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEM/IREA'I'ING
a ' become adflect to the Workers Cnmpateou a provisions of the Labor Coale,you marl SOILS FEE
{kl forthwith comply with such provisions or permit shall be damed revoked. WATER SCID/ICE
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
U O thereby affirm that is a conswction lending agency for the performance of Date Receipt#
{L N the work for which this permit is i...ad(Sec.309].Civ.C.)
O U Lenders Name atft-6 TOTAL:
LkI larders Address 1
[}.,t I ceniCy Thor have mud This upPlirntim,liar atom that,he uhnva lnfcavnmion is BUILDING FEE
UV) coven.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICALPERMIT FEE
U Z building construction.and hereby authoria representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We) me to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilides,jidgments,cosm.nd expenses which may irony waywctoe against said City ALT ER OR AILD TO MECH. PLUMIIING FEIi
in eansectiadw of the gunning of,hia perand.
APPLICANT UNDERSTANDS A_NWqLL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTIONTAX
nature nfApplic.m/Conmamor Data EXHAUST FOOD(W/DUCD HOUSING MITIGATION FEE
_ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoccupant store carbonate hazardous mmedal BEATING UNIT(TO I(XIIXXI BTU)
as defined by the Cupertino Municipal GNB,Chapter 9,12,and the Health and Safety
Code,Section 25532(.)9 HEATING UNIT(OVER 100,000 BTU)
❑Yes 0N Vf?N'IILATION PAN(SINGLE RES]D) PAID -
Will he applicant or futurebuilding by the Dl lire equipment or devices which Date Reccy,N
rdnn
emit hazardous air cmminams as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,(NI(1 BTU)
District?
'[D'I'AL:
❑Yes ON. HOILLR-GOMP(DVIiR IW,IXN B'TU)
I have reed the hazmdonsntural,us,mmmems under Chnptcr 0.95or the Cali AIR CONDITIONER ISSUANCE DATE
form.Healer&Safety Code,Sections 25505,25533 end 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,In'.
building does not comedy have a mmol,that i,is my responsibility in notify the occupant
of the requianeams which must Is,mel prt issuance ofd Cmificme of Occupancy.
Owner or uumotizeq.,art Data TOTAL: ISSUED BY:
OFFICE