28708 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO ' - - BUILDING-RLECTRICAIyPHRMIT NO. 28708
BUILDING
X7O8BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MFCIIANIC ,I,
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I ��► • t. SANITARY NO.. APPLICATION SUBMI'rIAI.DATE
�2oSo. T�� S' tL t.u'D LGCPr�ier7w¢>
OWNE 'S NAME,: PHONH: CONTRACTOR'. AME: LIC NO: `
• / LT/ 5VI4
. _ N/C...�., CONTROL#
ARCHITECT/lBsCINEER: LIC NO:. ADDRESS: " -, ❑ -
CONTACT: + PHONE: x's - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial ' BLDGELECT PLUMB MECH
❑ , El ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
-1 hereby amstn
ffirm at l hcettaed ander pntvlsimts of Clore,9(contributing - .JOB DESCRIPTION .
DagZ with Section 7")ofDivision 3ofthe Business and Professions Code,and my license is '
full force and affect. > PERMIT ISSUANCH
aVV in
Class Lic.x. " " ❑$FDWI. ❑KITCHF.NREMODF.I.
I-VW Dote Combat APPLIANCES-RESIDENTIAL � ❑ADDITION ❑PLUMBING BE PIPH
ARCHITECT'S DECLARATION � ❑MULT6UNIT - ❑STRUCTURAI,
Da)
MMODIl undesmnd my plans shall he used us public tedards PANELS
FICATION'
G UPT0200AMPS INTERIOR, ❑CHIMNEY REPAIR
I-I F'W Licensed Pmfessi...I 201.1000AMPS 1MPROVEMFNT-
EqiOWNER-BUILDER DECLARATION OVER'IOINI AMPS ' El BATH REMODELIREPAIR 0DEMOLITION
y 1 hereby affirm to that I oexempt from be Contractors License Law for the
x3SU following remnn.(---tion]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL C1 OTHER
which retain,v permit m enndaro.Mbar,improve,ran mli0f fir repair any immure
priorm avismanc,also requires the applicant forsuchperminafle a signed statement SPECIALCIRCUIT/MISC.
C6� that he is licensed purxuanuo the provisions ofthe Contractor's license Law(C'hepmr9 .
��ap0'(aommeneing with Section(IfN))of Uivisinn3 ofthe Bmineasand Pmfesslom C.,l THMP.METHR OR POLE INST.' COMMERCIAL:
a q o q that he is exempt therefrom and lie breis for he alleged exemption.Any violation of ❑NH W BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a pennh,wbjeds the rNhamnm a civil penalty of POWER DEVICIiS ❑TIiNAMI' ❑FOODSERVICE.
= } oto than Rvc hundred Jullabs($500). - IMPROVEMENT '
Ki as swnerofthe property,or my employees with wages as their sole compensation, SWIMMING MIOL ELECTRIC x
F - do the work,end the stmnure tanto intended ar nffercdfor sale(Sec.]044,Business ❑OTHER
IWil m and.Profcssions Code:The Conuacmes License law does nm apply m amnxmer rdOUTLETS-SWITCHES-FIXTURE'S
property who builds or improves tte
baon,and who does such work hli self or through A
bis own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL LLECTR -Q IT.
safe.If.however,the building or improvement is sold wiminare year of campinion,the �+ SQ.PI:FI: OA&A s/SQ.FT.
ser-builderwill have the burden ofpmving that hbdid notbuild orimprove torpor- ^ -
ptseofcle.). - . . • I I
❑I,as owner of the property,am exclusively combatting with h-entad a bon-tura to - TOTAL: 11416V 11996
construct the project(Sm.7014,Business and Profesiom Code:)The C.ntmnors Li- ��a is a -
came Lawdaosmmnlflymnm ownerofpmperty shebrildsorlmpn se,thereon.and QTY. PLUMBING PERMIT FEE T�r
who contracts for such projects with a conuuctood licensed Panama m 0m Contractor's ./aITV'1.1r, �Ur,�tJ f If,l
License I.aw. PERMIT ISSUANCE V 11 V K I.1
❑ Ism exam - der-ec. Y_'79 71 ,B&PCfm this rano fit
ALTER-DRAIN&VIs.NT-WATER(EA) VALUATION
1 Owner Dam -
WtJ ER:SC MPENS 0 E RATIO HACK ILOW'PHOTECT.DEVICE.
herebyaRz oder penalty of perjury one of the following declarations:
�• D I husband will maintain aCertificabeof Conamitosell'winsure for Worker's Compal DRAINS-FLOOR,ROOF,AREA.COND, ,
~ ,anion,as provided for by Section 37M of the Lahon Cn16,for the perfommme of the STORIES-' TYPE CONSTRUCTION
walk for which this permit is issued. - FIXTURHS-PI7R TRAP
I have and will maintain Worker's Compensation Imurance,us required by Section - -
3700ofthe Lohor Codo,forthe perfortaanceofthe work forwhich this permit is issued, GAS-EA.SYSTEM-1 INC,4 OUTLETS OCC.GROUP 4 APN
My Worket"s Compemation Insurance tarsier and Policy numhcr are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(G) ,
CERI'IPICAI 17 OF EXEMPTION PROM WORKERS' -
COMPENSATIONINSURANCE OR EAS191NDUSTRLWASTL INTERCEPTOR
(This secnlan read mm be c,nnplated dlne permit is forma hundred dollen(-IM) BUILDING DIVISION FEES
or less.) - GRHASETRAP PLANCHECK FEE
I certify that in the perforommi,ofthe work for which Nis permit is issued,)shall ,SEWER-SANITARY-STORM EA.201)PC
not employ any person in any manner so as to bemm�L subject it)the Wit Courtrai- ENERGY FEE
Z cation Lms,.f C.Iifim..Dma WATER HEATER WIVEN/IILECfR
O Apflipmt GRADING FEE t '
NOTICE TO APPLICANT.If,after making this Cert fico a of Exemption,you should WATER SYSTEMJTRRATING
a ; become subject to the Worker's Compensation provisions of the Labor Code,you most SOUS FEE.
W
Q forthwith earn,],wills such provisions m this permit shall be damned revoked. WATER SERVICE
'CONSTRUCTION LGNDINGAGGNCY NI:WRESIDENTIALPI.MB. SQ:FT. PAID
UO
I hereby afGmuhatthen is a couxouction lending agency f.nhe performance.! Date Receipt#
W F
,he work for which this permit is issued(Sac.3097.Civ.C.)
Q U Lender's Name - TOTAL'.
Lenders Address TOTAL:
I acid fy that I have rend this applicm inn and state Nat the above information is BUILDING TLE
fA Cortcait i agree m Comply with all city and county ordinances and state laws relating to qTV MECHANICAL PERMIT FEE
L) z buildingconstra"mi,and herebyouthorize represenmtiven of Nis city mender upon the SEISMIC IEE
t� all raimlaned property for inspection pumoscs. -
PERMIT ISSUANCE, ELECTRIC FEE
(We)agree m save,indemnify and keep hemdess the City of Caperton against '
Built ities,judg mba,4 costs and expa,me,which nmy in any vv iy uccme agaimt said City -
in con aquence of the granting of this permit. ALTER OR AUU TO MF.CII, PLUMBING FEE '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNI'['(TO 10,000 CPM)
SOURCE REGULATION-. MECHANICAL FEE.
AIR HANDLING UNIT(OVER IQfNp CFM) CONSTRUCTION TAX
Signature of AisiicanVContracmr - Dae EXHAUSTHOODOODUC1) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE:
Will the affliction or future building occupant stem no handle hazadma,mmerial HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cade,Crafter 9.12,and the Health unit Safety
Code,Section 25532(a)p ''HEATING UN I'I(OVER'IfQ000Ill Of
[3 Yes Fl No -
VENTILATION FAN(SINGLE RF.SID) PAID
Will th pplicam r future building wdupant use equipment or&,Itw which _ Dates'+s, Reccipn# ,
emit IF d u contaminants ax defined by he Bay,Arca A Quality lty Management•. TOTAL:BOILER-COMP(3HPOR 100.0W BTU)
Distnctf r
❑Vm No BOILER-COMP I INk0009TU) -
❑ ' 1 -
I have¢ad Ne finsomus mattock parammmt,under Chapter 6.95softhe Cub- - AIRCONDMONEk ISSUANCE DATE
fomin IInith&Safety Code.Sections 25505,25.133 and 25534.1 understand that if Ne' NEW RHSIDRNTIAL MF.CIL SQ.IT
building it...,currently base a tenant,that it is my respmsibility to notify the,rcupual
of Ne requirements which must be stet prior no ismance of a Certificate of Occupancy. - -
Ownermauthotizalagent - Dam TOTAL: ISSUED BY:
5
OFFICE ".