28817 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28817
11111 LDING PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
0� 33 is &n mar;n
OW S MF(n _t PIt NE: All R'SNA :: IC NO:
, d•! )6A [mets /�BQ T�+ gli SIC
COM'ROLN
ARCHIMCT/ENGINEER: 1 NO: `C A RE SI (J I ❑
ha—,,e , dD
CONTACT://�.�w PHONE: - BUILDING PERMIT INFO
`t..� (f&e e� yoFl 9'ss=6 06/ ❑ Consultant Fees Paid by Applicant(Initial) B� ELECT PLUMB MECH
s
/ L13� lCF Idl
LIC SED CONTRACTOR'S )IiCLARATIOQWZN QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
0
„ 0 h Section 70011)of Division 3 ofthe Business and Purifications Cole,and my license is IDENTI
0pin full force and effect. PERMIT ISSUANCE WL Ll KITCHEN REMODEL
�UZ�j License Class 'Lic.p gpPLIANCES-RESIDENTIAL. ❑AU ION ❑PLUMBING RE-PIPE
F 6 W Date Contractor
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCUPAL
I.=% l understand m lion shall he used as bl PANELS ZO YP pu is recoNs CHIMNEY
pt= .8 ATION
UPT0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Pndessinn°I 201-IoM)AMPS IMPROVEMENT
SY OWNER BUILDER DECLARATION OVER 1000AMPS ❑RATH REMODELfREPAI DEMOLITION
❑❑y 0.' Q 1 hereby affirm that 1 am exempt from the Contractors License Law for the
3yU fulowingoarom[Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
0.O('] which rcquims a permit reconstruct,alter,i applicant for su demolish,or repair any swnam
.71 thior s he in lensed qulsorequitue thovisisof for Contrach toiuofile aicense ned aw(Chapt em SPECIAL CIRCUITIMISC.
�} that he is licensed Oursuannu the provisions of the Contractor's License Law lCbapmr9
lyp0 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
0.L p eC that he is exempt Merchant and the basis for the alleged exemption,Any violation of ❑NEW BLD
G/�A
rDDITION ❑DEMOLITION
0.^N Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES 0TENAry 1Il1 (�i- ��Ji L']FOODS�RVICE
N„ y not more Nan five hundred dollars(S500). IMPROVEMENT
pG I,os owner ofihe pmPeny,nnny employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
p22(CC will do the work.end the strucmreix notimenJW oroffercdfor sale(Sw.]614,Business
0.a and Professions Cede:The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who holds in improves thereon,and who docs inch work himself is,through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL CLECTR SQ FT.
sale.IL Inwever.the building or improvement is sold within one year of completion,the SQ.FT.FLOORAREA LSQ.FT,
ownenbullder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
I,as owner of the properly,am exclusively contracting with licensed contractors to - TOTAL: t�CJ .21
coed La the es not )Sec.o an Business and Professions Code:) pro Convenor's Li-clude ��
whocoswdoesnotapplymts ownerofpmpeny Who
sedpor ant oodccontrn,and QT'y. PLUMBING PERMIT FEE
who contracts for such projects with a convunorfsl licensed pursuant m the Convenors
License Lew. / PERMII'ISSUANCE
' C]1 am exempt under Sec. ,B&P C fonhie reason '
Owner Data ALTER-DRAIN&VENT-WATER IIA) fVALUATION
�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following dMurutionn
•❑l have and will maintain aCenifcate of Consent to self-insure for Workers Compeer- DRAWS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
smion,as maided Tot by Section 37M of the Labor Code,for Nc performance of the
work for which this permit is issued. FIXTURES-PER TRAP
lel have and will maintain Workers Compensation Insurance,as required by Section
TIM oftJhGeI[.sCh�oJtnCode,for the performance ofthe work for
rrpwbhyich rtthhiis permit is iissS.s/ueed, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP N
MyWCamier'.(„(�,[_ saioni�e Policy No.yaft IgA GAS-EA.SYSTEM-OVER 4 EA)
CERTIFICATE OP F.MIMON PROM WORKERS'
COMPENSATION INSURANCE CREASP/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION 991
(This action nod not bcompleted i(the permit is outcome hundred dollars(51110) GREASE TRAP
or less.) - PLANCHECK FEE is
I,anythatinthe sperformance ay
work for which this the W rkers'W,Ishall SEWER-SANITARY-STORM F.A.2011 FT.
oat employ any person in any manner to vs to become suhjcn to the Workers'Compcn- ENERGY FEE
OZ sedan Lows of Cnlifomio.Date WATER HEATER WNIINNELECTR
Q NOTICE GRADING FEE
G y NOTICE TO APPLICANT:B,after making this Certificate m of Cxemptian,you should WATER SYSTIiM?ftLATING
a become subject[.,he Workers Caions or is permit
shal of the Lithour Cale,you must SOILS FEE \'
{2I forthwith comply with such provision or his permit shall tee deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U work
by which thi that them isswmSee.097.0lending
s.agency for the performance of Recnptp
fY Fa the Leaders for whichthis permitisissued(Rice.3097.Cis.CJ ,
Q U Lenders Name TOTAL: t'
Lenders ABdrns TOTAL: II y0O
1 certify that I have read this application and state that the above information is BUILDING FEE
UJ correct.l agree to comply with all city and county ordinances and nate lows relating to QTY. MECHANICAL PERMIT FEE
U Z building commaction,and hereby authorize representatives of this city to enter upon the SEISMIC FEIi
atswe-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino agaiPERMIT ISSUANCEnst ELECTRIC ME 173.H
liabil'nies,judgmetns,costs and expenses which may in any way accrue against said City ALTER OR At)])TO MECH.
in consequence of the granting of this pirrouL PLUMBING Flit
7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1X10 CFM)
SOURCE GllLATiO 5. / MECHANICAL
�,� s. lee_ AIR HANDLING UNIT(OVER IDOOt CFM) CONSTRUCUONTA 3(,BjaS
a'Bnabisure of ApplicanVContentor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION 1E
HAZARDOUS MATERIALS DISCLOSURE
Will the.OFlicaut or future building oceupamnnrc ur hostile hva.ordous material HEATING UNIT(TO 1111.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
F-1 Yes E]No VENTILATION FAN(SINGLE RFSID) PAID
Will the applicant or future building occupant use equipment or devices which Dam - Receipt
•emit haeallous air contaminants it,defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR)(0,1X0 BTU),
District?
[3 Yea EJ No (1(1 BOILER-COMP(OVER 1000BTU)
I have read the hozallous materiels requiretrlertts under Chapter,6.95 of due Cali- AIR CONDITIONER ISSUANCE DATE
1'omis Health&Safety Gyle,Sections 25505,25.133 and 25534.1 understood that if the NEW RESIDENTIAL MECH. SQ,FT.
bold gd n t utrend fin eaI t.Nut it is my responsibility to amity the ceavpard
ofthe uiremerypvhichmusthemetpnorwisuancenfa iyeax.f��cy.
Lao"'I'_
(GF1i6K curried agent — Date TOTAL: ISSUED BY:
OFFICE