28940 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 28940 8 9 q O
BUILDING DIVISION APPLICATION/PERMIT 'PLUMBING-MECHANICAL L VX V44
BUILDING PROJECT IIIENTIFICA'TION
SANITARY NO. APPLICATION SUBMITTAL DATE
O I. k� Cue PH}t]8'-TOez
ONT ACf(lR'S��.p—co� 2I� QO9/ NIC COM'ROL N
•ARCHITfiCT/IiNGINEER: LIC BIT
Ar/DII R S: O / 4V O O og-i / ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MFC
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Jaz withScctimn7000)ofD' in JnflheBusinessnnJP Cole n mylicen.eix
CO PERMIT ISSUANCE RESIDENTIAL:
in full force and effre r(�s/s j'
ak.UV UcenseJkllie.N e ( OJ 11 0.0 OSFDWL (KITCHEN REMODEL
N<d Data 11 (. Canuann APPLIANCI'S-RESIDENTIAL ❑ADDITION El PLUMBING R&PIPE
F,M 0 ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
z C vj z 1 understand my plans Mall be used es public records MODIFICATION
Oz-app] UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Iw�wp�F. Licensed Professional 20140x)AMPS IMPROVEMENT
aY OWNER-BUILDER UE Ce ContractRXI IONor's
OVER IfXM1AM1'g ❑BAT MODBUREPAIR ❑DEMOLITION
yetpx,K iad 6 1 nermy afro,mal 1 nm exempt from me Cnmmmor'e License Lew for the
W 3 L F fallowing reason.(Secuon 7031.5,Business and Professions Code:Any city w county SIGNS ELECTRICAL ER
Is7 y Q which requires n permit to conewcr,alter,improve,demolish,or repair any structure
prior m its issuance,also requires Meapplicant for such perm,to file esigned,wwmem SPECIAL CIRCUIT/MISC.
ythat be is licensed pursuunun the provisions of the Cnnaacwre License l..w(Chapwr9
CC (commencing with Section 7")of Uivision3 oftho Business and Professions Code)or TEMR MITER OR POLE IN COMMERCIAL:
L p, o' that he is exempt d;erefmnrund the basis for rhe alleged exemption Any violnion of ❑NEW BLDG/ADDITION ❑DEMOLITION
iG LL.
Section 7031,5 by any applicant fora permit subjects the applicant a civil penaltyof PnW1iR DHVICUS
Z Rl []TENANT ❑FOODSERVICE
t more man five hundred dollars y employees
6 �Lodie owner
work.and
property,ormyemplendedw.ffrorwages as heir SWIMMING POO •LECTRIC IMPROVEMENT
H. will Ju the work.andthe swctureisnot imended mroffered for sole(Sec.]014,Budin...of []OTHER
Lam and Professions Code:The CuntmOm"Licrn,e law docs mo apply ro an owner of OUTLETS- ITCHFg-PIXY
Property who builds or improves thereon,end who docs such work himself ue through
his own en;pinyee,,provided that such improvearenta art not intended nr offered for NI iW .SIDENTIAL ELECTR
sale.IL however,the building orimprovement I,sold within one year of completion,the SQ,FT.FLOOR AREA VSQ,FT.
owner-builder will have the burden of proving that he did not build or improve for put.
Pnaeof.sele). PAID
Q 1,as owner of the property.am exclusively contracting with licensed contractors to I I'
consvuct the project(Seo.70,14,nosiness and Profcrsions Codec:)The Contractor,I.1- NOVnselawdoesnotapplytoan�wnerofpropenywhobuildsorimprovesthercan,and QTY, PLUMBING PERMIT FEAV�/ ��/ 19
who contracts forsuch poijeclr with u mntriami(s)licensed pursnam tothe Contractor's a I
License Lw. PH MITISSUANCE
❑Ism exemptunder Sec. - ,D&1'C for his neon
r1TY
Owner ALIVE ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK VLOW PROTECT.DEVICE
I hereby affirm under pen a,,of perjury one of me following drelwwi...
haveand will maintainu Cenifcme of Cons<nun,elLin.vom for Works',Compen- DRAINS-FLOOR,ROOF.AREA,COND.
,amid.as Provided for by Section 3700 of the Lahr Cade•far he Performance of the STORIES TYPE CONSTRUCTION
work for which,hi,permit is issued. FIX'FURIS-PER'fRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN
My Wnrk tlpyr;yrLarrInsurance tamer and Policy
ngrj ��G Policy No.: GAS-EA.SYSTEM.OVER 4(EA)
M ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GftrASIVINDUSTRL WASTE I CEPTOR
This section need not be completed if the permit is for one hundmd dollars 1$100) BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCHECK FEE
Ioy any tori,-he say.-tact of the work for which this tperrol he Walk,.,
J.IshID1 SEWER-SANITA -STORM EA.200 FT.
not employ troy persun wavy manner w aur became subject the Wnrket%Compem ENIzRGY FEE
o ,� Applicant
Laws of California.Dam
� APPlicam WATER 11 W/VENTIELECfR GRADING FEF.
tiNOTICE TO APPLICANT.IC alter making this Cenitlem,of Exemption•you should WpTE ySTEMITREATING
E"! become subject to the Workers Compensation provisions of the Lebnr CWe,you rower SOILS FEE
{iW7 forthwith comply with each provi,mr,or this permit shall hedecmW revoked. pTER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
(J(:) I hereby affirm that there 1,a wtmaacJmn leodingage.ey for lhcperformareveal Dam ReceiPtp
IL H the work for which this permit is issued(Sec.3097.Civ.C.)
Q U LmWcr'x Name TOTAL:
lenders Address TOTAL:
G I ccrify that I have read this application and state that the above inmi
fonnon is BUILDING FEE
(01 correct.l agree to comply with all city and county ordinances and stem m m laws relming QTY. MECHANICAL PERMIT FEE
7
lJ ❑ building construction,and hereby authorize representatives milds city to enter upm the SEISMIC FEE
alawe-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELCMIC FEE
liabilities judgments,costs and expenses whichmay in any way aama.,nin,I said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,000 CFNI)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IE."CFM) CONSTRUCIONTAX
Signature of ApplicanVContructor Date EXHAUST HOOD fWMUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
c`
Will Neepplicant or furore building uccupanumn.r handle hazardous mown.] HEATING UNIT DO 100,000 BTU) ` J
as defined by the Cupertino Municipal Code,Chapter 9.12,anti the Health and Sufety
Code,Section 2557?(a)7 HEATINGUNIT(OVER 100,fg)BTU) .(/ ✓//y(//fin/
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID • •L-
Date Receipt
Wird mm ireaapplicant or my auture building by the
use equipment or devices which BOILER-COMP(JIBE OR 100,000 BTU)
`emit hazardous air conwminams as defined by thC Bay Area Air Quality Management TOTAL: �
Dismct7 BOILER-COMP(OVER 1001)0 BTU) q
❑Yes ❑Na �Z
I have read the wourobus materials requirenwnts under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fomio frelth ffi Safety Cwle,Scwions 25505,25577 end 25534.1 undcrsmni that if the NEW RESIDENTIAL.MECH. SQ.FT.
buih' g rout currently havcamnum,Not it ism resrymsihilirymtmtify the occupant
o f cis hich us c of n Ca I�at�f
mer or ambo zed.gem - Dam TOTAL: ISSUED BY:
OFFICE