28966 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELF,C'rRICAL PERMIT NO. ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - .. L
BUILDING PROJECT IDENTIFICATION -
BUILDINGADDRESS: - SANITARYNO, APPLICATION SUBMITTAL DATE
Va1.1,L o P1G-wY Iz'��
OWNER'S NAME: -PHONE: INTRACTIIR'S NAM LI N
4RCHITECT/E[JGINE LIC NO Li
O ADDRESS:U�
� Li `7g178' e
CONTACT //�� 1a`�• PH)NNE, /%�-/�.1 •TL,• - BUILDING PERMIT INFO
S1.\00 � 1 15-�B eIV_ ❑ Consultant Fees Paid by Applicant(Initial) JLD9 ELECT PLUMB MECH
❑ ❑
LICIiNSEDCONTRACIOR'SDECLARA'I'ION QTY. ELECTRIC PERMIT FEE
m Z I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing J B DESCRIPTION
OW (h Section 7BW)of Division 3 of the Businessland Professions Code.and my license is RESIDENTIAL:
�O with PERMIT ISSUANCE
nt IyF in full force and cffcm. ❑SFDWL ❑KITCHEN REMODEL
U License Class 'Lis.#
6 U APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F<t1 Dme Comrvmnr - _
ARCHITECTS DECLARATION El MULTI ❑STRUCTURAL
Z p y Z 1 understand my plans shall be used as public records PANE" MODIFICATION
--40 UP TO 200 AMPS `f�RV/IM1`TERIOR [I CHIMNEY REPAIR
'/z I"'; Licensed Ptofessiowl - 201-INX)AMPS / \MPROVEMBNT
a OWNER-BUILDER DECLARATION OVER 1011(IAMPS ❑BATH REMODEURF.PAIR [I DEMOLITION
CY
#� Q I hereby affirm that I am ucmpt from,he Commaors License law for the
OW
F following reason.(Section 7031.5.Rosiness and Profeszic ns Cede:Any city or couny' SIGNS ELECTRICAL ❑OTHER
F^O y which requires a pennit to construct,alter,improve,demolish,or repair any suname
prinrt 'n p,ako rc,uirc,the pgn a If hpermit t fl 'g 1 tatement SPECIAL CIRCUITIA115C.
y
=00 that he licensed p : e tt me provision, file C uo( Uopov L (ChapterB COMMERCIAL:
(commencing with Section 7")of Di asion 3 dithe Business and Professions Code)or TEMP.METER OR POLE INST.
d d c y that he is exempt themfrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
�H Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES ❑TF•NANT ❑FOOD SERVICE
not nmro than five hundred dollars 1$511111.
IMPROVEMENT
F7 SWIMMING the work,the,hcsum.nr myemntended withwagosrsale(Sec.compensation, SWIMIMING POOLELECTRIC
F
will do the work.and theswnure is not intended oroffcred for sale(Sec.713fY,Rosiness ❑OTHF,R
I�il m and Professions Code:The Contractors License Low does not apply to an owner of OUTLETS-SNITCHES-FIXTURES
4i 3 r progeny who builds or improves Ihemon,and who docs such work himself or hrough
his awn employees,provided thal,such impo,coar is arc nal inlatded m offered for NEW RESIDENTIAL ELECTR SQ IW.
sale.IL however the building or improvement is sold within one yeast completion.the SQ.FT FLOOR AREA $/SQ.FT.
,builder will base the burden of proving that he did not build m imgrnvc for put-
posLas alepe •/l/ /�
1,itstwee(Of pmpsm�antsinessexclusively contractProfessions with Iiih—coz—o'' Ito I CDP'J 08, ,f--1\
construct the project(Sec 7044.Business and I'ndcsaitns Cndcp'ITe Cnn«nemr's Li- �' Gl
cense Lew dxs not apply In an owner of progeny who builds nr improves thereon.and QTY. PLUMBING PERMIT FEE
wboeontrec¢for suehptojecis with ocontractorts)licensedgumuan tolhe Contractor's �`
License Law. PERMIT ISSUANCE. {I
❑ I am esemp prolcr Sec. .B&P C fonhis revson
Owner Dom ALTER-DRAIN&VENT-WATER(EA) - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICEF-
I hereby anion under penalty of perjury one ofthe following declatmions:
•O I have and will maintain a Cenilieale of Consent to self-insure for Workers Compcn- DRAINS-FLOOR,ROOF,AREA,COW. STORIES TYPE CONSTRUCTION
section,as provided far by Section 37M of the labor Cale,for the perfnfmnnce of the
work far whicb(his permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe labor Cale.for the Performance of the work for which this Permit is issued. GAS-W.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Inanmncc carrier and Policy number are:
Cartier: Policy Na: GAS-1?A.SYS'I'F,M-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(TTk section treed not be completed if be permit is for..hundred dollars(SI W)
GREASEAP
m less) 'BPLANCHECK FEE
Icenifythal inlheperformnnecafthe wink fon whi,limis facmil is kowd.[,hall SEWER-SANITARY-STORM EA.2W FT.
out employ any person in any manner sec as(t become subject[,,,he Workers'Contain- ENERGY FEE
Z ,Z cation laws of Califomia.Date WATER HEATER WNENTIELECrR
Q Applicant - GRADING FEE
t%1 NOTICE.TO APPLICANT:If,after necking this Certificate of fixcmption,you should WATER SYST'EM/TRCATING
became subject to the Worker's Cningen.ammn p o,isior,of the Labor Cale,you must SOILS i'HE ,
forthwith comply with such provi000eor this permu shall be deemed revoked. WATER SERVICE s
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U O I' khereby which
that here ....ssuuction lculing agency far the gulammnce of —� ReeeiptM
the dark for which this permit is Issue)(Sm.)119]?Civ.C')
(" Lenders NameTOTAL:
Lenders AdJrers �' TOTAL: BUI )1 FEE
E.
d s tic tion and ew(e mm the abase information is
I certifyI agree op1plarevthitya a
to coldiagcnsmuctcnngly herebylclty ansicounty
represntaimncesaldsmm lawerupingm QTY. MECHANICAL PERMIT FEE
UZ bulldingcnnstmetinn,and hereby apthorize representatives o[Ihisdly menrerupnn the SEISMIC PF.E
above mentioned property for inxi ctitn purpotts. PERMIT ISSUANCE(We)agree It save,indemnify and keep braless the City of Cupertino against ELI:CfRIC PE
liabilities,judgments.costs and expenses which may in any way accrue against said City PALTER OR ADD TO MECH,
in consequence of the granting of this permit �' PLUMBING 'E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(PO 10.000 CPM) FEEd1 _
SOU RE L TIO MECHANIC L J-�
Lw 2,,,�L- AIR HANDLING UNIT(OVER Ig11WCFM) CONSTRU ON TAX
ignaturc of Applicarm"nuacnr Dale PP EXHAUST HWD(W4)UCT) ,HOUSING TIGAT10N FEE
IIAZARDOUS MAT 1 .S DISCLOSURE
Will(heapplicant orfu(um buildi vpantnore nr handle hazardous neutral HEATING UNIT(TO 100,000 BTU)
as defined by me Catena.Municipal e.Chapter 9.12,and the Health and Safety
Cale.Section 25532(x)? �tn HEATING UNIT(OVER 100.000 BTU) •(/�I,a1
❑Ycs red No VENTII.A'I'[ON FAN(SINGLE RES]D) PAID
Will thea applicant or future building t use t or devices which Date Receipt#
pg gby the
eyuipmen BOILER-COMP(311P OR I00,00013TU)
mit hvarJous air mmaminants us defined by the Hay Anes Air Quality Mfanagemem
Di9flct?
Ypx v 15RNn BOILER-COMP(OVER 100.000BTU)
I have readthe harablans mmeda&requirements under Chaptvrfi95 of the Cali- AIR CON UITIONER f 01--
SSUANCHUNITE
forma Health&Safety Cade.Sections M505,25533 and 25534.I understand that if the ,NEN'RESIDENTIAL MECH. SQ.Fr
building tikes not currently have a tenant that it is my resom ethllily in notify the oecupsm
of lhe/rya an no'which most he met prior to issuance ala Cenilinne of Occupancy. -
Mer nr authorized agcm, Umc T ISSUED BY
rtI
t
OFFICE