28813 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO c BUILDING-ELECTRICAL PERMIT NO. 28813 w as
BUILDINGDIVISION APPLICATION/PERMIT PI,uMBiN6-MECHANICAL Cyl/ yVd -J;
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: p Qn�� � /'a��y � SANITARY NO, APPLE CTION SUBMI�DATI
ab ict Ia.�amds = 11 lb-2
O/yW'ER'S NA E. P110 E: _ CONTRA R'S NAMIi: LIC NO:
tr/ Q /� ��J -'/o -60ao �4on`O/^ NIC CONTROLM
ARCHITECT/ENGINEM: L111N.: ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
01(2 e ❑ Consultant Fees Paid by Applicant(Initial) BLUQ ELECT PLS Mix
(]/,o0 e r qkv p LICE TED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMrr FEE lam!`-RT 161 lel IS
1 hereby affum Chet 1 um licenud under pmvisions MChupsr 9(commencing JOB DESCRIPTION
Td2 with Section 70all mDivowr 3 wine nosiness and Professions Code,and my license is
Op in fail toand affect. PERMIT ISSUANCE.
�UV License Gloss LiaN FDWI. ❑KITCHEN REMODEL
Out Cmametar APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
F-Do, ARCHITECTS DECLARATION PANELS CMULTFUNIT ❑STRUCTURAL
2 0 f/1 4 1 understand my plans shall he used as public records MODIFICATION
0 2:1 W UP TO 201)AMPS
Licensed Professional ❑INTERIOR CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 2a1-101X)AMPS IMPROVEMENT
6 I hereby affirm that I am exempt from the Commich is License Law for the OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
LL00.0 fallowingreasan.(Section 7031.5.Business and Pori Code:Any city or county SIGNS ELECTRICAL ❑OTHFR
O E' which requires a Permit m consrucL alleq improve,demolish,or repair Moderator
,�y
Prior to its issuance,also requires the applicant for such permit file a signet statement SPECIAL CIRCULLIMISC.
that he is licensed pursuant in the provisions id'the Contractor's License Low(Chapter 9
X00 feommencing with Saturn'l000)ofDiviskm 3 ofNe Business and PmfessiasCade)or TEMP.METER OR POLE INST. COMMERCIAL:
that he is exempt therefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m fa, Section 7031.5 by any applicant for a pnmit subjects the applicant to v civil penalty of POWER DEVICES
.+y El TENANT ❑FOOD SERVICE
t marc ntm five hundred dollars($SW).
��C Les owner of the property,or my cmployecn with wages astheir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended oroffared for sale(Sec.7014.Business ❑OTHER
and Professions tide:The Counselor's License Law does not apply to an owner of OITTLEI:S-SWITCHES-FIXTURES
R' property who builds or improves thereon,and who does such work himself or through — a
his awn employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year ofewspletion,the — SQ.FT.FLOOR AREA EISA.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- /s`� / /TS
pose of wiled. 0 s f7 �,(�
❑1,as owner of the property,am exclusively contracting with licensed contractors to AL:
construct the project(Sec.71144.Business and Professions Coda)'Hic Contractor's Li- - V V
causew
Law does not apply to an on, of property who builds or improves thereon.and QTY PLUMBING PERMIT FEF:
who contracts for such projects with a contomem(s)licensed remnant to the Contractor's
License Low. PLRM13'ISSUANCE
C]1.exempt under Sec. ,B St P C for reason
Owner Data
ALTER-DRAIN A, -VENTWATER(EA) VALUATION
�`✓ys
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE aI6,, ��' •, �_
1 hereby affirm under Penalty of perjury one of the fallowing declarations:
❑Ihavevnd will maintainaCenilicme of Conttmmsdf-Insure for W'orkere Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
smion,oa provided In,by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37W uRhe Labor Cade,for theperformunce orthe work for which this permit is issued. GAS-HA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compenmticn lnsurvrte carnerand Policy number aR: -
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4 HDO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASIvINDUSTRL WASTE INTERCEPTOR
This section need not he completed if the period is for one hundred dollars TS 100) BUILDING DIVISION FEES
or lase.) GREASE TRAP PLANCHECK FEE /
Icerify that in the perfoumanceofthe work for whichthis parmitisioned,lsh.11 SEWER-SANITARY-STORM EA.200 FT.
a.amid,any penia.i.any manner so as m became auhject T.the Workers'Cornpw- 'ENERGY FEE �, a
0 z sation laws of California.Date WATER HEATER WNENT/ELECB
z Q Applicant GRADING FEE a W
(n NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a ^' became subject to the Worker's Compensation previsions of the labor Cale,you must SOILS FEE
27 Inn
G forthwith comply with such provision;.,,his permit Shull he decntedrevoked, WATERSERVICE
7 z C/1 il, it .
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date R� s�TY
U. 0 l for
rwhich rte thvnhereissue (See.30 lending agency for she performance of � glpl11 f,
U. f-+ the work for which this permit is issued(Sec.30Y],Civ.CJ -
0 U Lenders Name TOTAL:
Landces Address TOTAL:
96 1 rem y that 1 have read this application and state that the above irritation is BUILDING FEE E 7 i
UJ correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICALPERMIT FEE
U Zoe. building construction,and hereby authorize representatives orals city wenterupon the SEISMIC FEE 91, 76
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PEE 3
(We)agree to save,indemnify and keep harmless the City of Cupertino against // /
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTF.RORADDTOMECH. PLUMBING FEE O�.SB
in consequence of the granting of this Panama.
APPLICANT DERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) p
SOURCER ULATIONS/� MECHANICAL FEE J
�A � _ � /O�// AIR HANDLING UNIT(OVER IOpt111 CFM) CONSTRUCTION TAX Z 6 4.
Sig tnuwrc.f ApplicenVC-o'mVDOUS `�'aE" � b�me EXHAUST HOOD OVIDUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS Dsom,caSURF.
Will the eCal,animfuture.iti,l CoeChart morc2, adh Health
nns and Solrial HEATING UNIT(TO 1(X1,000 BTU)
os defined io the Cupertino Municipal Calc,Chapter 9.12,trod the Health and Safety
Cale.Section 25512(x77 HEATING UNIT(OVER 100,0110 PTU)
❑Yea C3 No
' VENTILATION FAN(SINGLE RPSIU) PAID
Date Receipt#
Will the applicant ior nfpsrt building by the B use equipment or devices which BOILER-COMP(SHP OR I0i BTU)
emit District?
us air conuminenu as defined by the Pay Area Air Quality Management TOTAL: a
Dlsrda7
❑Yes 7 N - BOILER-COMP(OVER IW,MNI BTU) .
I have read Ne hauNous materials rryuirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomie fleelth&Safety Gide,Sections 25505,25533 and 25534.1 undeswnd that if the NEW RESIDENTIAL MMIL SQ.FT.
building doe currcndyh Tenant.Net it is my responsibility naifyth occupant
of the rt menus whic t be met Prior m issuance j g,� �
O err or auNs�f orizcd agent /(l Dme TOTAL: ISSUEDBY:
OFFICE