28536 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING•ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDENTIFICATION 28 536_
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
/ OS I/ 01140e/A Y� 2 QA- A�_RS
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
It�N q NIC CONTROL#
ARCHITECT/EIJGINF.ER: LIC NO: ADDRESS:D Ie / G• ❑
CONTACT.
l// PHONE: 22 BUILDING PERMIT INFO
/o/T�` 0 2 #IGH ���_/ I �T ❑ Consultant Fees Paid by Applicant(Initial) BLDG IiL[CI' PLUMB MECH
b V ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby union that I am Iicensel under provisions of Chapter 9(cournaming JOB DESCRIPTION
0{s�0iZ with Section 7")Of Division 3 of Ne Business and Professions Code.anAmy is RESIDENTIAL:
E0O full force and effect // PERMIT ISSUANCE
OU License lues; �'�2� Ln.# 62-13V m ❑SFDWL ❑KITCHEN REMODEL
�Z
Due
�Commcmr //-nAI wn Ka./i.-s APPLIANCES-RESIDENTIAL CADDITION C1 PLUMBING RE-PIPE
ARC ECT'S DF.CLARATIO�Nr-�- i�— ❑MULThUNIT [I STRUCTURAL
F'>y> PA NE..IS
Z O��j G I understand my plans shall be used as public records ' PDIFICATION
O Z"-f UPTO 2110 AMPS `�'�OFI
D ❑IMPROVEMENTNTERIOR Y REPAIR
r,er'.Eqq"ti Licensed Profeuionel 201v[000AMPS IMPROVEMENT
2.4 OWNER-BUILDER DECLARATION OVER Iqp AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
WQ 1 hereby affirm that I am exempt(mm the Cartrector's License law far the
O y U following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
u which requires a permit In construct,alterimprove,demolish,or repair any structure
yap' prior to its i,amace.ulsorcymres lhcapplicam larsuch,mad to file.signed statement SPECIAL CIRCUITIMISC.
y that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
00q (commencing with Section 7")of Division 3ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d o LL that he is exempt thertfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4•
^m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT
F Z i not more Bun five hundred dollars(16500). ❑FOODSERVICE
< wi Lo the worafthe memore,or myem inaswi.furod as[hei(See comPcnution. SWIMMING POOL ELECTRIC OTHERIMPROVEMENT
O will dotheand thehe Corcarot intended o Law
osnot apply to an Business C1 OTHER
6'3$ and property
who
lisle:The ows thereon License Law does not apply m if owner of OUTLETS-SWITCHES-FIXTURES
his o ny who builds or improves thereon,i and who does such work himself or through
his own employee;,provided that improvements arc not intended or offered For NEW RESIDENTIAL 1?LECTR SQ fT.
aide.If,howeverms building.1 impruvcmem is sold isithinone year ofcamplemonthe SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving that he did not build
or improve far pury
poo of sale.).
❑1.as owner of the property.an eaclusively convecting with licensed contractors to TOTAL:
consumer the Project(Sec.7044,Business and 14nfessions Code:)The Contractors q
Li-
move Law does not apply to an owner ofpmperty who builds or improves reo
then,and QTY PLUMBING PERMIT FEF. i D
' - whocomtmclsfar such promu,sithucomuiamr(s)Ileensedpurs..n0o the Canm¢c[ors
License Lew. PERMIT ISSUANCE
❑I am exempt ander Seo. .B&P C ha dais aoson SEP e
Owner Data - ALTER DRAIN&VENT-WATER(EA) VA=VV
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CITY UI` �uf-•
I hereby affirm under Penalty of perjury one ofthe following declanumas: tkTl n
I have and will maintain a Cenificale of Convent to self-insure for Workers Compen. DRAINS-FLOOR,ROOF,AREA,COND.
sation,as provided for by Section 37M of the Labor Code,for the perfomunce of the STORIES TYPE CONSTRUCTION
work for which this l nso is issued, FIXTURES-PERI'RAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for the pertorosamof the work for which this Permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AFN
My Workers Co.NO.,/C Insurancecartim and Policy numb aR:
Cartier.�#(I-Si ♦+Y• I Policy Na.: GAS-RA.SYSTEM OVER 4(EA)
Ch y�TIFICA'fE OP EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GRHASFIINDUSTRL WASTE INTERCEPTOR
(This union need not be completed hNe permit is poroma hundred dollars($100) BUILDING DIVISION FEES
or less.) S13WER.TRAP PLANCHECK HE
Loy anythatinthe perfaounceofthe work for which this the W rkes'Comfoall
t- SEWER-SANITARY-STORM[?A.200 Ff.
norms Law of person in any manner so as become subject In the Workers'Compen- ENERGY FEF.
O z ..pian anws of California.Data WATER HLATER WIVENTMLECTR
O Applicant GRADING HE
yNOTICE TO APPLICANT.If.otter making this Certificau of Exemption.you should WATER SYSTEIV`UtHATING
(•-' hmonte subject to the Workers Compensation provisions of the Labor Code,you most SOILS FEE
Lakl F'�-t forthwith comply withsuch provisions or this permit shall be deemed revoked, WATER SERVICE
az CONSTRUCTION].ENDING AGENCY N14W RESIDENTIAL PLMB. SQ.pr PAID
U O I hereby affirm that there is a construction lending agency for the performance of Dale Receipt#
the work for which this Permit is issued(Sec.3097,Civ.C.)
O U Lender's Name
Lenders Address
f}.t 1 certify that I have most[his application and state that the above information is BUILDING FEE
LI W) correct.)agree to comply with all city and county ordinances and state laws relating to QTY. MECHA AL PERMITFEP.
U 4 building consvuaion,and heachy amborrese
iee repntatives Of this city m enmrupon me SEISMIC FEE
oboe-mentioned property for inspection purposes, PFRMI9'ISSU E
(We)rice to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilitieajudgmems.costs and expenses which may in any way accrue against said City ALTERO DD TO MIiCH.
in consequence of the granting of this Front PLUMBING FEE.
APPLICANT ' iRSTANDS AND WILL.COMPLY WITH ALL NON-POINT AIR NDLING UNITT9 WDXICIIIIfr2�
SOURCER UL 10 MECHANICAL HE
Sit r /e� At HANDLING UNIT(OVER FM) CONSTRUCTIONTAX
sigrovidop i roar, ])are F: AUSWOOD HOUSING MITIGATION FEE
ARDOUS MATERIALS DISCLOSURE
Will mea cam or,uture building occupern store orhand]e hmaMous material HTING 100.9 BT
as&firm by the Cupertino Municipal Code.Chapter 9.12,and the BRhaunt and Safety
Cade,Section 25532601li' TING UNI VCR
❑Yd Disk,
VE ILATION N(SINGLE ID) PAID
Dale Receipt#
ellme app ounucant rorfurore building occupant sexea Air rlordManaes which 8011 ,R-COMP(3HPOR 100,000 BTU)
miI hazardous air cnmuminenu as defined by the Bay Area Air Quality Management - 1;
xm.tr
❑Yea FIN. Bol 1. COMP(OVER IfNI,(gO BTU) 0.8
-
1 have red the Intention;Intention;mvedals requirtnrcnu AIR CO ITIONER under Chapter 6.95 of[he Cali- ISSUANCE DATE•
forma Health&Safety Code.Sections M505,25533 and 25534.P undersumd that if the NEW RFS ENTIAL MECH. SQ.FT.
building does no cunem]y have u terser[,that it is my responsibility m notify the occupant
of the no,darmems which most be at prior[o ism.nce of.Creffir eof Greater,
Owner or atnhouzed agent Date TOTAL: ISSUED BY:
OFFICE