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28914 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OFCUPERTINO BUILDING-ELECTRICAL 'PERMITNO. 28914 BUILDING DIVISION- APPLICATION/PERMIT PLUMBING..MECHANICAL LlS.f7�JJ BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: - SANITARYNO. APPLICATION SUBMITTAL DATE D rdr� r/� c C c r fig {�SBy✓ /O-2 S-9 '` OWNER'S NAME: PHONE:. CONTRACT'OR'S NAME: LIC NO'. . Y Z qZ4(9 r N��ICii' CONTROL# ARCHITECTIEJGINEEIC �LTC NO. ADDRESS: Zia CONTA - PHONE: BUILDING PERMIT INFO r- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB 'MECH L .. �. OS W ❑ ❑ ❑. LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE P8I hereby affirm that I am licensed under provisions of Chapter 9 Contacts,ng JOB DESCRIPTION wth Section 7000).&Division 3.&the Business end Professions Code,and my license is RESIDENTIAL: D O PERMIT ISSUANCE in] 11 forte and c t. QWU Licrnse Z Li, ❑SFDWL [I KITCHEN REMODEL Dale Contractor H'1 Le r x A.. PANELNCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE ARCHITF.CPS DECLARATION ❑MULTI-UNIT El STRUCTURAL Z O t2F, 1 understand my plans shall be used as public records - PANELS MODIFICATION UPTO 2 0 AMPS oz—, � El INTERIOR CHIMNEY REPAIR Licensed Professional 201-1 WIl AMPS IMPROVEMENT s��' OWNCmexemDERDthe Co TION OVER IOWAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION GOG I hereby.(firm on 1 1 exempt from the Contractors License Law for the pd 3 d U fallowing much.(Section]O3 stn t,alter, and improve, demolish, Code:Any city or county SIGNS ELECTRICAL ❑OTHER WW^O which its iisu a permit to construct,aper,improve,demolish,fi repair any stmdum 9 that he sticenancnrluardtorerthovisio sofnic Convermiuofileasigned aw(tammem SPECIAL CIRCUIT/.&Isco � (commencing with pSectio 7 N)provision of NC Convector's od Prsesaio CWe)or GOO (commencing Section amid the1xisinn3 nfthe..Ilh,dcorupton.Arty icCode)of TEMP.METES OR POLE INST. COMMERCIAL, o a that he is exempt thercfrmn and the basis for the alleged exemption.Any violation of [I NEW BLDGIADDITION ❑DEMOLITION h Section 7031.5 by vny appliuot far a permit subjects the applicant to a civil penatty of POWER DEVICES []TENANT ❑FOOD SERVICE p, rim more Nan five hundred dollars($500). - IMPROVEMENT ❑ I,as owrmer oflhe propmy.ar my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC wdl do the work,and the stmdmrc is not intended oroffered for sale(Sec.7144,Business ❑OTHER and Professions GMC:The ConureCtor%License Law does not apply to an owner of OIITLGfS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR t SQ FT. sale.If,however the building or impeavemcm is sold within one year afcompletion.the SQ.FT.FLOOR AR EA $/SQ.IT. owner-builder will have the harden of proving That he did not build or improve for put- pm.of It.). ❑I,n owner of the property,am exclusively contracting with licensed contractors to TOTAL: , construct no projwt(Sec.7044,Business and Ptofessiom Code:)The Convector's Li. - immeLow it.rotapply to.n ownerof property who builds or impmvea therwn.vnd QTY. PLUMBING PERMIT FEE who contracts for such pmjecn with a cormorants)licensed putaunno the Comment's License Law. PERM IT ISSUANCE ❑I am exempt under Sec. ,B&PC for his reason ALTER-DRAIN&VENT-WATER(EA) VALUATION Owner Date WORKER'S COMPENSATION DECLARATIONBACK FLOW PROTECT DEVICE / !-J'O l_ I hemby affect under penalty ofperjury one of the following declarations: v • JQQ ❑I have and will maintain a Certificate of Consent to self-insum for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. TORIES TYPE CONSTRUCTION u0on,as Provided for by Section 37M of The LuN ms Code,for e performance of the work for which this permit is issued.. FIXTURES-PER TRAP ❑1 have=6 will maintain Workers Compensation Insurance,as required by Section 37M of the Labor Carlo,for the performance of the work for which this permit is issued. GAS-EA.S YSTEM.I INC.4 OUTLETS OCC.GROUP APN My Carrieerat'f yea lnsprax"e•0 Poland y NEY number am: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION EELS (Thi.sectlon need nut In,completed ifthe permit is forone hundred dollars IS 100) or less.) GREASE TRAP PLANCHECK FEE I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner so as to become subjectto the Workers Co upon. ENERGY FEE X7 ,Z .tion Lew.of Conforms.Data WATER HEATER WIVENTMLECTR 12 Applicant GRADING FEE ' G rq NOTICE TO APPLICANT:IL atter making this Certificate of Exemption,you should WATER SYSTEM/IREAGNG became s.bj.t to the Workers Compensation provisions of the Latur Code,Y.most SOILS FEE 4{i7t �y forthwith comply with such provisions or this permit shall be thermal mpoked. WATER SERVICE yq CONSTRUCTIONLENDINGAOFNCY NEW RESIDENTIAL PCMB. SQ.pp PAID •i7 z � Date Receiptp ' V Q l for Nat there isaconstruction (Sce.3097 Cingagency performs theLe work fw which This permit is issued(Sec.7097,Ci . fie U Lenders theme TOTAL: LenderTOTAL: I reply that hm 1 have read this application and at the.Mv mfonnation is - BUILDING FEE � fa/J correct.l agree to comply with ell city and my ea 'q1VTn lewsreluting tar QTY, MECHANICAL PERMIT FEE U building construction,and hereby an ..., in not hf�int wanterul.mthe SEISMIC FEEAgo above-mendoned property for inspection pu PERMIT ISSUANCE (We)agree to save,indemnify and keep a lase Ne Cit n(Cupcnino against ELECTRIC FEE liabilities,judgmems,coneandexpenses which any way accme against mid City ALTER OR ADD TO MECH. in cunacquence ofthe g un ing of this permit. - PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14000CFM) SOURCE REGULATIONS, MECHANICAL FEE AIR HANDLING UNIT(OVER TO."CFM) CONSTRUCTION TAX Signunreof ApplicintAintmctor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE_ HAZARDOUS MATERIALS DISCLOSURE Wtll Ne applicant ar fuwre building a:cupam score rrhandl<hurardou%materiel HEATING UNIT LTO 100.000 BTU) I^ ae f as defined by the Cupertino Municipal Code.Chapter 9.12,and the Heuhh.nd Safety /•7 .31 •JO Code.Section 25532(4)7 HEATING UNIT LOVER 100,000 BTU) p 1995 ❑Yes E3 No VENTILATION FAN(SINGLE RESID) PAI[) Will the applicant or future building occupant use equipment m devices which Data ttmpt •omit haxWous air contaminants as defined by the Bay Are.Air Quality Management BOILER-COMP THP OR 100,000 BTU) District LI I I yr rTOTAIw U Isw ❑Yes ❑Na BOILER-COMP((WHR 100,000 BTU) I have read The huzmdous mmeriaNmquiremerns under Chapter 6.95 of the Cali- AIR CONDITIONER ., ISSUANCE DATE forma Health&S my Cale,Sections m5o5,25533 end 25534.1 uM.c Nvt if the NEW RESIDENTIAL MECH. SQ.PT. - builthinnian mantly have a tenant,That it is my responsibility to runty the-on t of Ne Tort H which m t ne met prior to i.uanC f v Certificate of cupvncy Owner or luthimied agent pate 'TOTAL: ISSUED BY: T) I9 A/T19gUV CC% " OFFICE