28767 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PhRMIT NO. a.a
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-ME1CHANICAL 6
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: p ( SANITARY NO. APPLICATION SUBBMI'ITAL DATE
12-.Z: S�h�SV G u .zlY2 fMt I�O� 11 �Z 7
OWNER'S NAME: PHONE: 11aRACTOR'S NAME:,/ LIC NO:
Sun/•.- +t/Ya y1f M+o2 L/&/7R1 (/A-.v/h li.a.ave-. J.17$d9 NIC
CONTROLp -
RCHITECTMNGINEER: LIC NO: ADDRESS: ❑ -
/ 47•e-a/a Pct e
CONTACT: - PHONE! BUILDING PERMIT INFO
SN ❑ Consultant Fats Paid by Applicant(Initial) BLDG ELECT PLUMB MECN
I
W ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLA ION QTY ELECTRIC PERMIT FEE
I hereby affirm thin 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aZ with Section]000)of Division3ofshe Businessand liofusionsCod<....my lice nu is Op RESIDENTIAL:
00 PERMIT ISSUANCE n
W� Liven ,Cie and eRcevp j �2 �L L ❑SFDWL ❑KITCHEN REMODEL
UW Dare Class 'O Liap APPLIANCES-RESIDEMIAh ❑ADDITION [I PLUMBING RE-PIPE
�<6 Date TSConDECLARATION
F, m ARCHITECTS DECLARATION PANELS MULTI-UNIT TRUCfURAL
1 understand my plana shall be road as public recoNs MODIFICATION
OZ^, UPTO2WAMPS ❑INTERIOR [I CHIMNEY REPAIR
W-.l:{Q Licensed Professional - 201-IWOAMPS IMPROVEMENT
au .aj OWNER-BUILDER DECLARATION pyF.R Iqq AMPS ❑BATH REMODEUREPAIR C1 DEMOLITION
I hereby affirm that 1 am exempt from the Contractors License Law for the
O U following re on.(Section]031.5,Business east Prefooiom Coda AnychytecamitySIGNS ELECTRICAL ❑OTHER
Ol7tj which requires a permit to construct.alter.alter,improve,demolish,or repair any structure
sprior to its issuance,also requires the applicant for such Ferninn file a signed statement SPECIAL CIRCUIT/MISC.
} that be is licensed pursuant to the provisions of the Contractors License Law(Chapter9
W CC (commencing with Section 7000)of Division 3 of Ne Business and Profession;Code)or TEMP.METER OR POIA INST COMMERCIAL•
Lp,C y mat he is exempt therefrom and the basis for Ne ulleg<d exemption.Any violotion of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmN Seedon]03LS by a,y,ppli...Ifor a permitsubjttts the applicant toacivil penalty of POWER DEVICES TENANT ❑FOOD SERVICE -
k t more than five hundred dollars($500). �'-J
Q ❑1,as owner of the propcny,nr myemployeeswithwagessstheirwlecompennminn, SWIMMING POOL ELECTRIC IMPROVEMENT
will do me work,and the solarium is not intended cluttered for sale(See 7l) .Business []OTHER
Gon and Pro(evonns Code:The Contractor's License Lew does not apply to an owner of OUTLETS-SWITCHES-FIXTURES a 00
.. property who builds or improves thereon,and who does such work himself or through his we employees,provided that such improvements arc not intended or offered for I NEW RESIDENTIAL ELF.CTR SQ ET.
sale.If,however,the building.,improvement isrold withirimm,car.fm,inpletion,the SQ.FT.IlOOR AREA 5/SQ.FT.
owns-builder will have the burden of proving that he did not build or improve for pur- -
Pose of sale.). -
❑I,as owner of Ne Pinion,am exclusively canmeeting with licensed exam octsus to TOTAL'
counsel the project(See.7M4,Business and Professions Code:)The Comment's Li-
censeLawdoesmtapplytoanownerofpropertywhebuildsorimprovesthereon,and QTY, PLUMBING PERMIT FEE
who conotwu for such projects with a connections)licensed pursuant to the Contractor's -
L.ic'mi,Law. PERMIT ISSUANCE '
1 am exempt under Sec. fl C for this mason
Owner
ALTER-DRAIN&VENT-WATER(EA) VALUATION,
Date
WORKER'S COMPEN NDECLARATION BACK FLOW PROTECT.DEVICE
I hcrebyaffuin uaderpcnvlt perjury one of Ne following Jttlm tions:
. I have and will maintains ,mate of Consent wlbi. .or Worker-Compen- DRAINS-FLOOR,JUDGE AREA.GOND. STORIES TYPECONSTRUCTION
sauce,as provided for by coon 3]00 of the Labor Cads,far the"to ne of On
work for which this pe is issued. FIXTURES-PER TRAP
I have and will mu an Worker's Compensation Inmmnce,ss requiml Section
3)110 of the labor C ,fonhejmrfionerveaftheworkforwhicb this permit snitad. GAS-EA.SYSTEM-I INC.40UTLEfS OCC.GROUP APN
My Worker s C , ation Insamnce carie,and Policy number art:
Carrier. P.licy Nn.: GAS-EA.SYSTEM-OVER 4(EA)
CE FLCATE OF EXEMPL'ION FROM WORKERS'
COMPENSA ION INSU ANCE / GREASFANDUSTRL WASTE INTERCEPTOR
(This sectio red a."
compltl��hc" ortune h�,u�rat�tltlsseee❑❑❑� g100) BUILDING DIVISION FEESor less.) GREASETRAP- PIANCHECK FEEIceIffi
ntheperformanceoftispc t rs ,Ihan SEWER-SANITARY-STORM EA.2M FT.
notemployonina manerjttn the Wo ri Campen- ENERGY FEE -
O �. section law 'untie. le WATER HEATER W/VENT/ELECTRGRADING FEE
Applicant 'NOTICET (CANT: after maki crtificateo xemption,youshould WATER SYSTEMRREATING
bccdmcNe Work Compm provisions a LahrCode,you must SOILS FEE
foMwith cith such visions or this pemnit shJeemedinvoked. WATER SERVICE
CONSTRUCTION LEND AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O Date Receipts
I hon that mere isacons.un' lending vgeney fonhe p<rfonnnceof
the work fthis Permit is issued(S .309],Ci¢C.)
Leders NTOTAL:
rcs TOTAL:
aI cervi( that I have re ,s application and sum that the above information is BUILDING FEE 31 d Q
y coorect.I ag tocomply all city and county'ordinances and state laws relining m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U building const coon, ereby authorize representatives of this city to cmc,upon the .S
ehuvrmcmtov Perry for inspection pugwses. - PERMIT ISSUANCE ELECTRIC FEE
(We)agree t.save,indemnify and keep hemdess the City of Catena.against
liabilities,judgments,costs and expenseswhich maylnany way accme.gainat said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL.HE
SOURCE,J E"GULATIONS.
�jI)ra"_Nil nr Ls. _ OZ/q1•. AIR HANDLING UNIT(OVER 10,110)CFM) CONSTRUCTION TAX
Signamtc of�A'ppl'i'csn0'/Cmtr ttor!^�M^�— 0 Ill M14AUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtbeapplicant a,future building occupantstmem-arvdle harade.,material HEATING UNIT(TO IM."BTU)
as dclieed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532(.)] HEATING UNIT(OVER 1010,00)BTU) q/sy�.�sr�S(4
(9 Yes (�No VENTILATION PAN(SINGLE RESID) PAID
are Recnrptp r
Will the applicant or future building occupant use equipment or devices which Receipt p
coal hazardous air connotation"as defined by the Bay Area Air Quality Management BOILER-COMP GHP OR I010d100 BTU) q TOTAL.
Diorin7 A o ILK a Q
• ,, ❑Yex - (h Nn BOILER-COMP(OVER 1'00,0100 BTU)
LhavereadthehazaN materialsmquimm tsuoder Llmpterfi.95ofthe Cali- AIR CONDITIONER - SEP os;rAfdGR.I3>-pE
forma Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT. z ,JUaQhr/
building does net currently have a mrlm4 that it is my responsibility to notify the occupant
of rhe iumemsy�' sett pe met poor to issuance of a Cenific�y fC);r,;wy. - - LII I 'lA�-rV-ys LoiIIYSJ
�Si,�14+"aY r+I.,�N^i'x-a.y b7 f22/ 43" IAP /7/VT`J(.C.CEI
Owner m autbomul agent a�re TOTAL: ISSUED BY.
OFFICE