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28706APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY OFFICE I' CITY OF CUPERTINO - BUILDING - ELECTRICAL BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL BUILDING PROJECT IDENTIFICATION PERMIT NO. O BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE Jowl topm A% I ell __3 OWNER'SNAME: PHONE: .. �A115it CONTRA OR'SN LIC NO'. NIC ❑ CODL . ARCHD'IiCTRINGINEIiR: LIC NO: � A2Li1� INC, ADDR ..: DC NTpcT.�`t^A PHONE: �+� Yom" ❑ Consultant Fees Paid by Applicant (Initial) BUILDING PF.RMITINFO 1, E PLUMB MECH NC ❑ ❑ LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that I.. licensed under provisions of Chapter 9 (emmnencag with Section 7000bmfDivision 3.f the Business and Professions Coae,mNmylicenseis in toll foreamo affect, Liana Class Lich Uvte ContractorAPPLIANCES QTY ELECTRIC PERMIT FEF. �Z Op til �', U(] Ze � 'rte 7' J B DESCRIPTION RESIDENTIAL, ❑SFDWL El KITCHEN REMODEL ❑ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCfORAL MODIFICATION PERMIT ISSUANCE �� FS -RESIDENTIAL ARCHITECTS DECLARATION DECLARATION 1 understand my plans shall be used., public recoNs PANELS i.I1PT2fN1AMPS p j 0 ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT Licensed Professional 201-10IN AMPS (LV ya OWNER-BUILDERDECLARATIONCe Contractor's 1 hereby ..firm that 1 oro exempt from the Cssionsmrs License Law for the following reasnn(Seninn]OJL5, Business and Professions Cad: Any. city or county which reyuirea a permit m constmd, elmq improve, demolish, nr repar. 1 strucmr poor m its issuance, also requires the applicant fm such pcmduo file a signed succors' ❑ BATH REMODEUREPAIR El DEMOLITION []OTHERWO OVER IOWAMPS SIGNS ELECTRICAL. S ECTAL CIRCUIT/MISC. pyo, J Op that he is licensed puaoom m thepmvislonsof the Contractor's license Low(Chapter9 (commencing with Sectio 7") of Division 3 of the Business and Professions Code) or'TEMP. METER OR POLE INST. C WW w } 6 o 3.oc+ that he is exempt therefrom and the basis far the alleged exemption. Any violation of Smoon 1011.11, any applicant far a pemtitsnbjeels the up,heam to a civil penahynf not room five thund perry, r yempl ❑ I,us oth,..,k, .d property, remyemntendes with wages ax their sole compensation, afontapply to will dothewon, anab: The Lure islal es incenseed Law owner of Professions Code: The ove, th a License law does not apply s if owner of a property property who builds or improves thereon, and who dues such work himself or through his own employees, provided that such improvements are not intended or offered for sale. It. however: Ne building or improvement is sold within ane year of completion, the ponsc o builder will have the burden of proving that he did not build or improve for par- pose of sale). W BLDG/ADDR7ON 11 © DEMOLITION ] ❑ NT ❑FOODSERVICE IMPROVE�f ENT II�/� Q --- F1 OTHER l9�yl a$ 1Js71 POWER DEVICES "WIMMING POOL ELECTRIC ' UTLbTS - SWITCHES - FI%TIIRES / NEW RESIDENTIAL ELECTR SQ FT. CI I Y f SQ. FT. FLOOR AREAfl I Ilvc O $/SQ. ET. IPI, as owner of the property, oma exclusivelyes,ad contracting with licensed contractors to the project (S«. ]M4. Business ana Pndessinna cal.:) The contractors Li- nseLawdnexnat applYman nwnerof progeny who huilJx nr impmvcs thereon, unJ QTY PLUMBING PERMIT FEE who contracts for such projects with a contractors) licensed pursuant to the Contractors PERMIT ISSUANCE License Law. El,lnod exempt under c. tl & P C for is reason ALTER - DRAIN & VENT - WATER (EA) VALUATION �- Own A.s Date WORKER;SCOMPENSA ONDECLARATION U,a1'fir under penaltyofperjury, aneof the following declautions: BACK FLOW PROTECT. DEVICE DRAINS- FLOOR, RUDE AREA, COND. IhaveandwillmainumaCertificateof Consent o self-insu, for Worker's Comprn- ration, us provided for by Section 7]110 of the Labor Cede, for the romance of the STORIES TY PE CONSTRUCTION FIXTURES - PER TRAP work far which this permit is issued ❑ [hove end will maintain Wmhera Compensation Inxutance, as by section 37M of the Labor Code, fm the performance of the work) It lis issued. GAS-EA.SYSTEM-1 LNC.4OUTLBTS OCCGROUP APN My Workers Compensation Insurance carrier and Policy n Canter: Policy Nn: GAS - FA. SYSTEM -OVER 4 (EA) CERTIFICATE OF E%EM1IPTION R M RS' COMPENSATION 5 R (Thissectionnaednatbecn plc It a amtisforoach drnddr,106($II ) or less.) OREASFIINDUSTRI.WA5TE1 ERCMTUR BUILDING DIVISION FEES GREASE TRAP PLANCHECK FEE SEWER-SANITA -STORM EA. 2011 FT. Icenily that in the per( the work forty' this ppm esued,lshall not employ any person in uy mm�ner as m l a om bj t to8te Workerv' Compm- ENERGY FEE z Q action Lvws of California. Date Altaic.., WATER HE WNENT/ELECIR GRADING FEE NOTICE TO APPLICANT. IL arm, making Of, C<niMate of Exemption, you should bacome subject to the Workers Cn.rr awtion provision. of the Loan, Code, you malt foMwith comply with such provisions or this permit shall ba domed revoked. WATER 'TEM/f1tEATING Wp SERVICE 7 y J a SOILS FEE 'W RESIDENTIAL PLM9. SQ. PL iz J Q F yLender's w i>, (A Z CONSTRUCTION LENDING AGENCY Thereby affirm Oat there isaconstruction lending agency for the pedannence of the work for which this permit is issued (Sec. 3097, Civ. CJ Lenders No PAID Dam RecciptM TOTAL: Address TOTAL: BUILDING FEE I certify Nat 1 have seed this application and stain that the ebrrve infnsmminn is correct. I agree to comply with all city and county ordinances and sate laws relating to building amwarwomr, and land,tuNnrizerepreaenotivesofOis city weram.,on the QTY MECHANICAL PIERMIT FEE SEISMIC FEE PERMIT ISSUANCE above-mentioned propeny for inspection purposes. (We).,ma to sum, indemnify and keep harmless the Cayof Cupeninn against ELECTRIC FEE PLUMBING FEE liabilitieajudgments. costs man expenses which may inanywaysccow against said City in consequence of Ina,moon, dthis parmn. ALTERORADDTOMECIL AIR HANDLING UNIT (7010.11W CFM) MECHANICAL FEE APPLICANT UNDERSTANDS AND WILL. COMPLY WITH ALL NON -POINT . URCF,REGULATIONS. 0 y, • �1 AIR HANDLING UNIT (OVER 110,001 CFM) CONSTRUCTIONTAX EXHAUST HOOD(WOUC) HOUSING MITIGATION FEE Signa of ApplicanVContoctnr O a HAZARDOUS MATERLAISDISCLOSURE - HEATING UNIT (TO 100,000 BTU) Wiilltheapplicantorfumre building occupant store or handle haurdous material s defined by the Cupeninn Municipal Cede, Chapter 9.12, and the Health and S.fety Cade. Section 25532(x)^ HEATING UNIT (OVER 100,000 BTU) ' ❑Yes fA No - Y Will the applicant ar future building sacupant use tampmam or devices which mit h odualms air comandra mu ns defined by the Bey Arca Air Quality Management PAID Dem Receipt Y VENTILATION FAN (SINGLE RESID) BOILER-CDMP(3HP OR I W,0009TU) 'TOTAL: BOILER-COMP(OVER 100,00 BTU) rstnct] E] Yea )eNa AIR CONDITIONER I have read the hazardous materickomairemens,under Chapter 6,95 of the Cali- ISSUANCE DATE NEW RESIDENTIAL MECIL SQ. FT. foods Health & Safety Code, Sections 25505.25533 trod 255)4.1 undeot.nd that if the building does not currently have a tenant, that it is my responsibility to notify the occupxnr of can whi must be p'rmissuanceof.canifcamof)ccupncy. t • Q915 weer nr orized nbenl I Uat ISSUED BY7:7' OP - OFFICE I'