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28619 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28619 BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI OWNS(/SS/LJ1AM�E: I,. PHONE: CONTRACTO 'S ME: I I-Nf1:�f/y�(I -1 1 `f ✓, ,�Y car n OL a .• - )r+ -`{YkA1-f-I NIC CONTROL p •ARCHITECflENGINEER: LIC NO: ADDS ❑ CONTACT. PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB PCH ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT::::]— ERMIT FEE 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION wOz with Section IIEMBofDivision 3ofthe Business and Professions Code,unJ my liccdneix RESIDENTIAL Fa�� in full Isar and id n PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL 6 V Liccnsc Lic.ft �L yzzw Dam - - Gommaror APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE ARCHITECTS DECLARATION PANEIS ❑MULTIUNIT ❑STRUCTURAL z o N 3 I endcrsmnd my plan,shall be avid nx public records MODIFICATION OZ- 201-L AMPS5 ❑INTERIOR ❑CHIMNEY REPAIR F 4424 Licensed ProiJasinnal 201-11100 AMPS IMPROVEMENT pg=[ OWNER-BUILDER DECLARATION OVER 10(g)AMPS El BATH REM EP R (�DEMOLITION Q 1 hereby affirm that I am exempt from foe Contractors License Law for the ` 1 3 L F following leaven.(Section I0JL5,Business and Professions C(de:Any city or county SIGNS ELECTRICAL (}THER [-r 04 which requires a permit m construct,alter,improve,demolish,or repair any swemrc MER promo itsissuance,also requires the applicant for such permit w file aspgnedstmemeat SPECIAL CIRCUIT/MISC. } Net he in limnsed pursuannn Ne provisions of the Commnors License Law(Chnp¢r9 I C) (commencing wit Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL C,,pp,,my that he is exempt therefrom and the basis for the alleged exemption.Any violation hf C3 NEW BLDG/ADDITION [I DEMOLITION W o' Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES I e than rive hundred dollvrs(SSOO). ❑TENANT ❑FOOD SERVICE E= mor01...wncrofthe . .Y..,my employees With wages as lwirsole cnmpensmim. SWIMMING POOL ELECTRIC IMPROVEMENT d,1'-C will do the work,and me structure is not intenhAmoffend for side(See96(q Business []OTHER ill m and Professions Cotte;The Contractor's Lioriol Law does nut apply to an owner of OUTL TS-SWITCHES-FIXTURES property who builds or improves formed,and who does such work himself or through his own employees,provided nonsuch improvement,nee not intended or offered for N[\ IDENTIAL ELECT0. SQ FT. sale.If,however.to building or improvement is sold within oneycar of completion,the SQ.FT.FLOOR AREA LSQ.FL ponr-builder will have the burden of proving that he did nm build or Ila a for u ,msale.). 6� g ❑1,az owner of the prosany,am exclusively convecting wit liccns ill TOTAL: construct the project(She.9044,Business and Professiow CoJe:)'Ii¢ r has Li- Q cense Law does non apply m an owner of property who builds nr improves er m,and ,I UMBING PERMIT FEE v �� who contracts for such projects with a commcmrfs)licensed pursuantmte tors 95 License Law. PERMIT ISSUANCE co y ❑l am exempt mile,Sec. ,B&P C for this reason U)' (al/j.t.. ALTER-DRAIN&VENT-WATER(EA) Owner Dare VALUATION -"I//VU WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE I hereby affirm under penally of perjury one of me fallowing declarations: El I have and will maintain a Cenificam of Comenn to self-insum for Worker's Compen. DRAINS-FLOOR,ROOF,ARI?A.COND. cation,as provided for by Section 31BI1 of to Luton Code for the performance Of foe STORIES TYPE CONSTRUCTIOt work for which this permit is issued. FIXTURES-PER TRAP ❑I have and will maintain Worker's Compensation Insuranceat requited by Section 3900 of thelE3TMr Code,for the performance ofthe work for which this pcdnh is issssuue. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN My Wt C nsu nE-c 'I rPoliy NcyJJplppl ar.�j�O I-f GAS-EA.SYSTEM-OVER 4(EA) Ua CERTIFICATE OFEX ION FROM WOOIRTKE`RS's'll COMPENSATIO INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR (This section Owed not he complete bfmc permit is fill one hundred della,S 111) BUILDING DIV IS ION FEES ar less.) GREASE TRAP PLANCHECK FEE Toy n that in that perfnnnvncc nfthcwork for which this pvndl is icwid.ishall SEWER-SANITARY-STORM EA.200 FT. notcmploy any pers n' an omc su 'cwt c _ ENERGY FEE Z xAuhu Laws.1C o nerve as s rs zO Applicant - WATER HEATER WNEM1T/ELF,CfR GRADING FEE IZi t6 NOTICE'1'DAPPLICANT:If,after making this Celli Ivaco of Exem n,you should WATER SYSTEM/1'REATING become subject m the We rkers Gmlpemmion pnrvisiorsc of me LVMr COJe,you must SOILS FEE W fonhwith comply with such prmiaihm milt,permit shall be deemed revoked. WgTIiR SERVICE aQ CZ CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.FE PAID U 0 ihcrcby affirm thatfocre uuconswnion lending agency fonhe perfonnance of Date Receipt Or Pthe work for which this permit is issued(Sec.3091.Civ.C.) 0 U Lenders Name C.1 Lender's Address TOTAL: TOTAL: Fy 1 certify that 1 have read this application and state mat the above intmu n ion is BUILDING FF.E rn aon¢ctlagree ill comply wire an wily and county ordinances and slate laws minting m CITY. MECHANICAL PERMIT FEE L) Z building convection.and hereby authorize replcscntanves of this city to crier upon the SEISMIC FEE above-mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree m save,indemnity and keep harmless the City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.in consequence ofthe gra mg ofthis permit PLUMBING FEE APPLICANT ON ERS ANI AND WILT.COMPLY WIT({ LL NON-POINT AIR UNIT(TO CFM) OU CE REG' ATI s MECHANICAL FEE /� a AIR HANDLING UNIT(OVER IO,000 CFM) CONSTRUCTION TAX Signature of ApplicsntAormandor Dam EXHAUST HOOD(W/DUCT) HAZARDOUS NINI'ER1ALS DISCLOSURE? HOUSING MITIGATION FEE Will theapplicantorfuture building ocetimmotheror handle haeardnus material HEATING UNIT GPO 10AJXA BOO air defined by to Cupsnido Municipal Code.Chapter 9.12,and the Ilealnh and Safety Code.Section 25532(x)? �/ HEAPING UNI"r(OVER IFOAA BTIp ❑Yes y3no _1 VIiNTILAI'ION PAN(SINGLE RESID) PAID Will the applicant or future building occupant use equipment of devices which Dom Receipt p mi erhaemdmn air annaminwts ns refined by the Bay Areaa Air r Quality Management BOILER-COMP(3HP OR 100,000 BTU) Dievin? TOTAL: ❑Yes Nn BOILER-COMP(OVER IOO,gp BTU) I have real the hazardous materials myna meAs under Chapter 6.95 of the Cali- AIR CONDITIONER fomin Health&Safety Calc,Sections 25505,25533 wit 25534.1 understand that if the ISSUANCE DATE building does low currently have amwnn,that it is my responsibility m notify the occupant NEW RESIDENTIAL MECH. SQ.FT. of the Ieyuircments which mull be men p.or,m issuance of a Cenificale of OttupatCy. _ Owner m i utomed iftem Dine p SSUED BY: OFFICE