28871 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LECTRICA]. PERMIT NO. ^ q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28871
�/8 8 1
BUILDING PROJECT IDENTIFICATION LV 1.
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1Vi50 �2Lt1 (ati,iii,�
OWNER'. AMC_ THONG: COu 'Sr AME: `LICGNO
Y Bel Yv NIC CONTROL
ARCHIT'EC AENG NE. : LIC NO: ADDRESS. I ( ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BrLDDGV ELECT PLUMB MECH
Q' CI ❑ ❑ ❑ -
LICENSEDCONTRACTOR'SDECLARAHON QTY. ELECTRIC PERMIT FEE
I hereby a0inn that I.,ittth,cr sal under provisions of Chapter 9 rce6•nnnncndlt6 IOB,DESCRIPTION
ooz with Section?I1o(Bof Division 3 ofthellusinessand Professions Cole.i Imylicee'is RESIDENTIAL: •
F O in full to. PERMIT ISSUANCE
�U9'
ZV License Class' Lic.# /� DSFDWL D KITCHEN REMODEL
�6S hatelfe�r Canuador -�.[ 4 9 APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
ARCHITECTS O[CLARATON -nP_— e-� DMULTI-UNIT [D STRUCTURAL
z O ro z 1 understand my plans shall he used as public records '`- PANELS MODIFICATION
Oz E3 n UP T0200 AMPS DINTERIOR C1 CHIMNEY REPAIR
F'r l:t,° Licensed Pmfessimnal 201-1000AMPS IMPROVEMENT
,,....1l OWNER-BUILDER DECLARATION OVER Ill00 AMPS LJ BATH RIiMODEL/REPAIR DUF.MOLITI N
yp, Q 1 hereby affirm that I am exempt from the Cantractors License law for the $per �P
uF following mason.(Section]031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL �GO HF.R ���
WRF`O Wa which requires a permit to construct,alien improve,demolish,or repair any suuetum *<;s to (-L ��•
hJ prior to its issuance,also xequires mcapplicaut fmsuch perming flea signedmmemmalt SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the prodsiuns of the Commewes Li...el,av Cimpler9
aec (comrrmncingwim Section]0o()of Division 3 ofine Bminessund Professions Cule)or TEMP.METER OR POLE INST, COMMERCIAL:
1la, e q that he is exempt mfro
emm and the basis for me alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
+ -M u• Section 7031.5 by any applicant far v permit subjects the applanat In a civil penaltyof POWER DEVICES
so OTENANT IMPROV DFOOD SERVICE
not more mw five hundrla;ft, rmyr110). E IMPROVEMENT
Q D hmuwncndthe pnspeny,anmy emmiulde,wim wages it od csmtpem,anex, SWIMMING POOL ELECTRIC
I
dotho work.andthe Btnt Curois notimm�dedorawdos of apply(it 94,Business UGTHER
and properly
who h Cfs or hhe'Contractor's License Law doe,not apply Ip an owner h OUTLETS-SWITCHES-FIXTURES
ao '� progeny who buil,,or Inlpnwth thereon,and who docs such amended
dtnsdl or through far
his own however
reth building that such mentis old within arc oil iyear of
or pffcrcd for NEW RESIDENTIAL ELHCI'R SQ 14,
owner-builder
will
have
he boong or m ofpmvent isid one tbuild or i uprovetfor the SQ.FT.FLOOR AREA $/SQ.Ff.
ownerhuilder will huvc the harden of proving mm he did not buil,car itnprnve for bur-
posc of sale,.
❑ I,as owner of the progeny,am exclusively contracting with licensed contractors to TOTAL: a ;1
consumer the project(See.7094,Business and Professions CsdeJ The Co tinuator's Li.
cense Law docs not apply to an owner of property who builds or improvesthemon,and QFV PLUMB( 'RMIT FEE
who contracts far such projects with a contmctoddlicensed pungaana the Commeme. OCT 12
License law' PERMIT ISSUANCE 1995
D l am ear ila muder Sec. ,B&P C fonhis mason s7S7ag
ALTER-DRAIN&VENT- ATER(EA) (I'y �r ItH VALUATION
•Owner Dare ( ern
WORKERS COMPENSATION DECLARATION BACK FLOW PR .DIiVICE �ryMF.yO
I hemby affirm under Penalty of perjury one of the following declamations: V
yuy l have and will maintain a Cenificme ofConsenuo self-insure for Wmkefs Camped. DRAINS-FLOO , ,AREA,CONU.
s'ut1Un,as provided fur by Section 3700 of the Labor Code,for the performvnce of theSTORIES TYPE CONSTRUCTION
work for which this permit is issued. dX URES-P RAP
D I have end will maintain Worker's Compensation Insurance.as required by Section
3700 ofthe tabor Code,for the perfoncenee ofthe work for wldchim
is porn Its Lxsum, GA'-EA.SYSTGM-I INC:40 LETS OCC.CROUP APN
My Warkcr's Com c�tinn Insuranc . I Policy n}y m
Cunier: A-G'PoIicy No O.l� GA. -EA.SYSTEM- iR HA) .
CBR'1'll'I OMPE SATIONONFRAN WORKERS'
COMPENSATION INSURANCE CRS SFJINDUSTRh A. ' "EkCEPIDR BI/11.IlING DIVISION FEES
(This section need oil be completed ifthe permit is foconehundoed dollars($100) GREA. TRAP
or less.) PLANCHECK FEE
I cenify that in the performance of the work for which this permit is issued,i shall SEWER- NITARY-STORM EA, q'
not employ any person in any manner so m m became subject to the Workers'Compen- ENERGY FEE
z cation Laws of California.Date WATER HENT/ELF.CT
R
OApplicant EAT WNGRADING FEE
O InNOTICE TO APPLICANT.IL after making this CenificmTI
e of Exemption,you should WATER SYSTEM? NG
aIZ , become subject to the Wader's Compensation provisions alone"hor Cale,you muss SOILS FEEFEEfanhwith comply with such provisions or this pemsit shall be dremed revoked. WATER SERVICE
Q
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. T. PAID
U O (hemby aRmr that hem is a construction fending agency for the perfotmvnce of 91 ppt#
(L H me work far which this permit is issued(Sec.3097,Civ C.)
O U Lender's Name TOTAL:
{i7 Lender's Addmss - TOTAL:
I comfy that f have mad this application end some that the°hove information is But
f�R] correct,i agree to comply withal)city and county ordinances and,tote laws relnting la QTY. MSCI IANICAL PERMIT FEE
U building construction,and hereby uumorim representmivesof this city to carer upon the SEISON
above-nmntioned property far inspemion proposes. PERMIT ISSUANCE'
(We)agree to rove.Indemnify and keep hannlexx do,City of Cupcnino against ELECT tEF
liabilioies,jadgnmms,ensu vnJ expense,which may in any way accrue ugainsl mid City ALTER OR ADD TO MECH.
in canscyucnce of me gmming of this permit.
PLUMBING P E
APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON•POINT AIR HANDLINGUNIT(TO 10.000CFM)
MECHANIC LFP.E
5 CP .AT
00 e AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRU ION TAX
Sig w 'cant/Conkactor Dam EXHAUST HOOD(W/DUCI] HOUSING 1ITIGATION Fri.MATERIALS DISCLOSURE
'lith applicant orfuture building occupent store or handle hoardaus material HEATING UNIT(TO 100.000 BTU)
as defined by me Cupertino Municipal Code.Chapter 9.12,end the Health and Sidety
Cade,Station 25532fa1? HEATING UNIT(OVER 100.000)BTL)
D Yes UNo VENTILATION FAN(SINGLE RPSID) PAID
Dow Receipt#
Will thedo.,air emus orfuturea building by the rd Bay A a Air Qualitent ory
dMana when BOILER-COMP UHP OR 100,(X10 BTU)
' emit hrxuNnus air contaminant,as ddin<J by the Bay Area Air Quality Management 'TOTAL:
Dntrml? BOILER-COMP(OVER 100,0110 BTU)
❑Yee FIN.
1 have mml the huxnNnuv mrim
ams myviremenu under Chapter 695 of the Cali- AIR CONDITIONER 'SUANCP.DATE
fomia Hcnlm&Soley Coda,Saclinns 25505,8533 and 25531.1 understand that if the NEW RESIDENTIAL.MECH. SQ,IT,
building docs not cutmmly have u tenant,that it is lay responsibility m nolify the occupatm
of the mquirentenls which must he met prior to issuance of a Cenifiane of Occupancy.
Owner.1 uuthorimd agent Date - TOTAL: ISSUED BY:
OFFICE