28807 (2) APPL16ANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CPLUMBING UPFRTINO BUILDING.ELECTRICAL PERMIT NO. 28807� � O
BUILDING
DIVISION APPLICATION/PERMIT G.-MECHANIGu.
BUILDING PRf1JEC'i'IDENTIP'IGPION
BUILDING ADDRESS: / � 4/L• y SANITARY NO, APPLICATION SUBMITTALDDATI
90H-'K% ✓' m Q
OWNER'S NAME: (�PHON': CONTRACTOR/'.��1A�M�Ee: LIC NO'.
CI Ott) O e5 7O 8s OCO VY/ OI', N/C CONTROLp
•ARCHITELT/ENGINEER: LI NO: ADDRESS: ❑
CON//TACT: PHONE: - BUILDING PERMIT INFO
/dee ye (/ El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
00 Or Ili1 fQ
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE Jam' W
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ad
with Section 70flflpd Uivision3of the llueinns and Professions Crxln,and mylicenm is
�� in full mr.tual effect. PERMITISSUANCE
pt 1FDWI. El KITCHEN REMODEL
U U Limnu Class Lic.M
in GL Oam Contractor APPLIANC[S-RESIDENTIAL ❑ADDITION C]PLUMBING RE-PIPE
F,M0 ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑ AL
STRUCTUR
yps/1Z lunderstundmyplans sh.11 be used as publirmcmds MODIFICATION
pZ a UP TO 200 AMPS [I INTERIOR ❑CHIMNEYREPAIR
5 W Licensed Professional 201-taro AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODELiREPAIR El DEMOLITION
Q I hereby affirm that I am exempt ffom the Comment's License Law for the
W4 U following remor.(Section 7031.5,business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
W NEe' which requires a permit to construct,idler,improve,demolish,or repair any structure
yyy.4 prior to its issuance,also reaches to applicant fofsuch Permian Glen signed statement SPECIAL CIRCUIT/MISC.
p<� that he is licensed pursuant to one Provisions ofthe Contnures License Law(Clmpoer9
CO (commencing with Section 7")of Division 3 oldie Business and Professions Code)or TEMP,METER OR POLE INST. COMMERCIAL:
4 c eG Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ro Section 7031.5 by any applicant for o permit suhjmv the applicant to a civil penalty of POWER DEVICES
^m ❑TENANT FOOD SERVICE
not mom Nan five hundred prps dollars y employees
f?� ❑Lo rot the work,
the property,or myycmntended with wages astheir Sm. 044,Business SWIMMING POOL ELECTRIC IMPROVEMENT
and dothework,andthe he Counselors
License Law
sale(Sec.toan owner
[]OTHER
0. and Professions illsCode:The Conwnora License Liw does not apply s if owner of OUTLETS-SWITCHES-FIXTURES
property who bulls.or improves t such i,and who docs such tints himself or through
his awn employees,peidi.1 not such improvements arc not.mended of afloat for NEW RESIDENTIAL ELECTR SQ FT.
sale,IL howeveall have the bur impmveovint is at he did n one build
or improve
the $Q.PT.FLOOR ARCA LSQ.IT.
,voic a bile).will have the bunco of proving the he tis not build nr improve fur pur-
po.enf.ale) //gg 4q ais7
construct
me Pofthepmpmy,am exclusively amessions with The
to TOTAL: �7,rrfe bl
onstmcd rteproject(Sec.oan Business and Professionsdsde:) pro Conwaon, Li-cense
who
nractsfr such
Loan with
er aofpepeny who
sedprsuant toles Cotton,and QT•y, PLUMBING PERMIT FEC _]Q �
who canvas for such projects with a commctoKe)licensed pursuant to Ne Contractors
License Law. - PERMIT ISSUANCE
O tum exempt under Sm ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE � 7 /��
I hereby affirm under penalty of perjury one of the following declarations:
❑ Ihavc vnd will mvintninta Certi0wm of Cotlsennn self-insure for Workers Comperr- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCT ION
station,as provided for by Section 3701 of the Labor Code,for the performance of the
work for which this Formal is issued. FIXTURES-PER TRAP
❑1 have mad will maintain Workcfx Compensation Insura me.as required by Smile.
37M of the Labor Code,for the performance of the work for which this pewit is issued. GAS-EA.SYSTEM-IINC.4011TLETS OCC.GROUP APN
My Workers Compensation Insumnce coiner and Policy numher are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be complied if the permit is forone hundrtddollarsl$I(p) GREASE TRAP
or less) PLANCHF.CK FEE
Loy saydem parsm I.saynu,farrmmccofon.bec l'nfwhich this iflise tis issuedComfoot]rt-
SEWER-SANITARY-STORM EA.200 FT.
.at employ any person in any manner so es to baonm subject dt the Workers'Cnmpen- ENERGY FEF?
Z waists Laws of Calif ansa.Dole WATER HEATER W/VENT/ELECfR W u.
Applicant GRADING FEE
NOTICE.TO APPLICANT:If,after making this Cimif^cate of Exemption,you should WATER SYS1'HMTREATING
become subject to the Worker's Compensation provisions of the Labor Code,you nwsl —
27
forthwith comply with such pmvkinw or this pewit shall he deemed revoked. WATER SERVICE d[Fi�uu
A1B. YA
U O SQ.FT.
nate) Recef to
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PL
Thereby affirm Lha there is iconswction lending agency Tonic performance of
the Werk for WdllClt this pefltdL is would Sm.3097.L'IV.G.)
Q Under's Name TOTAL:
U lenders Assess TOTAL:
'tk..�soy I certify shut 1 have it this application and state Routine abve oinformation is BUILDING HE /O e
i-. V) correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICALPERMIT FEE O
U 4 buiWing ums9metion.nnd hereby authorize representatives of this citymmner.,on the SEISMICFEE �9sr
above-mentioned pmperty for inspection purposes. l —
(We) ^
(We)agree to cava indemnify unit Imp harmless Be City of Cupertino egvinst ELECTRIC PEE 7�ar g
liabilities,judgmems.costs and expenses which may in any way accrue against said City ALTERORADOTOMECH. Ire /U
in consequence of the gran)Ing of this permit. PLUMBING FEE i�T • 7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(101(.OKI CPM) MECHANICAL FEE
SOURCHREGULATIONS. - ",4
AIR HANDLING UNIT(OVER IR0110CFM) CONSTRUCfIONTAX
Signature of ApplicanllConwnor Date EXHAUST HOOD(WdDUCD HOUSING MITIGATION REE
HAZARDOUS MATERIALS DISCLOSURE
Willon.,licam or future holding aocupvntnom or handle hmmdous material 11BATINGUNIT(T0100.0001ITU)
as defined by the Cupertino Municipal Code,Coupon-9.12.and NE Health and Safety
Code,Section 255320)? HEATING UNIT(OVER 100,00)BTU)
ED yes ❑Nn
VENTILATION PAN(SING(.E RESID) PRN
Dole Receipta
Will thedons applicant contaminants
linantse building by the nt use Bay Area
Air ent or.cony evices whichManagement
BOILER-COMP OHP OR 10.000 BTU)
emit hazardous we contaminants as ddnW by the Bay Area Air Quality Manmgemem TOTAL:
District?
C]Yes ❑Nn BOILER-COMP(OVER 10.000 BTU)
Ihave readthe hazardoilinelerials requirement under Cbaptef 6.95 of the Cul i- AIR CONDITIONER ISSUANCE DATE
limn.Hwlth&S ety Cade,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildugdoesn urrendy hat nam,thin itis my respmisibiit tonoufy cupent
of the is which met no issuatt<e f C yX�cads of Use j
c!G�fU�/�6 p
Davao,.,munificent.,out s Data TOTAL: - ISSUED BY:
OFFICE