28843 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION 28843
BUILDING ADDR SANITARY NO. APPLICATION SUBMITTAL DATE
OW ER'S Ny{'i� /�� 1' ONE: Cf 'S NAME: IAN
- ,Pr/ra�Y•� VkefgoNIC COMI'ROL»
I ARCHITECI'l1iNGR EER: LIC NO: U SN ' V 110000 ❑
ccyRller�r PHONE: HIJILDINC PERMIT FO
qsSL ❑ Consultant Ems Paid by Applicant(Initial) BIAG ELE P
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
OG I hereby affirm that I am licensed under provisions ol'Chapter 9(commencing JOB DESCRIPTION
y90p wifallRom T3 hpceDivision3of N<Hminess and Professions Code,and my license is PERMIT ISSUANCE RESIDENTIAL:
�F U� m full force and effect. :z0al
a.UZ�j Li ue Cla ..,,_{q.��Lia» :z0al 1,� - ❑SFDWL El KITCHEN REMODEL
Camrucmr APPLIANCES-RESIIIENTIAh / »5�k��D,DITION ❑PLUMBING RE-PIPE
Fp AR CHI'ECPS DECLARATION PANELS LIMULTI-UNIT [I STRUCTURAL
Z O I understand my plans shall M used as public records MODIFICATION
OZ .. - UP70200AMPS
O INTERIOR [I CHIMNEY REPAIR
Lmensed Rolcasinnul 201-1000AMPS IMPROVEMENT
NNOat I am exempt fr mDECLARATION
yy�+d0 1 hereby.(firm that I em exempt from the Contractor's Cu License Law for the OVER IOW AMPS ❑BATH REM(jDEI/1tEPAlR1]DEMOLITION
W 3 0.F following reason. nnna(Section]u3L5,Ilus)let,and Professions Code:Any city stcounty SIGNS ELECTRICAL ❑OTHER �—p�au=ar./s�'
which requires u p,rmi[m ennst th'*utter,improve,demolish ore.sig nny toucam 9-DAC
prior mics issuance,also rcquirezthe applicant for such permiuo filen signed smramem 'PECIALCIRCUTUNIISC. '��
p. that he is licensed Pa....,to the provisimrsofthe Cmussmrs License Law(Chapter 9
GAO (commencing with Section 70k)of Division 3 ofthe Businessland Padessians Code)or TEMP.METER OR PILE INST, COMMERCIAL: +
Ihm he is.tempt Iherefram and the basis for the lihi rd cxemptiun.Any vmhnion of ❑NEW BLDGIADDTTION ❑DEMOLITION
a�
Section 701 IS by any applicant for a penit subjects Ne applicant o acivil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y not more than five hundred dollars 155W). IMPROVEMENT.,
Oa C] SWIMMING POOL ELECTRIC
I,os owner of the pmpmy,nr my enrPloyces with wages as their solecompensation,
will do the work,and the saccate is not imended ur offered foetal,(Sec.7144,Business a []OTHER
and Professions Code:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propedy who builds or improves hereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
.sole.If,however.the building or improvement ixsold withinone yearofcmnplelion,he SQ.FT.17LOOR AREA LSQ.FT.
owner-builder will have the burden affirming that he did not build or improve for pr. -
powof sale.).
❑ I,as owner of the plopeny.am exclusively contracting with licensed contmemrs to ��
conrbuct he project(Sec.7144,Business and Profcssians Code:)The Cnmracmr's Li-
cense Lawdoes not apply to an ownerafpropeny who builds,),unpmvcarhe..and QW.. MB GPERMIT FEE
who contracts for such projects with a contrecmrts)licensed pursuant to Ne Comracmrs
License Law' l PERMIT IS HCE
❑ lam exempt under Sec. ,B&PCInr Nis reason
Owmr Date I ALTER- N&VENT- Had still /A TRai
I WORKER'S COMPENSATION DECLARATION BACK fl.( R ?Cr.DEVICE M link
1 hereby affirm under Penalty of perjury one of the following decl.mtions:
❑I have and will maintain a Certificme of Consent to self-insure far Worker's Compen- DRAINSFk R.R :A,CON . STORIE Will;CONSTRUCTION
ration,as Provided for by Section 37M of the Labor Code,for he perfonnence of the
work for whichlhis permit is issued. FIXTURES-PERTRA
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
J]Wnf Ne LaMn Code,forth.perfnntunre,)(the work(orwhich Nis permit is issued. GAS-EA.SYSTEM-1 INC.40 .EL'S �' OCC.GROUP .AEN
My Workers Compensation Insim ce carrier and Policy number are:
rftm Comer: Policy No.: GAS-EA.SYSTEM-OVER 4(RA)
CERTIFICATE.'OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTORrM*VI SIGN PL'ES
(This section need not be completed iflrepermit is fmoaehundmildollars(SIM) GNEASETRAI'
or less.) PLANCIiRCK PB
Loy anyrheinthe pelfianoanymannrn as t work for whichtto the ud Wisissucd,ishall SEWER-SANITARY-STORM PA.200 IT, e
norm.Lmo.f person in any manner an¢s m become subject m the Workers'Compen- ENERGY FE
Z spoors Laws of Colifomw.Date
O Applicant WATER HEATER W/Vf�/EL[CI'R GRADIN L
V) NO]]CE TO APPLICANT If,mw,asking this Certificate of Bwmption,you should WATER SYS'I'EM?REATING
a [" become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS F
fy forthwith comply with such provisions or this permit shall Ie deemed revoked. WATER SENVICE
0
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,Iq'. PA
L)O Ihereby affirm Nat there is a construction lending agency for the Performance of to Receipt»
P, F the work for which this perant is issued(Sec.3097,Civ,C.)
O U Lenders Name TOTAL:
Ig) Lender's Address
tk, I certify that I have mad this application and state that the above information is BUILDING
rA cored.l a gree to comply with all city Quay oNinances and sate lawsrelatingm QTY. MECHANICAL PERMIT FEE
U butting construction,and hereby au erepresenmtives of Nis citymemar upon the SEISMICF
above-mentianed property far ins cti rt purposes, a PERMIT ISSUANCE
DVx)agmemsave,inde n sndkeepharmlesshe City of Cupertino against ELEMI FEE
luddlities,judgirmaxcasts on a Inset which may in any way acerae against said City ALTER OR ADD TO MI.'CH.
in nsaquenccohhe 41.alimi,sPenni. PLUMNI FEE
APPLICANT UNDEAND L COMPLY WITH ALL ON-POINT PIN HANDLING UNIT(TO IO,IKKI CPM)
50t CE REGULA MECHA CALFEE
/ ^�i AIR HANDhING DNIT[OVER I(I,pX1 CFM) CONSTRUCTIN TAX
Si ware o(APPI'u ContIU ATERIALS DISCLOSURE;
Dwe I!XIIAUST 11000(W/DUCT) f HOUSINGMRIGA'ON FEE
AZ.- E:
Wigh ,',,cpZ
antor fu m ilding occupant store or handle hamNous mmerial HEATINGUNIT(TO100,OII(i
.s definedenino copal Code,Chapter 9.12,and the Health and Safety •.T -
Code,Sect )n HEATING UNIT(OVER Ro,clo IITU)❑ ❑No VENTILATION FAN ISINGLE RESID) PAID
Will he applicem or(care building nccupnm use equipment nr devices which s 00 da
emit haamdous uir comomimutls as defned by the Bey Area Air Quality Mamgement BOILER-COMP(3HP OR 100.000 RTU)
1.:
District^ BOILER-COMP(OVER 100,0(11)BTU) f V/-
❑Yes ❑Na
AIR CONDITIONER UVIyh
I how mad the hvvdnua materials requirements under Chapter 6.95 of he Cali- ISS T
teE
fomia Health&Safety Code,Sections 25505,M533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does or cmmody have a nant,that it is my wipme,obility m ramify the occupant
of the requiremems which most be mer prior In iomance nf.Cenifirne of Occupancy.
erthred
Ownorauonagent Date ISSUED Y:
OFFICE'