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30174 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO % I BUIILDING-ELECTRICAL PERMIT NO.. IN O��/ /I BUILDING DIVISION APPLICATIONIPERMIT ' PLUMBING-MECHANICAL 3 / (� BUILDING PROJECT IDENTIFICATION, u BUILDING ADDRESS© � - ',2 / SANITARY NO. APPLICATION SUBMITTAI.DATE 33 7��7 9 OWNER'S NAME: ',PHONE:' CONTRA 9'OR'S#AMP.: ' - LIC NO: ' -5 �✓1 >= - (�..C'!( f f6at �/LS 'L�O rvrc coNTROL#' ARCHITECT/ENGINEER: •"-' LIC NO: r, p RCSS:� �: 3Y' r - ;v+ ❑ ,. CONTACT: -PHONE: - - I BUILDING PERMIT INFO l s ❑ Consultant Fees Paid by Applicant(Initial)-' BLDG ELECT PLUMB MECH. I LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑ ' QTY ELECTRIC PERMIT FEE I h by nfin.that I am Imomee pride,p '. ofCode, 9(commennng .-ly JOB DESCRIPTION -OCy sveis i 11 X1B)ofo vrsron3onhe Bus dProfession,Cale,and myleensex - PRESIDENTIAL Op PERMIT ISSUANCIi �.F. in NOfr `d'f `t2 LI 15�yB 4 �SFDWL El KITCHEN REMODEL AUU License Cl a Lin tr hl kLe t-k-� 5U • APPLIANCES RESIDENTIAL ❑ADDITION [D PLUMBING RE-PIPE 6 Date _ Cmnlra _ . F❑rn ARCHITECTS DECLARATION - PANELS. '❑MULTI-UNIT ❑STRUCTURAL zbH I understand my plans shall he used as public records - MODIFICATION UP'102MAMPS O'Z b-M ` " ❑INTERIOR - . C1 CHIMNEY REPAIR � J Licenmd that..trial, 201.1000AMPS IMPROVEMENT ' OWNER-BUILDER DECLARATION OVER IWO AMPS rO BATH REMODEVREPAIR El DEMOLITION s 1 M1reaso n(Qrm.mm 1 am exempt from the Conmaem o :Any c Law for the iypi55 O U following reason.(Section 7031s,Business and Professions Code:Any city or wuntySIGNS ELECTRICAL T/y which requires a permit to conswct,alter,improve,demolish,or repair any structure 1��/f'/ /7 1'6/ prior.us issumat'ilsa requires the applicant for such permit to file a signedstatememt SPECIAL CIRCUIT/MISC. f / F P that he is licensed pursuant tu thatiowititasofline Conmerors License Law(Chapter 9 _ (commencing with Section 70gE.fDimnon3of1be Baslnen,and Pretensions Code)oa TEMP.METER OR POLE INST. COMMERCIAL: that he is exempt therefmm,ad the basis prime alleged exemption.Any violation of , ❑NEW BLDG/ADDITION ❑DEMOLITION r^ Section 1031,5 by any applicant for a permit subjems the applicant to a civil pemllyof POWERDEVICES ❑TENANT ❑FOOD SERVICE not more than five hundred dollars y emp. IMPROVEMENT' 60 ❑ Lo the work,theand property, re is emplended withwages rsale(Sec.sole compensation, SWIMMING POOL ELECT RIC willand dothework,Code The Contractor's License soaaw does not salepplyt an Business OTHER m and Professions Code:The Commereon Lndw Law does not apply to vv owner of OUTLETS-SWITCllES-FIXTURES property who employees, pr improves that such improvements tare n work deed or ffered gh , h le.If, employeese provided that such ansisoldw are not intended or offered for NEW RESIDENTIAL ELECTR SQ PI'. however will have building bur improvement is h did none Hit nl'0[mpleinn,the SQ.PT.FLOOR AREA S/SQ.PT. of sal will have me burden of proving that he did not bond cr improve for puo„purse f I ) c cbh lcontractors to e t the property,ran a cls i, onswct the Project(Sec 944 BiahwO,addP f TOTAL: Cal )lh C t t r L - vence Law does notapply i an owncriodproperty who builds or impove thereon;and QTY PLUMBING PERMIT FEE ' who contracts fo such p 3 is with a conventions)licensed purstaintEdtireComr tors r Liverve M I am exempt under Sec. B&PCfor this on s PERMIT ISSUANCE a Owner Dem ALTER-DRAIN&VHNT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / I hereby affirm under penalty of p jury ono of the following declarations: l/ .E'I have and will maintain a Certificate of Con.enfto self-inure for WorkerVVV's Conlon- _ DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION salon,as provided for by Section 37W of the Labor Cade,for the perfermaam of the - ' weak for which this permit is issued. FIXTURES-PER TRAP ❑ I have and will maintain Worker's Compensation Insurance,as required by Section 37M of the Labor Code,for the performance of the work for which this permit is issued. � GAS-EA.SYSTEM-I INC.4 OUTLETS 1 OCC GROUP APN My WorkeG'�CoJnpellelipLr lnsumnce carierand Polley h „ Cerrier:3/NTe J�� n_Policy No.: �Z/r�1��7�a� '� i GAS-EA,SYSTEM-OVER4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' " COMPENSATION INSURANCE GREASDINDUSTRL WASTE INTERCEPTOR - (This section need not be completed,fthe permit is fh inchundred dellws(SIts)) BUILDING DIVISION FEES or less) GREASETRAP PLANET{EEK FEE I vinfify that in the performove opinework f hich this From,is issdIthall SCWHIT SANITARY-STORM EA.200 FT. " not ply y person any n e .o as t become sbje t t the W k C mpen ENERG smlaw,orC liform.D to Q 7" onl WATER HEATER WNENT/ELECTR 77O NOTICE Applicant - GRA^TNG FELY r.ttY Lr\I INN gy .NOTICE TO APPLICANT,if.Compensation atithis Certificate the Exemption,dyou should WATER SYS'f1iMfIREATING abeeomo subject to the Workers Compensation provisions of the Labor Code you must SOUS"FEE [LI forthwith comply with such provisions or this permit shall be deemed revoked.' ' WATER SERVICE Q .. s ,w CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID I hereby affirm that here is a construction lending agency for the performance of _ Dow Receipt# _ W the work for which thix permit is issued(Sea 3091,Cie C) - Q ULender's Name TOTAL: W Lender's Address - TOTAL: ,Tyr Ca 1 eerily that 1 have read this application and slate that the above information Is, BUILDING FEB Ft V1 correct.I agree to comply with all city and county ordinances and&rate laws reining to QTY, MECHANICAL PERMIT FEE U 4 building conswctian,and hereby authorize represenhdives of this city to enteruponfie SEISMIC FEE '-C) above-mentioned property for inspection purposes. .. (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE liabilities,judgmetw,costs and expenses which may in any way accrue against said City gLTF,R OR AUD TO MECH. in consequence of the granting of this permit PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQOW CIT1) MECHANICAL FEE SOUR ERBGUL TIONS: - - ' Az/ I /J /G f AIR HANDLING UNIT(OVER 10TOICFM) CONSTRUCTION TAX Sig fApp1 VC Y Dal ,y EXHAUST HOOD(W/DUCU HOUSING MITIGATION FEC - HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(Tri,IOTOIXI BTU) as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety - Code,Section 25532m)? _ - I -I HEATING UNIT(OVER 100,000 BTU) ❑Yes E]No PAID " VENTILATION FAN(SINGLE RESID) Will the applicant or future buildIQ occupant use equipmem or devices which Date (THP OR 100,000 BTU) Date Receipt# emit hazardous air contaminants as defined by the Bay Area Air Quality Management _ Districtl TOTAL: ❑Yes - - �No Y BOILER-COMP(OVER 100,000 BTU) v (have real the hnmrdousmamrials reyuiremen[s under Chapter 6.95 of lbs Cali- AIR CONDITIONER - ISSUANCE DATE - - fomis HcaIW&Safety Code Sections 25505,25533 and 25534.1 nndersmnJ that if the NEW RESIDENTIAL MECH. SQ.IT. building does not currently have ntehant.that it is my responsibility to notify theaeupnm of the requirements which must he met prior to issuance of a Ceei ficate of Occupancy. r Owner or authorized agent Date 'IOTAL: ISSUED BY: V z OFFICE