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S 1489-APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING -ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL HtITNO. 1489 v` BUILDING PRO11iC'1' IDENTIFICATION BUILDING ADDRESS: NO. APPLICATION SUBMITTAL DATE fSANITARY I _ �'C 9 gg' OWNERSNAME(? PHONE: �A{VNI _ N'rRACFOR'S NAMED / LIC NO' N NIC ❑ CONTROL ARCHITECT/ENGINFER: LICNO: F S: CONTACT: PHONE: 6UILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hemny vllinn that 1 am ,tamed undo, provisions of Chapter 9 (utmmencing QTY ELECTRIC PERMIT FEL JOB DESCRIPTION with Serino 7000) afluvision 3 crthe Business and Prfiesviluds code, and my license isRESIDENTIAL is full fume and atmoo 4 il- r'C ^ Liven lass Liatr _(O�I��IIJ Contractor El SCOWL El KITCHEN REMODEL El ADDITION El PLUMBING RE -PIPE El MULTI -UNIT []STRUCTURAL MODIFICATION N PERMIT ISSUANCE APPLIANCES -RESIDENTIAL ARCHITECTS DECLARATION 1 understand toy plan. shall he weed vs public reco PANELS IIP TO 200 AMPS ❑iNI ERIOR El CHANTY REPAIR IMPROVEMENT SWIMMING POOLS [I BATH REMODEIJREPAIR El DEMOLITION Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am eae dept from the Contractor's License Law for the 201-1000AMPS OVER 1000 AMPS SIGNS ELECTRICAL following wawa (Section 7031.5, Baroness and Prefesioms Code: Any city or county ❑ OTHER which requires a permit to co rodeo, alter, imprnee, demolish, or repair any structure, prior in its issomme,also require the applicant for such pemsit to file a signed statement SPECIAL CIRCUIT/MISC. that he is Penwell ....aunt to the provisions sef aha Cro racmr's License Law (Chapter9 TEMP ME TER OR POLE INST. COMMERCIAL: (empowering with Section 90X1(pnflJivmime 3of,ha Busimr,,tml Pro, ...nnu Cnde)or that he is exempt therefmnt and the basis for the alleged tadr,d.on. Any violation of ❑ NEW BLDG/ADDITION ❑ DEMOLITION POWER DEVICES Section ]HIS by any applicant fore pernit subjects the applicant to a civil penalty of not inure thin five hroated red..(55fall ❑ I, as owner of the property, or my employees with wages as their Sole c lldwusaiun, ❑TENANT El 17001) SERVICE IMPROVEMENT SWI MMING POOL ELEC ERIC will do the work, and the slrmwra is not intended or offered for sole (Sec. 9094, Business OTHER and Professions Code: The Contractors License Law doer not apply to an owner of OUTLETS -SWITCHES -FIXTURES Popery who builds or improves thereon, and who does such work himsalf of through his own employees, provided that such irepnwemente are net intended or offered for NEW RESIDENTIAL ELECTR SQ FT. SQ gBOOR AREA VSQ. Ff, ,.It. If, howevegthc building in improvement issold within one yootofmmpletien,the owner-huilder will hoe the burden of provin,,h., he meant build or improve for put- 1 1J pose of salt.). ❑ I, ux owner of the prapeny, con exclusively contmedng with IicenxeJ commemrs mI� mswm the p Ject (Sec 704Q Business and Professions Code:) Ibt Cnnhumors Li- se Law does notapply to an owner afpropeny who builds or improves thtreon, and QTY PLUMBING PERMIT FEE who contracts for such projects with a commemgs) licensed pursuant m the Commmors License Law. ❑ I ant exempt under Sce. ,B& P C Far thi,paredr Yv (\ 1 BVU rITYUruur� PERMIT ISSUANCE ALTER -DRAIN & VENr- WATER DA) Owner Data VALUATION BACK FLOW PROTECT. DEVICE WORKF.k:SCOMPENSAT10ND1iCIARA'f10N 1 herehy oflirm under penalty of perjury one of the following deelomdans: DRAINS- FLOOR, ROOF, AREA, COND.STORIES El I have and will maintain a Certificate of Consent to self -insure for Worker's Cnmpen- of.d. m provided for by Section 3700 of the Labor Code for the perfroll of the 'TYPE CONS' 1' RUCTION FIXTURES - PER TRAP work for which this per is issued. ❑ Hi and will maintain Worker's Compensation Insurance, as refund by Section 3700.Uhc Labor Cndc, fur the pafarprowasfthe work f,whichthie.ecoid it Lmued, GAS -EA. SYSTEM -I INC. 4 OUTLETS OCC GROUP APN a 44 Warlocks o n hon lnsmmncc carrierand Pricy nn tp PandPutic Grrien GAS-EA,SYS'FEM-OVER4(EA) FlCA'I'F:OP BXEMPTIUN FRUM WORKERS' COMPENSAIJON INSURANCH ('fhissurmn need not Be completed pike pe Iran is Baine hundred dollar, (A 00) or less) GREASMNDUSTRL WASTE INIIiRCEFTOR BUILDING DIVISION FEES GREASE TRAP PLANCHECK FEE SEWER -SANITARY- S'TORM HA. 200 Fr. Ioyany tbminthe afforanypmancenf lheworkfor whichlhto permit isissuCmr,m not employany person in any manner an as m heeome suhjut to the Worktrs' Cnmpen- ENERGY FEE WATER HEATER WAIENTIELECTR satitn Laws of Culifornia. Data Applicant GRADING FEE NOTICE TO APPLICANT: If, after making hits Cenihcac of Exemplion, you should become sunjed to the Workers Compensation provisions of the Labor Code, you must WATER SYSTEM/TREATING SOILS FEE forthwith comply with such provision, .,,he, pe real shall he deemed menace. WATER SERVICE CONSTRUCTION LENDING AGENCY I hereby ORrm that therein sconxwdion leading agency tradeperfrmawOe.f PAID Dotc Re ipt# NEW RESIDENTIAL PLMB. SQ. FT. the work for which this permit is issued (Seo. 3097, Civ. C.) Lenders Name TOTAL: Lenders Address TOTAL: 1 unify that I normal this oppleptim. and State that the abovr information is BUILDING F tremor, I agmen, comply ,all Army anteriorly ordinances and stale laws relating In bundle, romans ion, and hereby aulherize na,awnlalives of thin city In emerupan the QTY. MECHANICAL PERMIT FEE SEISMIC F . . abova-mentioned property for inspection purposes. (We) agree m save, indemnify and keep handles the City 'f Cupertino ngainxt PERMIT ISSUANCE ELECT EE lotbailiea,judgmank,utsts and expenses which mayln any wayacerte against said Ciry to onsegmenea of the granting of this Permit, ALTER OR ADD I'O MECH. PLUMBING 'B AIR HANDLING UNIT(T'010,000CFM) MECHANI AL FEE APPLICANT U DL STANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REG L .ATI( NES.r AIR HANDLING UNIT (OVER 10,000CFM) CONSTRU IONTAX Signalur cfA tit o pate 11 IAZ,=BS MATERIALS DISCLOSURE EXHAUST HOOD(W/DUCT) HOUSING TION FEE HEATING UNIT (TO 100,00X1 BTU) Will the p licunt orfulaw building occupant store rehandle hazardous material as deFlned by d 'upertinn Municipal Code. Chapter 9.12, and the I lenith and Sul'my Code, Section 25532(a)'? HEA'T'ING UNIT (OVER H)n,IXth B"IV) ❑Yee Fl No Will the vppreand or idiom b,dldingnccmponl use equipment or devices which onll hazardous air wmmmmunb O defined by the Bay Area Air Quality Mtnagentenl Dean,,? ❑Yes 7 N PAID Dnm Rcccipt# VENPILA'I'ION FAN (SINGLE RGSIU) BOILER-COMP(3HYOR IOO.OW B'fU) TOTAL: BOILER- COMP (OVER leisiI BTU) AIR CONDITIONER Ihave actuarial haanrdous mutes,, outmanned, under Chapter 695 of the Cal, ISSUANCE DATE NEW RESIDENTIAL MECH. SQ. PT. forma Hcalth & Safely Cada Sections 25505, 2.5533 and 25534. I understand shot if the building doer not currently have a retire,, that it is my responsibility m notify the occupant ofthen diremema whichntua bane, prior In issuance oda Ceriticote ofOecuponey. ISSUED BY: Owner or authorized agent Dam TOTAL: OFFICE