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00050007 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT-PEN ONLY 00105-000 1 CITY OF CUPERTINO I - BUILDING-ELECTRICAL. —' PERM{Z� BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOool L11� BUILDING PROJECT IDENTIFICATION ' iuUILL`D`ING ADDRESS: 4 SANITARY NO. APPIf HONSUBMITTA.DATE — V )Wo f5—Ali SNE'. CONTRACTOR'S NAME: LIC NO: �NTR R S /O 1 N/C CONTROL# RCHITECT/PNGINEER: LIC NO: ADDRESS: - OW ❑ fL3Y3 S 'ro CONTAQ IA., PHONE: 406 BUILDING PERMIT INFO �• ❑ Cousultant Pees Paid 6y Applicant(Initial) BLDG ELECT PLUMB MECH J ca 1 253 0412 0?' Rr �r ;K- LICENSED CONTRACTORS DFCLARAfION Qty' ;ELECTRIC PERMIT s t EEE. I hereby affirm that I licensed d p f Chapter 9(commmn in6 - JOB DESCRIPTION M=Z with Section of Division 3 of 0e Business and Professions Code and my lcen.eis - E Oci PERMIT ISSUANCE. RESIDENTIAL n full force and elle"' �CWJV License Clnss Lich ❑SFDWL ITCHEN REMODEL Zzw Dam Crmwarum APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE ARCHITECT'S DECLARATION -PANELS ❑MULTTUNIT ❑STRUCTURAL �t ZOr.jr4 Trade rmand my plans shell ne uses av puhlic rmoNs MODIFICATION OZ4O - UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR F�2ed Licensed Professional 201-1000AMPS IMPROVEMENT OWNER-BUILDER DECLARATION - ❑SWIMMING POOLS Ry-1 C d I hereby affirm that I am exempt from the Contractor's License Law for the OVER HAMAMPS ❑BATH REMODEUREPAIR 0 DEMOLITION x 0.V bellowing reason.(Section 1031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OTHER W LL W vi which requires a Permit to construct,alter,improve,demolish,or repair any stracmre prior to its issuance,also mquircp the applicant or such permit to file a signed sitcom SPECIAL CTRCUIT/MISC. f�fyyy"a that be is licensed pursuant in the provisionsofthe Contractor's License Law(Chapter 9 -- A ^ ad (commencing with Section HIM)o'Division 3 ofthe Busin,"mul Professions code)., 5BMP METER OR POLE(NSTQXQMMMQIAL, 0.y eG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION W^m Irel u]0315 by any applicam for a Permit subjects the applicant to a and penalty of POWER DEVICES F_Zy not more than five hundred dollars($50T. El TENANT ❑FOODSERVICE yQ 1,asownerofthe rt,orm employees with woes as innersole counersuii., - SWIMMING POOL ELECT RIC IMPROVEMENT wilS A D prose eture Yot iP Y 6 P 4{-� and anthewons node,fin Contator&License Lavetedforot apply town Boniness ❑O'CHER Cm andProfessionsC.da.Theure,mcmr's License Lowdoesnotapply toanowner of OUl'LGTS�SWITCHES-FIXTURES - 5 his o ny who builds or improves thereon,and who dace such work himself f through his awn employees,pmvided that such improvements are not intended or offered for NEW RESIDENTIAL RhEC'fR SQ IT sale.If,however the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ FU nicierrabrilder will have the burden of proving that he did not build or improve for put - predm ole.). - ❑1,as owner of the property,am exclusively convecting with licensed contractors t. TOTAL: construct the project(Sec.9040,Business and Professions Cod.p'me Cnntm...s • cause Law does not apply to an owner obpr.peny who builds or Improves thereon.and QTY: PLUMBING PERM IT FEE' who contracts for such projects with a commaemr(s)licensed pursuant o the Contractor - License Lew. PERMIT ISSUANCE ❑ I it,exempt under Sec. ,B&P C for this reason ' ALTER-DRAIN&VENT-WATER(EA) VALUATION comer Dnte /j WORKER under Penalty DECLARATION /� O , ©g BACK PLOW PROTECT.DEVICE `y, have andhereby will mai unacr peoahy to perjury one of @e following declarations:Co: ❑(have and will for etion3700 of the sent toLabor self-Code, the Worker'se of the DRAINS-FLOOR,BOOP,AREA,GOND. S9 RIES TYPECONSTRUCTION work r Provided fur by Section 9]00 0[the Lahnr Q�de,for the performance.Rhe kl'nrwhich this permit issued. FlXTURF;S-YF:R TRAP work (haveand will maintain Worker's ante alike work hihrequitedby Section 3 IXl ofthe LuhorCale,for the performance of the work four which this penvit�is-uvsned. CAS-E3A.SYSTBM-I INC.40lTCL13T5 OCC.GROUP R4—•p7�� C rWfrk�Qompe vp�Eonlysurgnpmrrie policy Nn.and P y n4e^b 4''060 GAS'-EA.SYSTEM-OVER 4(EA) / TCERTIFICATE OF EXEMPTION FROM WORKERS' GIt F.ASGIINDUSI'Rl.WASTE INTERCEPTOR COMPENSATION INSURANCE ? - E 13611 DING DIVISION FBFS; i (This section need not be completed ifthe permit is frronchurdred dollars(SIM) GREASE TRAP nrlessJ PLANCHECK FEE I certify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM F.A.200 FT. not employ any pe any manner sgye be me subject to the Workeri Cumpen- ENERGY FEE Z anion Laws aajj'fnmm.Dow D � O A licam /7tw1 WATER I(EATER WNENT/ELECTR PP l - GRADING FEE NOTICE PPLICANT:If,after making this ertiticam of Exemption,you should WATER SYSTEM/TREATINGa > become ser Oto the Worker's Compensation pr Win., of the Labor Cade,yon must SOILS FEE forthwith with such previsions.,thin permitshall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLACE. SQ.M. PAID U O 1 hereby affirm the there Is a anclending agency for the performance of Do,. ec Reipt# 4, r. the work for which this permit is i,csued(Sec. 3 31N7,Rv.CJ ' 0 U Leader's Name TOTAL( W Leader's Address - TOTAL: F4 I certify that I have read this application and staterhn the have Information is - - BUILDING PEE correct.laree t.cont with all cit and ordinances and state laws relating t. t s comply horn county s QTY. MECHANICAL FEE - U z buildingconsvudtiomand hercbyvuNonpurposes. Lives of this city to enter upon lM SEISMIC FEE -�' .hove-(We)areproperty for emnif an keep homeless (We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC PGB ' Imbiline,judgments,costs and expenses which may m my way recmengainst said City ALTER ORADD TO MECH. PLUMBING PGE in nsequenee of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) Sr 'RCE REGULATIONS.' MECHANICAL FEE AIR HANDLING UNI'F(OVER 10,0110 CFM) _ CONSTRUCTION TAX stare ofAp,lic.V .nvamor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MA RIALSDISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UN IT(m)I W,000 BTU) as drained by the Cupenigo Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(x)9 HEATING UNIT(OVER 100,OW BTU) ❑Yes . VENTILATION CAN(SINGLE RESID) ' PAID Date Ravipt# Will nc�applicant or future building occupant use equipment or devices which BOILER OR IW,fH1D BTU) emit hazardous sir competition,as defined by the Bay Arm Air Quality Management TOTAL District? El Yes BOILER-COMP(OVER 100,000 BTU) rz_ 1have read the hazardous p,Se ions2555,a 53an order253 Chapter the Call- AIR CONDI'T'IONERfor - P ISSUANCE DATE builds Healthg does&Safety Coup,e a Sections 25hat i 25533 eta 25534,I understand that if ate NEW RESIDENTIAL MECH. SQ.ET. building apes not currently ich haveotennnh That it is my responsibility to notify the occupant of,, re mucang is hlch mustb primm.,wanceofi CeniOn b vpancy. or authorized agent ate TOTAL: ISSUED BY: get OFFICE