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B 0466 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY; CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO. e 0 4 6 6 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S�� BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: / /u M /� ��(///��/� SANITARY NO. APPLICATION SUBMITTAL DATE ^JT'r/I O( 'V/ 57 L l OW NAME:- / esO � / C Nt7t� RS Nrytl rn r� / LIC'O. N/C CONTROL# /1 C [iV e/1. ,O/ L/f/ fg,,, ARCHITECTMNGINEER: LICNO: ADDRESS: ❑ CO �� PHONE: BUILDING PERMIT INFO IG ❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PL�MyMECH LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE,I hereby alum that I am licensed ander provisions of chapter 9(enmmeneing JOB DESCRIPTION HOZ thgation]OW)of Oivision3of the Business erd Professions Code,std mylianse is RFDFII NNTIAL, F- wrfull force and effect. I'ERMIT'ISSUANCIi ds W�' i" force and ❑SFDWL KITCHEN REMODEL QUU License Cl Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF-PIPE 6 a Dam Gnnmcmr 1 F.Om ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL ATION ZOzn4 lundersmnd plans shall be used mpublic records / 2 - ❑INTFRIGR �CHIh1NlMODIFICY REPAIR .".J1 UP'1'0200AMPS FBF w Licensed Professiowl 201-IgX)AMPS IMPROVEMENT SWIMMING POOLS �ydE_1 OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEI/REPAIR [I DEMOLITION y C C Q I hereby alErm that 1 am cnemial from the Contractor's License Law for the X 31 U followir reason.(Section](131.5,13miness and Professions Code:An t t ❑OTHER 41 g vi city or county SIGNS ELECI'ftICAL �N which requires a permit re uirewck alcor,improve,demolish,ore.sir ed oaucmrt ¢ Pnorto itsissesselpal...tto realsoviP sof for CoM1ractoit toicense awstammrnt SPECIAL CIRCUIT/MISC. Z thatme ccensW pursuan70(Kh of Division 3 the Contractorsndprofessions roelnw(ChaptersCdoonr �� (commencing is axe nid tSectionn ad the basis r theof al ageBusiness xempt ion.A.iu i Code)or TEMP.METER OR POLE I S L X e n' X1 Comm out he is exempt thertlrom and the basis ler the allege)exemption.Any violation of EINE L�fG AUDI i N DEM ITION 4• SoOmn]031.5 by any applicant far a permit subjects the applicant to a civil penalty of POWER DEVICES T f 10 oe nm more man live hundred Dollars(SS W). ❑TEND h. ❑FOOD SIiRVI FZY IMPS EMENT =Q ❑I,asowmerofthepmpeny,mmyemployceswithwagesmtheirsolecompensation, SWIMMING POOLELECfRIC adIAY 0 1999 ad will do the work.mdthe structure is nal inuendcdofeifered for sale See.70,14.Business ❑OTN13 RSI and Professions Cade:The Contractor's License Law docs not apply to an owner of OUTLETS-SW RCHES-FI%'TURES 0 6 3 propeny who builds or impmves thereon,and who docs such work himself or through his own employees,provided that such improvements ase not intended an offered for NEW RESIDENTIAL ELECTS SQ ET. sale.If,however the building or improvement is sold within one year of completion.the S �-�_ er-builder will have the burden of proving that he did not Wild or improve for par. pose of salt.). 1,as owner of the properly,am exclusively contracting with licensed contractors to 1 construct the pmjm((Sec.7044.Business and Professions CodeH The Contractors Li- cense Law doe.s not apply to on owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE who contracts for such projmts with o commands)licensed pursuant tome Contractors License Low. PERM]r ISSUANCE 3 r C] I am exempt underSa. .B&PCforthiareaaon OwnerDate ALTER-DRAIN&VENT_WATER(EA) VALUATION D © Q WORKER'S COMPENSATION DECLARATION BACK MOW i'ROIIiCT.DEVICE I hereby illi under penalty ofperjuryone of the following Becm: moves as and will foibinetion 37M of the Labor Code.fortmoure fir-Worker's ce of th- DRAINS-FLOOR,ftOOIi AREA,COND. 5'tOR1ES TYNP,CON$TRUCfION tion,m provided for period Section 3]00 of the Inbar Code,for the Performance of the 11 w rk��nd this prams issued. FIXTURES-PER TRAP J Moate and will Code. for Workers Cance of thi w Insurance, h required by Section 3hd]00 of �bo"rpC�ode,for lns'u/eanormanc<ofd°Policyforpwhich thisPermitisismd. GAS-EA.SYSTEM-1 INC.4OUTLETS OC�ROUI' ANN Carticr.�Q(lsA; Policy Herrn / GASB-EA.SYSTEM-OVER 4(EA) 33 CERTIFICATEOF EXEMPTION FROM WORKERS' GREASI%INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES (This seelionned not W completed if the permit is Imone hundred dollars(11000 GR17ASETRAI' or IessJ PLANCHECK EYP. I certify that in the performanccifthe work forwhich this permit is issued.l shall SEWER-SANITARY-STORM PA.200 FT. not employ any Person in any manner so as to become subject to the Workers'Compete.. ENERGY FEE zZ cation taws of California Data WATER HEATER WNENT/ELECTR Q Applicant 1 GRADING FEE 12, h NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER a SYSTEMiTREATING tt; become subjeco the Worker's Compensmion provisions of the Labor Code,you must SOli's FEE forthwithcomply with such provisions or this perand shall be dame)revoked. WATER SERVICE Q CONSTRUCcIONLENDINGAGENCS- NEW RI'SIDENTIALPLh1B. SQ.FL PAID U 1 hereby oRthi that there is u constructed m Receipt p ion lending agency for the Performance of !+ thework for which this permit is issud(Stu 3097,Civ.CJ U. 1-" Lenr3ers Nome IDTpI.: LJ Lenders Address O L: 0. I certify that I have read this application wd sm a that the above information is B WG FEE V) correct.I agree to comply with all city and county ordinances andstate laws reining nt QTY. MECHANICAL PERMIT FEF V Z building constmnion,and bertby amhorizc reprcanutivm of this city to enmr upon me SEI TC FEE above-raccomnd property for inspection putposex. PERMIT ISSUANCIi (We)agar,to save,indemnify and kap harmless the City of Cuperdnc agdrot CLE tr F liabilities,judgments,cents and expenses which may in any way same agaimt said City ALTER OR ADD TO MECH. PLUM1IBING FEE 3 x inconsequenceollhegrantingof thiss ram. APPLICANT IDERSTANDS fN1)WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000C E) MECIIANICALFEE SOURCT RP d ; 10 K ARX q� /•//.11(IfC� AIR HANDLING UNIT(OVER IgfKK)CFM) CONSTRUCTION TAX Signature of 4plailmoConteracter Dom\ E%HAUSTHOODOVIDUCUI HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE ��,111f((JJJ Will the applicant orfuturebuildingeccupaat store orhmdlummedous atonal HEATING UNIT(TO L00,000 BTU) as defined by ma Cupertino Municipal Code,Chapter 9.12,and the Health end Safety Code,Section 25532(0)' / HEATING UNIT(OVER 100,000 BTU) ❑Yes VENTILATION FAN(SINGLE RES ID) PAID Data Receipt 0 Will the applicant or furore Wilding occupant use equipmem or Devices which coat hazardous air conmminams ue defncJ by the Bny Arca Air Quality Management BOILER-COMP(3HP OR IW,gXI BTU) Do , / TOTAL: �Ycs ['g�sN BOILER-COME(OVER IIq,IXXIBTU) _ - AIR CONDITIONER e - � (hove read the hazntdcus orals tugoiremenw under Chapter 6.95 of the Cali ISSUANCE DATE fomia Health Safety Cdc.Sec m 255(15,]5 JJ and 25534.I utderstnml awl if the NEW RESIDENTIAL MECH. SQ.PC /✓� p building x tcurrcncn have nun4 that it' y spnnsihilirymnodfy the acu�p./anIt J A of Cher nt' bmuata fuagent c�Pa T Ow, ag tag t TOTAL: ISSUED BY: OFFICE