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S 4356WOO W U a Z852 OZr�—C F-xitw CyXJ 6i% 'XOyU FLLOv p555p��yyyyyy�yyy4 aaOC 0 X LL FZis C �c i3= L U_ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING .ELECTRICAL BUILDING DIVISIONAPPLICATION/PERMITPLUMBING. MECHANICAL. BUILDING PROJECT IDENTIFICATION PERMIT NO. S 4356 BUILDING ADDRESS: /0-2-27 CEF-S- 'ro nl DIZ SANITARY NO. APPLICATION SUBMITTAL DATE -26 n OWNF;R'S /LpGiv QV t)OA/LD .?03S 0� OMI RAC'1'OR'S NAME: LIC NO: N� NIC ❑ CONTROLa ARCHIFECT/ENGINEER: LICNO; ADDRESS: CONTACT: PHON' - BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MEECCH/ lG✓ LICENSED CONTRACTORS DECLARATION I hereby affiant that I em licensed ander pmvidons of Chapter 9 (error a,ing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION PERMIT ISSUANCE with Section 7000)nf Division31d,ha Bminessavd Pmfessirns Code, and my license is in full force and effect RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL TIAPPLIANCES - RESIDENAL License Class o.p Dam COcwcall CADDITION [I PLUMBING RE -PIPE [I MULTI -UNIT ❑STRUCTURAL MODIFICATION C:) INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT ❑SWIMMING POOLS ARCHITECTS DECLARATION I understand my plans shall be used as public records PANELS UP T02(10 AMPS I Licensed Professional 201-1000 AMPS OWNER -BUILDER DECLARATION 1 hunion that 1 em exempt from the Contractor's License Law for the following rtason. (Section ]031.5, Business and Professions Cole: Any city or county maso [I BATH REMODElaREPAIR �DFMOI,ITION ❑OTHER _ rVla-RGe'�-I�s7-- OVER IWaAMPS SIGNS ELECTRICAL which myunes a permit to construct. mar. improve. demolish, or repair any swcture SPECIALCIRCUIT/MISC. r.70 prianoits issunttce, also reyuircs the npPliwm for such permiuo fleasigncd statement that he is licensed pursuant to the provisions of the Convectors License Law (Chapter 9 tOMMERCIAL (comntendng with Section 7") (if Division of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of TEMP. METER OR POLE INST. ❑ NEW BLDG/ADDITION ❑ DEMOLITION Section 7031.5 by any applicant fora permit subjectsthe applicanr to a civil penalty of POWER DEVICES ❑ TENANT ❑ FOOD SERVICE a. more shun rise hundred dollars ($501). IMPROVEMENT E] 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business and PmRssioas Code: The Convector's License law does not apply a an at, of SWIMM LNG POOL ELECTRIC ❑ OTHER OUTLETS -SWITCHES -FIXTURES Q property who builds or improves Inc.., and who does such work himself nr through his own employees, provided that such intpmvements are not intended or nfr.d for sale. If, however, the building ini onowerem is sold within one yam of completion the NEW RESIDENTIAL 17LEMR SQ PT. SQ. FT. FLOOR AREA 5/SQ. FT. ner-(wilder will have the burden of proving that he did not build or improve for Pur. ef salcJ. s owner of the property, am exclusively emanating with licensed contractors to T4 't onswet the project (Sec. 7044, Business and Professions Cade:) The Cammnor's Li. wase Law does not applymm owner ofproperty who buildsor improves thereon, and QTY. PLUMBING PERMITFEE lob, whocontrtets for such poicas with aconvenor(s) licensed purmantm Ne Commcter's Licence Law. I am ewe under. c. . B & P C for this reason JUN 2 g7qpIf ,-g� PERMIT ISSUANCE ,J U� ALTER - DRAIN & VENT - WATER (EA) VALUATION Own Date BACK FLOW PROTECT. DEVICE DECLARATION WONKder 1st al irom pro yofpc qon penalty of perjury one or elf-ifor for STORKS"'-""�••--. 'ONKTRU ION Cdeclarations: t, Worker's have and w maintain a of Consemtr Worker's Compen- ❑Ihavc erdwia DRAINS -FLUOR, EDGE. AREA, COzz Code. for the section, az pmviJad for mi Section 3](10 of the Labor Code, for the performance of the I., byneCettili700 work for which thio permit is issued. FIXTURES -PER TRAP ❑ I have and will ode. fon Workers ante of the work hi az capturedrm by Section 9700 oldie labor Code. for the performance ofthe work for which this permit is issued. GAS -EA. SYSTEM.I INC. 40IlTLETS OCC. GROUP APN My Worker's Compensation Insurance carrier and Policy number are: Carrier: Policy Nn: 01 11) GAS -EA SYSTEM OVER 4 (EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREAS[ANDUSTRL WASTE INTERCEPTOR BUILDING DIVA ION FEES Mix .,firm need pan he completed if the permit is for one hundred dollars IS l(W) or Ins.) GREASETRAP PL4NCHECK PEE - SEWER -SANITARY -STORM EA. 200 FT, ENERGY FEE IwrtifythatinBe, performanccofrhe work far which this permit is issued. [,hall not employ any person in any manner so as to become subject m the Workers' Compen- WATER HEATER WNENVELECTR GRADING FEE Laws of California. Dam 1 Applicant NOTICE TO APPLICANT'. IL after making this Certificate of Exemption, you should become xuhject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. WATER SYSTEM,TREATING WATER SERVICE C! SOILS FEE is • CONSTRUCTION LENDING AGENCY construction 1 1 hereby affirm that them is a construction lending agency for the performance of NEW RESIDENTIAL PLMB. SQ, P. PAID Receipt TOTAL the work for which this permit is issued (Sec. 3097. Civ. C.) Lender's Name I Lender's Addrtss 1 certify that I have read this application .6 slate that the above information is 1 correct. l agree m comply with all city and county onireaces and amte laws relming to building construction, and hereby amborica represemmims of this city to enter upon the BUILDING FEE QTY. MECHANICAL PERMIT FEE' SEISMIC FEE PERMIT ISSUANCE. ELECTRIC above-mentioned property far inspection purposes. (We) .,me to save. indemnify and keep harmless the of Cupertino agvirot PLUMBING FEE liabilities,judgments, costs and expenses is ¢ hich may in any way areaagainst said City in smamptima, of the gor it, of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -MINT e. ON mss ' ALTER ON ADD TO MECH. AIR HANDLING UNIT (TO to." CFM) MECHANICAL FEE Z O AIR HANDLING UNIT (OVER 10,lNp CFM) CONSTRUCTION TAX %�RF (,1jY(jyg ax/""`^'x..�t Signature of AppcmVContmctor Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the application or Bruce building occupant store or handle haaurdous material BEATING UNIT (M IMB00 BTU) , as defined by the CuNi in r Municipal Codc. Chapter 9.12, and the Health and Safety Cade, Section 25532(a)7 HHATING UNIT (OVER IOBWU BTU) E] Yes ❑No - VENTILATION FAN (SINGLE RESID) PAID -- Dote Receipt# Will the or lleanr or future building «cuPant use compmem or devices which emit hamrdoes air contaminants as defied by the Bay Area Air Quality Maregemem BOILER- COMP(3HP OR 100.000 BTU) BOILER - COMP (OVER 100,000 BTU) District' EJ Yes C] No P 'AIR CONDITIONER Cm - 1 have rtml the hazardous materials rcyuiremenB under Chapter 6.95 of the Cali- fnmia Health & Safety Cade, Sections 25505, VISO and 25534.1 understand that if the ISSUA CE DA/TE') 1� ( A NEW RESIDENTIAL MECH. SQ. ET. building does not currently have a tenant that it is my responsibility to crafty the occupant r O �' I _ s of i hieh tenor to issuance of Certificate of Occupancy. �11 womins miil'ida g nt Date ISSUED BY: OFFICE