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S 3090
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.ELECTRICAL PE ff NO. Q Bun.D�ry�:nrvlNlpN APPLICATION/PERMIT PLIIMItING�MECIIANICAL 0�J O BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SURMITI'A�L1DA�'fJF. Z2Zf CU/�6&7/A% ddt7 - T 0 O ' - 'S NAME: PHON t: CONTRACTOE' NAME:'' LL LIC NO: NIC CON ROL k Y ❑ C ITECT/IWGINI!CR: LIC NO', ADDRESS: CONTACT: PHONE: BUILDING PERMIT Pes ^ EDnSu Colfant Fees Paid by Applicant(Initial) RL❑DC F.LECI' Limit M MECH fa V ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECIRICPERMIT' FEE 1 herehy amrm mat[:anlicensed under pmvi.donx of Chapter 9(commencing 108 DESCRIPTION GSy with Section 7000)of Division3nf the Runinasand Professions Code,and my licence is © RESIDENTIAL, -O p PERM I f ISSUANCii FgUt L ease Class effect. ❑SFDWI. ❑KRCHEN REMODEL GU�) lydc Class Lica APPLIANCIS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE FZW Dam Contractor m660MULTI-UNIT ❑STRUCTURAL ARCHITECTS DECLARATION Zp-F,p m PANELS ti CHIME MODIFICATION a IunJersmnd my plans shall beuscd as public records UP'TO 2(q ANTI'S ' pz..� ❑IMF.RIOR ❑CHIMNEY REPAIR 1=4F'ty Licensed PoRtlimml 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS 90' d OWNER-IUILDER DECLARATION OVER IOIN)AMI'S ❑BATH REMODELIREPAIR ❑DEMOLITION Pj 6'a 6 1 hm ereby affirm that I aexempt from the Comracmrx License Law for the �6 d CJ followin6 ream...(Sceiimn]113 L5.Business and I'rofesxienx Code:Any city nr aentY SIGNS ELECTRICAL OTHER 1+1'3 6 Fwhich requires a permit to construct,alter,improve,demolish m repair any structure O_ minroritsissuance,alsorcquirn. h npplieem forsuch permit...tile.,i,endsontemir SPECIAL CIRCUI DMISC. ymmheisl!cepsedpurs.ant tome,rovid....flue Com.o.e,License lew(Chapter Y aOC (commencing with Section 700(dof Division 3ofmm BeisinessunJ Professions CA10.1 TEMB METER OR POLE INST. COMMERCIAL: 6 Q. than he is exempt merefmm end the bast,for the alleged exemption Any viothtion of [1 NEW BLD6ADDITION ❑DEM0IA HON Sciatica 7031.5 by any applicant for a permit subjects the applicant to a civil peruhy of POWER DEVICES OTENANT ❑FOOD SERVICE Zy t mo ownerfve hundred dollar,(SIM). IMPROVEMENT �S6 of the property,or my employees wim wmgesis their sole compensation. SWIMM INC,POOL ELECTRIC b... Ildashe work.and the svucmreonotintendedoroffcr forsale(Sec.7144.kusincss ❑OTHER 63 m nJ Prdesxirns Cndc:The C..nlmcmrs Liccnsc Low Jnes oat apply m an owner of OUTLETS-SWITCHES-FIXTURES property,who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or oI cred for NIiW RESIDENT[Al.ELECT R SQ sale.If,however,the bulldingcrimprovereent viscid within one year of mntpletien,the SO,FT FLOORAREA $ISQ.FT. ownerhaidder will have the burden of proving that he did not build or improve bor pur- i pose of sated. 1,us owner of the pmpeny,am exclunt sively coracting with licensed smuctu ass to TOTAL: construct the project(Sec.7144,Business end Pramssiums Codc:)no Gntmmtors Li- c so Low does net apply to an owner or property who hi ills or improves thereon,.,it QTY. PLUMBING PERMIT FEE TTrf/- wheeonlLwo,name cots wimacsmuaet s)Iicemed p...mom Ilse Contmnors Licenm taw. PERMIT ISSUANCE C� ❑]a�xemp A .B&P C for this renin. L ALTER-DRAIN&VENT-WATER(EA) VA UA9'ION own Time _ If WORKER'S COMPENSATION DECLARATION CK TlOW PROfEC'r.DEVICE 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain aCenihcaa ofCnnsenun ulf-insure for Workerscompem DRAT '.00R.k D. STORIES TY PE CONSTRUCTION talion,us providod far by Section 3700 of the labor Cnde,for the performance of the work for whichmis person is timed, FIXTURES- ERTR U In 1 have and will maintain Workers Compensation Insurance,as required by Section 3]IX)of melabur Cnde,fnrme performance of the work for which this pemrit is issued. NO Y."F.MI INCA .TS OCC.GROUP AI'N, My Workers Compensation Insurance carrier and Policy number arc: Cameo Policy Na.: GAS-GA.SY F. 4 CERTIFICATE GF EXEMPTION FROM WORKERS' GREASPANDUS"I RL WASTE CEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES (Thisscclum need nm becompdetel if the permit is fee"..Threshold (S I( - I or less) I'LANCHECK FEF, I codify that in me performance dthc work forwhich this permit ix issued,l shall SEWER-SANITARY-STOR .2001-7. not employ any person in any manner son to become subject to the Workers'Compen- ENERGY FEE emion Laws of California.Date WATER HEATER WIVENT/GLEC'T,, GRADING FEEz 0 Applicant N NOTICE TO APPLICANT:If,after making that Certificate of Exemption,yon should WATER SYSTEMiTRFATING� SOILS Flit F become suhjee to the Workers Compensation provisions of the Labor Cal,you most fnrhwim comply wiN such provisions or this permit shallbedeemed revoked. WATERSERVICE Q M CONSTRUCTION LENDING AGENCY NEW RESIDEM'TAT,PLMIL SQ.FL PAID Da Receipt g V O 1hombyafftrm that there iso construction laadia,mancy brain pedbmmnceof he work for which this pencil is issued(Sec.3117,Ci,C.) Q U MAL: LeeJer's Name T W Lenders Address 'TOTAL: 1 eenify that I have read this Pppliention and stole the the obovc information is BUILDING F P T0./Y correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MIiCHANICAL PERMIT FEF, V Z building construction,and hereby authorize m,memmivesofthis city menmrupon the SEISMICfq alive-memioned progeny for inspection ParPt'se, PERMIT ISSUANCE LLF.CfRIC PE (We)agree Ir save,indemnify and keep harmless the City of Cupertino against liabbmv.judgments,comsa expenseswhlchmayinanywn ca5ainsrsd City ALTERORADDTOMECIL "LUMBINC ITE msequence of the Bran B of this pemsit. APPLICANTU )h ANDS ANDW COMP WITH AL LN -P INT AIR HANDLING UNIT(TO I(TOM)CFM) SOURCE REG ONS. MECHANICAL ITE AIR HANDLING UNIT(OVER HT0MCFM) CONSTRUCTION TAX gnmurcof ppl Contractor Date EXHAUST 11001)OVIDUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Wilit pplimnt or future building occupant store or handle baaardome material HEATING UNIT(To 100.IXI0 BTU) as definedthe Cupertino Municipal CWe,Chapter 9.12,and the Ilcalth and Safdy Code,Section 25512(a)'3 HEATING UNIT(OVER Ig1.fMM1 BTU) ❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID Date Rtteipl M Will the applicant or furore building occupant use equipment or devices which BOILI!R-COMP OHP OR I0(kOfN)BTU) n hamrdom mi air contaminants as definW by the Bay Area Air Quality Management TOTAL: DisRicP BOILER-COMP(OVER1IMMO BTU) ❑Yet 0N I have read the hanumnemiciims requirements under Chapter 695of he Cali- AIR CONDITIONER ISSUANCE/DAT. forma HeaWr&Safety Code,Se lion,25505,M533 and: 534.1 understand that date NEW RESIDENTIAL MECII. SQ.Fr. huilding Joe,not cunemly have.ranant,me it is to,responsibility to ratify the recupmnt of me reyuircrcents which mustbe met prior to issuance ofa Cenifcate of(kcupnncy. 'Owner or authorize)agent Dme TOTAL: ISSUED BY:% OFFICE