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S 1474 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL L PEIk"IT"° 1474 BUILDING DIVISION APPLICATION/PERMIT DI.G PROJEBING-mEDENTIFIC. PEES IIUILDING 1'ROJ F:CT IDENTIFICATION ' BUILDING ADDRESS: SANITARY NO. APPLICATION S�hU(HMITTAL DATE /OC / G l e) OWNERS NAME' 1{ONE: CONI' ACTOR'S NAME: / LI�X10� / NIC CONTROL# �A CHITECTI.NGINF.ER: LI NO: A ^� F/ A 1'C /(Op CONTACT: PHONE. 7 )V/ V C'G BUILDING PERMIT INFO or4/N r/� r J--©n'o Consultant Fees Paid 64,Applicant(Initial) Bh ELE PLUMB CH illto LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby affirm that 1 am licensed under provisions ofchapter 9(commencing JOB -SCRIPTION �IYZ wim Senion]INX))nf DivinianJof the Business so up dessinns CA, lndnrylicmtulx RIESIDENTIAL u10p inPERMITISSUANCE FF full forcca teff ❑SFOWL ❑KITCHh:N R1iMODEI. aUF Ln°'# APPLIANCES-RFSIDENTIAI. ADDITION ❑PLUMBING RE-PIPE {y Date ` Cnnlrndnr aL ARCHITECTS DEPA CLARATION MODIFICATION MULTI-UNIT ❑STRUCTURAL E"h Z I oramsh ndend my plans a11 he used as p.hill records NELS ZOZ4C UP TO 200 AMPS ❑INTER IOR [I CHI MNEY REPAIR F•,N..F,W Licensed Professional - 20I-100IAMPS - IMPROVEMENT 0SWIMMING POOLS �S4 OWNER-HIIILDER DECLARATION OVER TOO AMPS ❑BATH RF.MODEI/RF.PAIR [I DEMOLITION K K.e 1 hemby aftlin that 1 am exempt from the Contrectur's License Law for the _ O6 U followi..roam..(Scudo..70315,limine.,,and I'rofessirnu Cvdae Any lily or county SIGNS ELECTRICAL [IOWER I++LLLLEv-1 which requires a permit m cornmou..[,a,improve,demolish or repair any swnure O 6 prior to its issuance,also requires the applicant for suchperm..to File auquitJsmmment SPECIAL CIRCUII9MISC. }2 that he is licensedpursunnt.,he provisionsnf the Contractors license Law(Chapter 9 ItsC (commencing with Station 1(10)of Division]of the nosiness and Professions Cost I LMR MG I'FR OR POLE INS'f. �' TID Qryyll 4 X m c that he Is uxempt therefrom and the basis for the alleged exemption.Any violation of ❑NE DDI N'^eL'155FFMOLITION GXl Iiy Section 9031.5 by any applirnm for.pemJt subjects lheupplicunun acivil penalty of POWER DEVICES ❑T}' f ❑FOOD SERVICE Gnetmere man live handled dollar, @IPBW€dl (TUrLHIA0❑1,as snvncrafthe propeny.or my cmployeeswim wagesslhcireole nnnpcnsmion, SWIMMING POOL ELECTRIC will do the work,and the swnum Is net intended or oliumd I'or sale(Sec.7044,Business -(]OTHER- 63 and Pnsfes,iems Cale:The Commico e,License Ww doos a..apply to an mwmr of OITI LETS-SWITCHES-P]XTUHFS I Property who builds m improves mersm,and wha does such work himself or through hk own employees,provided that such improvemend am not intended or offered for NEW RESIDENTIAL.ELECTR SQ FT. sale.If.however,the building or improvement is sold a.imin one year of completion,the SQ.FT.FLOUR AREA SISQ.FT. r-builder will have the burden ofproving that he did nm huildorimpmvefofpur- O rose of sal'.). f/O ❑1,.,,—car of the propeny,am exclusively cemruding with Iicen,al commeors construct the prolcd(Sea 7044,Basi ness and Professions Code:)The Conwcmrs Li- cerise Law does not apply u'an owner of property who builds or animates memon.unit QTY. PLUMBING PERMIT FEE who contracts for such procca s with a comma r(a)licensed pursuant o the Contmcmrs b—V✓ License Lao, PERMIT ISSUANCE I am exempt under Sec. ,B&P C far this reason _ ALTER-DRAIN&VENT-WATER(GA) VAI UUAAII[OONp��s���.r ter Datc V•W WORKERROWS COMPENSATION DECLARATION HACK W PR(TfECT.DEVICE I hereby affirm under penalty of perjury one of the following declarations: ❑Ihave and will'swinmin a Certificate c(Consentm self-insure for Worker's Confer- DRAINS-FLOOR,ROOF AREA,COND. STORI[S TYPE CONSTRUCTIOI smien,as provided for by Scvian 3700of the Labor Catc,far the performance of Nc work for which mis pmmit k issued FIXTURES-PER TRAP I M1ave and wilTmaintain Workers Compensation Insmmi as required by Section J]Wofthe labor Code,for the performance of the work fur which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS (KC.GROUP APN My Worker's Cempensode n Imsunmee carrier and Policy m mt er am'. Currier: Policy No.: GAS-EA.SYSI'RM-OVER 4(EA) CER'TIFICA'TE OF EXEMFI'EON FROM WORKERS' GREASVJINDUSTItL WASTii INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION -ES or lass.) (This section need not he completed alhq Permit is fortune minimal dollars($In)) GRRASETRAP PLANCI IIiCK FEIi I ready hot in the perforsmall,fthe work farome.h this penitis issued.Idiot SEWER-SANITARY-STIT.ORM EA.2W I. not empleyunypernn u inunymunns•[s y, bject m the Workers Compen2 - ENERGY ME? s.Iran f Ckoia�)af ( d WATER HEA'ILR WNf:NT[ELEC 11 z Applic C(s rd(NL/' GRADING FEE FN-t NOTICE'0 APPLICANT:If,after nuking this Certificate of Esemptiun,you should WATER SYSTEMUREATING SOILS FEE F+ become subject In the Workers Compensation provisions of the Labor Cade,you must fothwith comply wimsuch provisions or this Permit shot]ba deemed mvuked. WATER SERVICE O CONSTRUCTION LENDING AGENCY NEW RISIDENTIAL PLMH. SQ.FT PAID Data I eceiptp I hereby affirm auhem is amsweion lending agency Gal he pan erformee of m w the walk for which this permit is issued(See 1097,Civ.C) L O U Lender's Name U Lenders Address BUILDI sE cA 1 equity Ihm I bile,rcuJ this application anJ stem thud the above informming is r4, Vl crcngemnieemao,and hardly and represnNinmces andsmmlawsreladngm QTY. MECI{gNICAL PERMIT FEE SEis 'F-11. L) z huilJingemxwctien,and hereby mnhori¢represcnmtives(it this city mercer upon the above-mentioned pmpeny for inspection fropmal. Micro r ISSUANCE ELI: sE (We)agree to save,indemnify and keep harmless the City of Cupertino against Iidili lies,judgments,cars and expenses which may in any way accrue against said City ALTER OR ADD TO MECI. PLUM ING FEF O in consequence of the gaining of this Permit. APPLICANT UNUILIRSTANDS AND W)J,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBWOCEM) MI:CHANICA FIiE O SOURCE -;U TION' 0/��� AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUC ON TAX Signemreof App,licanifiClarmullhim, Dom EXHAUST GOOD(W/DUCf) HOUSING ITIGAMON ME HAZARDOUS MATERIALS DISCLOSURE Will theapplicant orfamrt building Heinen,dean,handle havWoustnamri.l BEATING UNIT LTO 100,000 BTU) as defined by the Cupeniao Municipal Coal,Chapter 9.12,and the Bashi,and Safely HIIA'I'ING UNIT(OVER Iuadud PTU) Code,Section 8532(.)'! ❑Yes [IN. VENTI IA I'ION FAN(S]WILL RES ID) PAID nta Receipt# F Will the do-air commtm(umrc ldefired byding the nt use Bay Area AirQualitynt or anaes which BOLI Iik-COMP(]IIPUR IIN),(NN)BTU) canal M1vnrJnus air cnnmtninum,ns dcGneA by the Buy Area Air Quality Management TOl'AL: District? ;CONDIT10ENER 00.0IBHTU) Yes F7 No I have read the havemous materials requirements under Chapter 6.95 of lie Cali- ISSUANCE DAM forma I lo:dlh&Safety Code.Seeiom 8505,25533 and 25534.I maloodomd that if the I. SQ.P)'.buildingdoes not embodyhave a terms.that it is myresponsibility mnotify the occupat of Ibc rcquireari which must be met pror to issuance ofa Cenificate of Occupancy.Owner or atiflowned agent Datc ISSUED BY: FICE