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S 2538 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECURICAI" PERMIT NO. BUILDING DIVISION APPLICATIONIFERMITPLUMBING-MECHANICAL S HuildING PROJECT'IDENTIF'ICATRIN 2538 IRALDING ADDRESS: SANITARY NO. APPLICATION SUBMIIIAL DATE 194 L -9y OWNER'. AME: I NE: COM' " OR'S NAME: LIC NO: A/ G Q /s_ NIC CONTROL# _ARCHITECf/ENGINEIeN: li� LIC NO: ADDRESS: UL` (19 /�L ❑ © P Z reto CONTACT PHDNE: /-GG BUILDING PERMIT INTO y p p� ❑ Consultant FecS Paid by Applicant(Initial) sit DO/ ELECT _ PLUM SPEC][ LICENSED CON TRACTOR'S DFCLARATION O QTY ELECI"RIC PERMIT FEE JOB DESCRIPTION I hereby affirm that I am licensed under provisions of Chapter 9(commencing O0Z with Sution]000)of Division loftheBosine'sopa Pmfcstons CtWe.end my license,, !O RESIDENTIAL I+f O p In PERMIT ISSUANCE 36 F.ly full force and effort. --� ❑SFDWI. ❑KITCHEN REMODEL �uu I.iecnu Jas, Lica APPLIANCES-RE.SIUCNTInL ❑ADDITION ❑PLUMHING RF.-P[PE F W Date Commcmr vrzW ❑MULTI-UNIT El STRUCTURAL F,Om RCHITIiCTS DECLA N PANELS MODIFICATION z O m z 1 understand.,,[.,,ban he axed an public record, OZr3- UP TO 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR f-..pFW Licensed professional 201-HNIOAMPS IMPROVEMENT E]SWIMMING POOLS ��2•,.1 OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATI I REMODHIJREPAIR [I DEMOLITION Yi C d I hereby affirm that I am exempt from the Contractor',License Law I'or the 0.�((O M U following ransom.(Section 7031.5,Business and Pmfessinn,Code:Any city or county SIGNS ELECTRICAL ❑OTHER fkI µ0yQ which requires a Nolut in construct.alter,immerse,demolish or repair any stmmure w .J prior to its harmonica,elsorequira Neapplicam ha Veb perdiit m fileasignedsmtetnem SPECIAL CIRCUIT ISC. or WY thin be is liccrosed puauant rot he pmvtstonsof the Common?, Law(Chapter') CIAL' ��0 (commencing with Section 7000)of Division 3oftha Businesand Profession,Codt)m TEMP METER d 6 c W that he is exempt rberel'mm end the basis for the alleged exemption,Any violation of NEWDG/ADDITION ❑DEMOLITION W^m Section 7031.5 b;any applicant fore permit subject.the applicanuoacivil penalty of POWER DEVICES ❑FOODSERVICE not more than five hundred dollam(goals. EMENT xC ❑I,as owner of Nc prop<ny,nr my employee,with wages as theirmle axmlen.mion, SWIMMINGPOOLELECI'RIC p... wiEd.,ha work,and the structure is not intended..offered Pottle(Sec.AF/4,Business yyW m amt Professions Code:The Contractor's License Law docs not apply wan owner of OUTLETS-SWITCIIU FIXTURES5_ <4��k _;.. pmpeny who builds or improves ihercon,and who does such work himself or through his own employees,providal that such Improvements.m not intended or offered for NEW RESIDENTIAL ELECTR S sale.If.hawevtr.the buildingor impmvemem is sold within ;ue ycandcanplctinn,the FL FLOORAREA EISQ.FT. caner builder will have the burden of pmving that he did nm build nr Improv¢for pur- IroeofsoleJ, []'I,as xwner of the pmpeny,em ex,omd,aly cnnimcan,with licensed contractors 10 m,.cl the project(Sec.701f4,Business and Professions Cwle)The Convuctnts Li «ase Law it,.not apply to anownernf property who builds,,,improves the re.....ad QTY. PLUMBING PERMIT FEE who contracts for such projects with a comorcmr(s)licensed p.,..at a rhe Comment's Ltctnse Law. PERMIT ISSUANCE ❑l am exempt under Sec. ,B&P C for this rea.mn ALDER-DRAIN&VENT-WATER fEA) VALUATION Owner Date D 61 WORKER'S COMPENSATION DECefollo following HACK FLOW PR[Tf1iCT.DEVICE Jf b 1 hereby al mai under penahy of perjury one of the following d orker'in Condom- O (have and will maintaine tion 37W ofConwor to Laor xelpimFore for Worker'seofhe DRAINS-I L(K)R,ROOF.AREA,CON[' STORIES TYP6'CON}TRUCTIOt ,,link,as hick provided fur al lection 3]W of the ladu Cale,fonts perfonnance of the work for which this permit is issued. PIXt'URE.S-ITER TRAP ❑I have and will maintain Worker's Compensation Insurance,as required by Section GAS-FA.SYSTEM- INC.4 OUT LETS �(:��� Oat of the Labor Code,for the Performance of the work for aluelohixpcman is issued. OCC.GROUP wsf� l My Workers Compensation Insurance carrier and Policy number err / � ' s-` Y11 Canner. Policy Nn: GAS-EA.SYSTEM OVER4(EA) (� Z CERTIFICATE OF EXEMPTION FROM WORKERS' GREASIIINDIISTRLWASI'EINTERCEMOR COMPENSATION INSURANCE BUILDING DIVISION FEES (ThisaectionneeJ not beannpleted iffaepermilisformnehundual Jnllam PMOKB GREASLI'RAP in lc x) mer PLANCHF.CK PEE icenifythatinthepM nnnnceaf the workforwhich lbispennitlxissued,(,hall SEWER-SANITARY-STORM ITA.200T. oat employs,pe non man sees hecon �ry jec nrkers'Compcm ENERGY FEE zZ satin,,laws of C: ' .Date WATER HEATER W/VENT/ELLCTR GRADING FE' Applicant AA 4 ti % NOTICE'70 .IC as ak' c. a d Exemption,you should WATER SYSTEM/TRF"A]'ING SOILS H E' become au ena the nrkar's Cnmpenco n pmv aac of the Labor Cale,you mutt Wforthwith comply with such Provisions ur Nis permit>hall b:deemed revoked. WATER SERVICE Q PAID CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.('LMR. SQ.F E Data Receipt# L) O (hereby affirm that there is a construction lending agency for per oreance of Da F the work for which this permit is i...ad bac.3097,Civ.C.) .T OC.) [.enders Name W Ledo,,Address t( 1. D. 1 certify that I here read this application and state that the ab:ve information is eU 1 FEE W coned.l agree to comply with all city and couaty ordinances and stele IRs,doingm QTY, MECHANICAL PERMIT FEEC"'• IJ 4 building construction,and hereby aummue representatives of this city to enter upon the S THE a J above"metnioned pmpcny for inspection purposes. PERMIT ISSUANCE RIC FEE I 0 (We)egret to cost,and expenses xpen and hick may in an the City of CuP-nits against liabilities,judgmentse gumming expenxexinit. may in any way,tame,gens(said City ALTER ORADDTO MECN. '✓7 PLO RING IEE 0 ' consequence of the gumming of this permit. SOURCE AREG LDER. 'ANDS AND WI "C(MI' WITH ALL NON-POINT RHANDLIN 3 UNIT IT 0 I0.0mT CIM) ME HANICAL.FEE IQ SOURCBREGUL NS t. 2 Ilt fiA .LNG VER 11,0n)CFM) C(NSTRUCT10N TAX 4010k .Sig IA a ,mmc r rndSo EXHAUS'I'IIOOD LT) )USING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Wlllthe applicant or future building occupant stare or handle hetetala I H TI ' f 1 ,1100 BTU) as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Hurl ry BEAT INC,I1N1'I'( IINI,(Nla BTIO Cada, Dye,25532(al'! ❑Vexo VEN ILATION FAN IS GLE RESID) PAID Dat - D V e Receipt p Will the applicant or future building occupant use equipment or l vlaiy R 100,000 BTU) emit huzmdo is air contaminants as Jclind eby the Buy Area Air Quality .nage NI 'AI, (![/ District! BOILER-COME(OVER Ip,T,BTU) ❑Yes I have read the momirow material.,mgairemems under Chapter 695 of the Cali- AIR CONUI'1'IONER ISSUANCE"DATE" h fmmla Health&Safety Code,Senons 255115,25533 and 20534.I understand Nm if the NEW RESIDENTIAL MECH. SQ.En �J building docs oute ntly moc.'a...t,It,it iso .:buity to notify the excupant or the reap.; .,which must fox amu' a of a Cenificntem Otempancy. O c tautagent Data T TAI: ISSUED BY: OFFICE