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99120076APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY 1-' 60 IV CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERNIT PLUMBING. -MECHANICAL. BUILDINGVROJECT IDENTIFICATION • ' PERMIT NO. BUILDING ADDRESS: - SANITARY NO. APPLICA MITTAL DATE /0725 DE AId ZA 6L /D 11-23 F OWNER'S NAME.: PHONE: /G 1 CONTRACTOR'S N M Zq %� G % ry0: L �y J NEC ❑ _ CONTROL# I- I'ARCf F.CT/BNGIN�FER' LIC NO: +� -sl I "G -'i5943. ADDRESS - -75' 6eWlS r.CAD 50) 71F 2� CONTACT: - PHONE: - - ❑ Consultant Fees Paid by. Applicant (Initial) 7 BUILDING PERMIT INFO RLK BLP.Cy' PLUM MEC LICENSED CONTRACTOR'S DECLARATION;. I hereby affirm that 1 an licensed under provisions of Chapter 9 (commencing ELECTRIC PER !!' FEE '1 JOB DESCRIPTION PERMIT ISSUANCE with Section 7000)rf Division 3of the Business and Professions Code, andmy license is in full f and effect. 48 � 0 RESIDENTIAL: ElSPDWL [I KITCHEN REMODEL APPLIANCES -RESIDENTIAL License cOue tos Lich Dam— '_ - CWmemr ❑ [RATION ❑ PLUMBING RE -PIPE ❑MULTI -UNIT L1 STRUCTURAL MODIFICATION INTERIOR MODIFICATION REPAIR ARCI{ITF:C'fS DF.CLARAT ON I armasom en,,laos shall is users, public rea.Ns PANELS UP'T021MIAMPS Licenced Professional OWNERBUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the 201-1000AMPS - IMPROVEMENT SWIMMING POOLS Ob ATH :M EIIBF 1 OVER IWO AMPS 4% SIGNS ELECTRICAL follnwfng reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to consumer, alter, Improve, demolish, or repair any structure SPECIAL CIRCUIT/INISC. Prior to its issuance, also requires the applicant for such permit o file a signed statement — that lie is licensed pursuant to the yroviseemi of the Contractor's License Law (Chapter9 (cohnismang with Section Than of Division 3 the Business and Professions Code)or TEMP. METER OR POLE INST. COMMERCIAL: chat he is dicams therefrom and the basis for the alleged exemption. Any violation of ❑ NEW BLDG/ADDITION ❑ DEMOLITION Section 7031.5 by any applicant for. pmmltsublemsthe applicant too civil penally of no'more than five hundred dollars ($500). ❑ L as owner of the property, or my employees with wages as their rile compensation, will do the work, and the structure is not intended occurred for..0 (Sce. ]044. Business POWER DEVICES - ZAEIQANT ❑ FOOD SERVICE - IMPROVEMENT ❑ OTHER SWIMM I NO POOL ELECTRIC sad Professions Cede: The Chinni Levemee Law does ton apply to ton owner of OUTLET'S -SWITCHES -FIXTURES property he builds or improves thereon, and who does such work himself "'through his own employees, provided that such improvements are not intended or offered for sale. IL however, the building or improvement is sold within one year of compledomom NEW RESIDENTIAL BLECTR SQ Pf. SO. FIT FLOOR AREA II/SQ. Cr ownerTudder will have the burden of proving that he did not build or improve for Aur- - pose of sole.). ❑ I, as owner of the propeny, am excessively contracting with licensed rnmmnors i- TOTAL: and i- enema the project (Sec. Code:) The Conmagon, Li- - rtcLawdoesnmapplyto;rs ownerofprepertywhoboomsor thereon, and censeo an owner of property who QTY.. ._ •'PLUMBING PERMIT FEE rnimproves who commcre former projeus with n comnunor(s) liwrmed pumuam tothe Contractors -PF.RMITISSUANCE License Law.' lam oxonnpl underSec ,B&PCfor this reasw Owner Date ALTER - DRAIN & VENT- WATER MA) VALUATION WORKER'S COMPENSATION DECLARATION - under penalty of perjm oneerim of the declarations: Co BACK FLOW PROTECT. DEVICP. DRAINS -FLOOR, ROOF, AREA, GOND, have and will mai ,ridansumfor ineCion 370 of the Laor Code, farce Worker's Comp the ❑mantas and will for smirk, as provided for Bodies 3]00 of the Labor Code, for the performance of the STORIE TYPE CONSTRUCTION work for which mi is FIXTURES -PER TRAP illcpermp 1 have maintain Worker's Compensation Imumnce, required by Section orke. ' swill of h 3]110 of the Labor Cada, for the pertormance of the work for which this permit is ixsuui. GAS -EA.SYS'CEM-1 INC 40UTLE'fS OCC.GROUP AP O My Work� �Comppensmtinn Insurayt'e carne and Policy my1 b�� ¢ Carries KC-Pill31 t ( I L1DEYt\lDlNnlicy Nn.: LSI "LOQ% r., GAS PA. SYSTEM -OVER 4 EA) CERTIftIC�ATE OC• L'�XL'•M f10N FROM WORKERS' COMPENSATION INSURANCE I GREASFIINDUSTRI, WASTE INTERCEPTOR x - - - x K TBUILDMG, DI VISION P8E4 (This sedion modnrrte completed if the per mit iIfonme hundred dollars ($ lot)) rrlcse.) GREASE TRAP PLANCI{F.CK THE - I certify lhelintbe perfrmnancnof One work for which this permit isixsued, l,hall not employ any person in any manner xn a, In become subject to the Workers' Compen- SEWER -SANITARY -STORM EA.20f1FC ENERGY FEE WA9'ER HEATER WNENT/ELECTR ,scion Laws of Calimmla. Date Applicant GRA NO FFE Q NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should heu;me subject m the Worker's Compensation provisions of the Labor Code, you must WATER SYSTBM/fRP.ATINO B� SOILS ` 1 .WATER SERVICE forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that is a consuucrion lending agency for the performaneeof PAID Date Receipt# i NEW RESIDENTIAL PL M. SQ. IT. _ the work for which this permit is issued(See 3197. Civ. C.) Lendcr'aNvmn - TOTAL: Lender's Address TOTAL: BUILDINGJF 1 certify Ihim I have recd this mmliesum and slate that the above information is conte. l agree to comply with all city and county ordinances and state laws relating In building composition, and hereby authorize representatives of this city to eater upon the QTY MECHANICAL PERMIT' .EEG SEISMIC FEE PERMIT ISSUANCE ELECTRIC PEE above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against ALTER OR ADD TO MECH. PLUMBING HE Iiabilitiec,judgmems, cousand expenses which may in any way acerae against said City in asequence of the granting of this permit. AIR HANDLING UNIT (TO 10,000 CEM) MECHANICAL PEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE EGUL TIONS, AIR HANDLING UNIT (OVER 10.000 CPM) CONSTRUCTION TAX /n/ ��*, Signa plirmtdC7 mcwr iIALS DISCLOSURE EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT Cry 100,00t) BTU) - Will Will the applicant r future building occupant store or handle meanness materlml m defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(x)^ HEATING UNIT (OVER IWood BTU) El Yes ' ❑No Will the applicant or future bedding y the B use equipment Qu or devices which corn haeardnus air contaminants ax defined by the Bay Area Air Quality Management Duhin1 Yee E:lNr PAID VENTILATION FAN (SINGLE RESID) Dam Receipt# - BOILER -COMP (3IIP OR 100,000 BTU) ✓1'O'CAL , BOILER - COME (OVER 100,000 BTU) AIR CONDITIONER5 I have ;tad the hamNous mulerials cormorantsenis under Chapter 69of the Cali- forma Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the huilding docs not currently haventenant, that it is myreaponsibilily to notify the occupant ISSUANCE DATE //r -Q F NEW RESIDENTIAL MECH. SO. FC. ofthc reyuircmems which must be met prone issuance of n Certificate of Ocmnpnncy. /// ISSUED BY: Ownermmnmiudagem Date , TOTAL: OFFICE