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S 2235 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PH NO. BUILDING DIVISION APPLICATION/PE RMIT PLUMBING-MECHANICAL. �IT2235 BO/UINGDRESS ISUILDING I'ROJF.CT IDEN'1'II+ICATTDN' : /I � ^ I� 1 SANHARYNO. APPLICATION SUBMI''I"DATI OWNf R'SNA.F: PHONE: CNAME �.J�IC�N(y,� N/C CONTROL. _ARCHLY C m l '?k: LIC NO: ADDRESS: ❑ ©b-3 CONTACT_ /V r , PHONE t. 'BUILDING PBRMINFO - `rLll�la��Y/-tel �IIR �/f_,_ _ ❑ Coneul[0n[Fece 'P Applicant(Initial) BLDG ELECT PLUMB MECH PKJfA- 1 ❑ ❑ T--I/ ❑ LICENSED CONTRACTORS DECLARATION ARATION QTY, -EL RMIT FEE lQ I Hereby affirm the 1 r e a p f Chtr pl 9( 'mg _ _ _ _ JOB DESCRIPTION "O Zn O wulfii.n 700B)afDs o ' n9afthusc BtessatdP-f� tlo, :n .CArood nryfse's RESIDENTIAL r PERMIT ISSUANCE; fy-it A Itinerant]effect. L1 SCOWL ❑KITCHEN REMODEL 6UV License Class Li..N A ❑ APPLIANCES- ❑ RESIDENTIADDITION PLUMBING RE-PIPE P z w Dale Contractor ARCHITECT'S DECLARATION ❑MULTI-UNIT OSTRUCTURAL ZOtr'Z l understand mY plans shall he used as public records PANELS MODIFICATION OZ4� UP 10200 AMPS El INTERIOR ❑CHIMNEY REPAIR �13tu1 IJcesel Pmfe,sinart 201-1000AMPS IMPROVEMENT SWIMMING POOLS •�.....11l OWNER-BUILDER DECLARA'T'ION y6 1 hereby affirm that I em exempt from the Contractor'x License Law fnr the OVER 10010 AMPS ❑BATH RI:MODEWREPAIR []DEMOLITION X O d U following reason,(Section 70315,Business and Professions Code.Any city or county SIGNS ELECTRICAL ❑01 HER _ 3 W y which requires a permm it to amsnact,alter improve,demolish,or repair any structure n 1 prier to its k,naneealso requires the applicant hasuch permit m file a signed statement SPECIALCURCUIT/MISC. S` G A-I f that Tax Rcensed parwmmu,,the proefdonsofthe Conforms,Liverw Law(Chaplin �l u1 d� (commencing with Sectlon70(0)of Division stir We Branessand PmaNinnsCde)or TEMP.METER OR P01.9INS'L COMMERCIAL: C that he is exempt therefrom and 0o basis I'or the alleged exemption.Any violation of - ❑NEW RLDG/ADIATION ❑DEMOLITION W..y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penully of POWER DEVICES ❑TENANT ❑FOODSERVICE not Inure Wan it,.hundred dollars($500). F'ZY IMPROVEMENT 6 D [,as owner of the ptvpeny,or my employees with wages'as their role compensation, SWIMMING POOL BLEC'I'R Qp will Profession, ande heCou larder,License ofwdoesor.,apply I.a,, Business []OTHER m and Rofwhob Code The botanist, tactor,License Lawdonsnotapply himself or OUTLETS-SWI'PCIIES-PI property who builAr or improves thereto.and who does such work himself or lM1mugM1 ' his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL E :C,R S sale.If.however.the building or lmprovemem is sold within one year comparison,the SQ.PL FLOOR AREA $/SQ.Uld ownenbuilder will have the burden of proving that he did not build or improve for pur- pose of sale.). - r E31,as owner of the property,ern exclusively contracting with licensed contractors to 1 AI onemm the premier(Scc.7044,Business and Pore,,sions Code:)The Cmadwmr's Li- come Law does not apply to an owner of property who hadd,or amprow therson,and i-comeLawdoesnotapplytoanownerofpropertywhohalmsorlmpmvcthereon,and Qw. PLUMBINGPERMIT FEE. who contracts for such projects with a comrcaor(s)Ileensed pursuant to the Contractors License Law. PEIiMI'TISSUANCE ❑ I am exempt under Sec,' - ,B&P C fnr this reason Owner Dale ALTER-DRAIN&VENT-WATER(EA) VALUATION O l WORode,"aOMPENSATION DECLARATION HACK FLOW PROTECT DEVICE have and will ai ands pemlry to ofCon enc of the inure for d orkei' Co ❑ Ihaas and will main tains Certificate ofConsent for Compel- DRAINS-.LOOK.I100P.AREA,COND. STORIES TYPE CONSTRUCTION cation,as Provided for by Section 3700 of the Labor Code,fnr We perfommneo of the r which this permit ix issued. FIXTURES-PER TRAP w have and will maintain Wnrkeds Compensation Insueraw,as required by Section 00, the Labor Code,for the perl'ormancenlthe work for which this permit is issued- CAS-EA.SYS'I'HM-IINC.4OUTLETS 0C MIN My Worker's Compensation Imurso.wrier and Policy mmmbm.,a Carrier: Policy No GAS-P.A.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR _ 7 n .j,;J1jTI)jNVfTVI9IONFR[S " (Tide section Hord not bcemnplated if lM1e.erznil is fnrtme hundred dnllu�($1011) GREASETRAP .r less) PLAN HE employ an I eerily that in IhnpetTnnnsnce of Ihewark for which This permit in issued,I shall not em 59WF.R-SANITARY-STORM EA.ZIIII lT. p y person In any manner,o as m become sngject to the Workers'Compeo- _ BN9ROY F99 O smLl ion Law-,mf California.Date WATER HEATER W/VENT/ELECTR Uf 7 Applicant mO FEE q NOTICE TO APPLICANT:If,after making this Cambrian Exemption,you should WATER SYSTIiMfl BEATING - EK" M.u,me subject to the Workers Co mpennalion......ion,of the Labor Coda,ymi nest SOILS PEE !� „y forthwith comply with such pmvi,inne or this permnit shall M1c dacnstl rcvokrd. WATER SERVICE d CONS TRUC'I'ION].ENDING AGENCY NEW R ESIDENTI Al.PLMR. SQ.PT. PAID z Ihembyarfitmthatmed kisatioarumion lentling agency for the performance 6f Dm Rewiptk the work for which this permit is issued(Sec 3097,Civ.C.) F Lenders Nome TOTAL'. G Lender',Adduces 'I' TAL: Q. I ratify that 1 have rend this n.plicati.n and a re that the ahMme infommli.n i, - �- . . BUILDING 1 (A correct.I agree to comply with all city and county colleges and stat laws slating to QTY. MECHANICAL PERMIT PEE , V Z building eradication,and hereby authored representatives of Ilk city to emermanthe SEISMIC FEE a eve-tnormsedpmDely for Inspection pnrpoaw. PERMIT ISSUANCE (We)agree In rave,indemnify said keep harmless the City at Cuperirm agninn ELECTRIC Iiabililles,judgments,was and expense,which may in any wayaceruaagalmt said City AFTER OR ADD TO MECH, consequencein of the gnmting of this permit PLUMBING PEP APPLICANT UNDERSTANDS kD WILL COMPLY WITH ALL NON- OINT AIR HANDLING UNIT(TO IQ000 CFM) Ek iC LATIO MECHANICAL FE' 114 q l;m , AIR HANDLING UNIT(OVER 10.000 CVM) CONS'TRUC'TION TAX .ignamm ofApplieant/Comnttur Dale fff EXHAUST HOOD(W/DUCT) I LOUSING MI'TIGAT'ION FEE HAZARDOUS MATERIALS DISCLOSURE Willthc applicant ar future buddingoccup,mcare or handle hamomv.mmerinl HEATING UNIT(TO 100,000 BTU) as defined by the Camerm.Municipal Code,Chame,9.12,and the Health and Safe,, Code,Section 25532(a)R HEATING UNIT(OVER 100.000 BTU) L]Ye, I]No WPAID - N'1'ILA'1'ION PAN(SINGLE,kESID) Data Receipt N Will the applicant or fumy buildingsrripim use equipment or devices which BOILERCOMP(3H1'OR 100,000 BTU) emit htim,mardair_contaminants as defined - by the Ray Area Air Management CA Dmmct, ❑Yes 7 N BOILER-COMP(OVER 100,000BTU) ,. . IM1vve rrnA lM1e hazvMnus materia.syuiremenn under Chapter 695 of the Chli- AIR CONDITIONER ISSUANCE DATE (atria Hmllh&Safety Code,Seem...25505,25533 and 25534,fundmistund that if the NEW RESIDENTIAL MECH. SQ.PT. (y baildmgdrivran mon d I tenant,firma nmyms.onslbility to nyo�ti(fy�tqhweyoycaryr�are of re lir Hent",nun, c ,et prinrto da Cem_/I9 �I76 Chsam.ramhmrieul agent �I(A((] Data /v TOTAL ISSUED RY: OFFICE,