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30581 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. rr� 1 BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. O V H1 BUILDING PROJECT IDENTIFICATIO\ 12NN AD)RFSS� SANITARY NO. APPLICATION SUBMITTAL DA NE E:NAMIi: PHONE: CONTRACTOR'S NAME: LIC NO: 10 '' G NIC pNTROIA ❑ `/'V7f, 4R HITE '1t"I1NG1 EER: LIC�O: AD�Pi55: 72) 'ONTACI': PlIONE: ❑ BUPER ILDING MIT INFO 1 AI I/C 5_0 8110 Consultant Fees Paid by Applicant(Initial) .D EJL�LEC(T� PLUMB /MCEy�CfH' 4� 1{'" •LICIEN,S`E-D'CCONTR`-ACCT'OFR'S DECLARATION ( ' �pI hereby alum Nat I am licensed under provisions n(CM1apon 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION Z. with Scolmin 7UW)ofUivision3ofum Bvsineesand Profic,o %Cole.and my license is RESIDENTIAL, H n] Ilforcc and eIT PERMIT ISSUANCE. ��_ aUf License Class � Lie. � ❑SFDWL [I KITCHEN REMODEL tIl F-aW Com APPLIANCES-RESIDENTIAL Z ❑ADDITION ❑PLUMBINGRE-PIPE p ARCHITECTS D-CLARAf10N ❑MULTI-UNIT []STRUCTURAL H PANELS Z O y I understand my plans shall he used as public records I MODIFICATION OZ�A UPT02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR .<4 t wit Licensed Professional 201-1000AMPS IMPROVEMENT �ow,j OWNER-BUILDER DECLARATION Contractor's OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION Q 1 hereby affirm that 1 OWNER-BUILDER from the Contractor's License Law Iia Nc 3 W F following reason.(Section 7031-5,Basinccs and Prof es:ion,Code:Any city m county SIGNS ELECTRICAL OOTHER F LL C which acclaims a permit it)constrict.uhcr,improve,demolish,or repair any sttumure Fit w prior to its issuance.also regmres the applicant for such permit To rile a signed statement SPECIAL CIRCUIT/M ISC.107 j. That he is licensed personal to she Provisions of the Conwemrs License Law(Chapter 9 e X11 � (rommcncingwithSectioa7(IW)of Division3ofthe Bus;nesvundl'rofessionx CWe)or TEMP.METER OR .'IN' ' C that he is exempt therefrom and the basis far The alleged exanptit n.Any violation of ❑NEW B /A Dglq� C DEMOLITION Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of POWER DEVICES p ,I�4 FOODSERVICE ^Z} nm more than five hundred dollars(SSW), ay�T' f=C ❑1,us awnendthe property,or my employ«s with wages as TM1cirurle compensation, SWIMMING POOL ELECTRI JM,RbVEmah ^ W~ro will do the work,and the structure is not intended or offered for sale(Sao.7(144,Business ❑OTHER EH r�I Wand Limitations Cale:no Commences License law does not apply m an owner of OUTLETS-SWITCI IES-FIRTUR a 1 �— propeny who builds or improves thereon,and who does such walk himself or,hrnu,M1 his own employees,provided that such improvements are nm intended or offered for NEW RESIDENTIAL ELECTR SQ En ,life)LM1 seaccr,the building or improvement is sold within one year of completion,the SQ.FIt FLOOR AREA YSQ.FT. owner-builder will have the burden of provi ng that he did not build or improve for put- �/ 131of saleac cy -to NC � 1, f owner of The property,nm exclusively contracting with licensed comnemrs n, T 1 compact Tire protect(Sec.704,1,Business and Professions GdW The G;mmcmr's Came Lswdocxnmapplr roan with er ac,,oeavCy who licensed pulsaor tion,ves Qlry. PLUMBING PERMIT FEEwho Came Law doescts rsuch not apply to a owecof mo,ar(s)lhobuilpunuannothe Conuacml's License Law. ❑laPERMIT ISS NCE 63 6 m exempt under Sec. ,B&P C for this reason Owner Data ALTER-DRA VENT- ATER(EA) VALUATION M • WORKER'S COMPENSATION DECLARATION BACK FL R()T .D IC "0 ///y W Iha<bflim yam tinder Penalty oflurjury oneofthe folluwingdeclantionz a3 " ❑ I have and will maintain a CenificateofConsem to self-insure for Worker's Confer. DRAINS-FLOOR,Rpt-QNILA.COND, satien,as provided for by Section 37(X1 of the Labor Code,for the parformm�ce of theSTORE S TYPE CONSTRUCTIO: work for which Nis permit is issued. FDCI'URES-PER TRAP ❑1 have and will maintain Worker's Compensation Insurance,ex required by Section 3700 of the labor Gale,for l he perfommancc of the work for which this pcman is issued, t GAS-PA.SYSTEM-I INC.4 OUTLETS OCC.GROUT' MYWr f �s9yma ayL/Y aryrr end YNo.:nu beton:: 4 _96 GAS-EA. r? R TI $MMA00ON OMWORIlti KERSSYSTEM-OVER 4(BA) CERTIFICATE OF EXEMPTIONIRAN WORKERS' COMPENSATION INSURANCE GREASFIIN'DUSTRI.WASTE INTF.RCEPI'(lR or lcssJ (This action need not becamplemd if NGREASE TRAP e Permit is Larval,hundred dollars(SIM) BU (VISI FEES PLANCHECKF tI / '3 Loy any arrom in Iflanyma ameofmto ork f Immuawobjech ttopee Woo issued.Calan- SEWER-SANITARY-STORM EA,2W FT. 7 not employ any perms in any manner so as m hecunse object Ne workers Compcn- Z smionlaws oCaliornia.Dam ENERGY FEE ApplicaWATER DEALER NNENELECTR 7J - z !q� y NOTICE TO APPLICANT:If,after making this Cendicme of Exertions,you should © GRADING PEE WATER SYSTEM?BEATING become subject to Ne Worker's Compensation provisions of the Labor Cods,you must foMwith Comply with such pmvidons or This uil,hall hedn'med revoked. SOILS PNG aQ Per WATER � CONST RUCTION LENDING AGENCY z NEW RESIDENTIALPLMB. SQ.FT. PAID V 0 k for rwhichirm that Nen issued construction lending agency for the Performance of Dam Receipt 4 I-+ the work for which this permit is issue)(Sec.3097,Civ.C.) l-' � Lender's Name � Lenders Address I-y ps I cem y that I have read Nis application and state that the above information is 'W BUILDING PGE rA correct.1 agree tocomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE V Z building construction,and hereby authorize repmsemanves of this city to enter upon the SEISMIC FEE / above-mentioned propcny for inspection purposes. ` PERMIT ISSUANCE. (Wc)agma t)save,indemnily and keep handless the City of Cupertino against ELECTRIC FEE Iiuld ities,judgments,cngsand expenses which may in any way accrue remain said City gLTER OR ADU'TO MECH. 1• in rnmqueuecf the granting of this permit. PLUMBING APPLICANT UNDERSTANDS AND WILL COMPLY WO IT ALL NON-POINT AIR HANDLING UNIT CIO ILOBI CPM) U SOLATIONS MECHANICAL FE AIR HANDLING UNIT(OVER 10,OW CFM) a CONSTRUCTION TA 11.iga�aluna of ApplicaMCon actor [).to EXHAUST HOOD(W/DUCT) HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION F Will the applicant or fuwrc building occupantstmeorhandle hvnrdous Commit HEATING UNIT(TO IW.000 BTU) as defame)by The Cupertino Municipal Cala Chapter 9.12,and the Heahh and Safety Cale,Scene.25532(x)'! HEATING UNIT(OVER 100.0%)BTU) C]Yet [2 No VENTILATION FAN(SINGLE RESID) PAID Will the applicant or future building occupant use equipment m devices which Data Recti N mit havallons air contaminants as defined by the Bay Area Air Quality Management HOLLER-COMP CHPOR I W.OW BTU) , District! ��aD/, ❑Yes e. BOILER-COME(OVER 100,0001TU) AL I have read the harordaas commit;requirements under Chapter 6,95 of The Cali- AIR CONDITIONER IT. ronin Health&Safety Crede,Sections 25505,25533 and 25534.1 understand That if The ISSUANCE DATE building t<urtently have area That iT i<my resptmsibility I.minify the occupant NEW RESIDENTIAL MECH. SQ,FT. of 0 uireTra a whic�hJm t To i, a ,a Certificate of 0ccu 4. ser or emhorizW mum Dme l- ISSUEDBY OFFICE