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S 1653 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO PLUMBING-MECHANICAL ECH RICA(. PLlyp'T NO. 1653 BUILDING DIVISION APPLICATION/PERMIT PINGPRNOCT IDENTIFICATION l`J RIIILDiNG PROJECT IDENTIFICA'T'ION BUILDING ADDRESS: SANITARY NO. APPLICATION SERVE TEA DATE aaL1 Rai �( WNER'S NAME: /l'HOiG N'I�I[$S'�ME'. LIC NO V 1If!'')) NIC CO TROLp -� ARCH__a NCINGER: LIC NO: �Sti�DgEl lH JJ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) PI.DG ELECT' P UMB MI:CH ❑ ❑ ❑ LICENSED ad,,p DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby arum Inn l dm licensed anon provi,dnns tr chapter v a�nmtmeneing JOB DESCRIPTION Woo'z with Sermon 700101of])isdin 3 tame laimermal Pmoes,mr,Code,wdmy licenm is RESIDENTIAL, F• Woo, full force and elfin PERMIT ISSUANCE Xl F 5I ❑SFUWL ITCNF.N REMODEL aUU Licenu Cuss Lic.p APPLIANCES-RESIDENTIAL. ❑ADDITION I MBING RF.-PIPE F L Bum—C4���4 Contractor�TI{ aL n� ARCHITECTS DECLARATION E3 MULTI-UNIT STRUCTURAL (..,❑m PANELS MODIFICA'T'ION Z O 1 underswnd my [.,,,,hall be used us public records oy�o UI'T02I1UAMPS E3 INTERIOR [-]CHIMNEY REPAIR Licensed Professional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS J OWNER-BUILDER DECLARATION ❑BATH REMODEUREPAIR [IDEMOLITION a 04 Q 1 hereby affirm that I am exempt from tine Contractor's License Law for the OVER IpM)AMPS Q.X 3 LL F following reason.(Section 703 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER F.�.a.y � which reamers a Permit use construct,deet,improve,demolish,or repair any structure pnormits issuance,al.sures,doo the applicant forsveh m file le unignedsmm ment SPECIAL CIRCUITIMISC. � that he is licensed pursuant to the provisions ofhe Commnm's license Law l Chuprr9 ly �� (Ionmencing with Scetlon 7000)of Division 9 nfthe Business and Profasnieas Code)or 'I EMP METER OR POIX INST. COMMERCIAL: Ps o y that he is exempt meml'rnm unit the basis fnr me alleged exemp0on.Any vintinion nI ❑NI:W BLDG/ADDIH[ON ❑DEM01.19'[ON �^},m Section 7031.5 by anyapplicam for a permit.bjaztshe applicant to a civil penaltynf POWER DEVICES / ❑TENANT ❑FOOD SERVICE t more than five hundred dollen($500). F•Z i IMPROVEMENT < ❑1,azowner of the pmpcny.or my emNnyces win wage,az Meir role wtmpenserion, SWIMMING POOL ELECTRIC will dothe work.and the amaure is not intended orofered for sale(Sec.71X4.Business ❑OTHER 63 m and Professions Code:The Contmcinh License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such Impmventents are not intended or offered for NEW RESIDENTIAL FLECK SQ FF. sale.If,however the buddingor improvement is sold within one year of contpletinn,the SQ.FT.FLOssifftA A $SQ.FT. owner-builder will havo the harden of proving that hedld nm build or improve fnr par- ss. pow of,ale.)' TOTAL: AY 1 El I,as owner of the pmpeny,am exclusively contracting with licensed contmemrs to 3 /IIf(1r entertain me project(Sec.7044,Business dad Professions code:)The Commcmr's Li- ,euva, d Law msnolapplym an owner of poapmt,who builds or improvesCl/ thereon,and QTY, PLUMBING PERMIT FEE V y (Jf- who License Laws for such Projects with a contracmKs)licen d pursuant to the Contractors Iourlrl Lil HSV ❑ Inn exempt under Sec .R&to C lin his reason PERMIT ISSUANCE. ALTER-DRAIN&V HNT-WATER O A) VALUATION Owner Date WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE 1 hereby affirm under penalty of perjury One of me following dedi mtinns: ❑(have and will maintain aCenificme of Conserv mself-in.rtfor Workers Cnmpen- DRAINS-FLOOR.ROORAREA,GOND. STORIES TYPE CONSTRUCTION .tion,as provided for by Section 3700 of In,Labor Cade,for the Ferfonnance of the work for which this permit is issued. r%TURFS-PER TRAP I I] 1 have and will Liman In Worker's Cam petndfirm Insurance,as rerouted by Section 3700ofthe Labor Coda for the poodmaancc oflho work for which his pennit islssued. GAS-EA.SYSTEM-I INC.40VI'LETS OCC GROUP ANN My Wnr 'r'n CnntpLasulion lnsumnw carricnmdpolicy mG 'r•: V ru Carries Policy No: 'e 7 1,T L'(a LIQ HAS-EA.SYSTEM OV17R 4(EA) CIiRTIEIC TE Or LXIzmll ION FROM WORKERS' GREASFANDUSTRL WASTE,INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION F E-S ('(Tis union need nm becomplacJ if the permit is fmane hunJmlJoll:vs l$IW) GREASETRAP or less.) PIANCHECK FEE I certify that in he perfornerve ofhe work for which this permit in issued.I shall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner so as In become subject to the Workers Compen- ENERGY FEE z •� .tion Laws of California.Lane WR'I'ER HEATER WIVRN'MLECTR Q Applicant GRADING FEE f, ? NOTICE TO APPLICANT:If,after making mix Certificate of Excmplion,you should WATER SYSTExto BEATING become subject rot Ota Worker's Compensation provisions of me Loon Cade,you must SOILS FEE lorawih comply with such Provisions or this permit shallbe drained revoked. WA'FI7R SERVICE 0 7Z CONSTRUCTION Ltion lending agency NEW RESIDF.NTIALI'LMB. SQ.FT. PAID Hate Rmei V Qthere by amnn that them issued(Sec.30 len ding agency fnr the perhsrmance of the wok for which this permit is issued(Sea.3Ul].Civ,C.) 0 F" Loaders Name T4TAiaw L V Lender's Address T[ W� Ii1111.D1NG FEE i unify that have rend this dppllcutlnn and smm(het the uhnve Inlonnation ix y correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL-PERMIT FEE (,) Z FEE building construction.and hereby sutnonze representatives ofthisciny to enerupon am SEISMIC construction. imnve-mentioned property for inspection Purpose'. PERMIT ISSUANCE (We)agar ut.ve,indemnify snit keep harmless me City of Cationnno against RLECTRIG FRE liabilities,judgments,cwtsund expenses which may in any wayaccrueugaimt.id City AUIER OR ADD TO MF.CH. PLUMBING FEE in asequence of the granting of this permit. APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT Ant HANDLING UNIT UTO 10,000 CFM) SOURCT Rf?CULAI'I11.V5. MECHANICAL PBH %/1 r n.. (A II a/vp �/p 0S AIR HANDLING UNI'I'[OVIiR 10,000 CPM) CONSTRUCTION TAX SigTem fAAppl(i/�c�un�J mmac lo/r AU/w' ) J Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FI HAZARDOUS MATERIALS DISCLOSURE. Will he applicant or boom buildirneccupant stare or handle hazardous material HEATING UNIT(TO I01.0I)BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade,Section 25532(0)! �,� HEATING UNIT(OVER 100,000 BTU) ❑Yee' , A'n V HN'HLATION FANS I NGLE RESID) PAIR _ Dam Re,:eiFl a Will thedous air connotations mommas building by the Brt yse Area Air mor lity evices which Management BOILER-COME L3HPOR 100,000 BTU) emit hamNous air nmtmninants as definnl by the Nay Area Air Quality Management TOTAL: District? BOILER-COME(OVER 100,Om)BTU) ❑Yes _i!!0o I have madthe hasrdous rwtmais reruirentems under Chapmrfi95of me Cali- AIR CONDITIONER ISSUANCE DATE forma Health&Safety Axle,Sections 25505,25533 and 25534.1 understand that if he NEW RESIDENTIAL.MECH. SQ.Irl'. M1nilding aced nnl currently have a Icnnnl,tout iI ix my rcaponsibilily da nntily the axcupanl of the memernients which must be met prior Ito issuance of a Ceniliwto of Oa upaney. qPP Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE