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S 2975 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPE.RTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL fIl1,"ING PROJECT IDENTIFICATION BUIIAING AUDRPSS�. � SANITARY NO. APPLICATION 9V§DATE. o ItT - 2� 4 OWNER'SNAM;: / Cyr/PHONE:p CON TRACTORS NAME'. LIC NO'. 7[)G� aQ( L�dy,N/❑C CONTROL p AkCHITECTIEN NEF,k: LIC NU: ADDRESS. +r� / 22 SiarlraT- UrC g S� CONTACT: PHONB: BUILDING PERMIT INFO ❑ Consaltsont Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH 37 G'7D 0 ©� LICENSE])CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 bomb,officer Out 1 um Eeenad coder provisions orChapter 9(commencing JOB DP,$CR�TION 110z with Scetion 9000)of Division3 of the Business and Pml'eseions Code,and my licenvcis RE ID AKU� L ane Class and e0ea. O dB� PERMI'TISSUANCE ! ❑ SIDE TIA El KITCHEN REMODEL COO License Clvss O Lv`0 v W Dale 5 /' r� Commcm APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE ARCHITECTS DEC ARAT PANELS ❑MULTI-UNIT ❑STRUCTURAL zpm l understand my plane shell he used mpuhliere ds oz-, UP TO 2IX1 AMPS MODIFICATION F,y.(-''¢] Lmen.reA&ofcssrunal ❑IN'T'ERIOR El CHIMNEY REPAIR OWNERBUILDERDECLARATION ]01-1000AMPS IMPROVEMENT 0SWIMMING POOLS W W st 1 hereby offirm that 1 am exempt from the Gmlmemr's Licence Law mor he OVER 1 WOAMPS al"i REMODEIJRF,1'AIR El DEMOLITION W 3 a F fallowing reason.(Section 7031.5,Bminess and Professions Code:Any city or c mm, SIGNS EI.BC'i'RICAL ❑OTHER F O md which requires n pencil m consumer,alma improve,demolish,or repair any swcture I* s4 print t Iso q ,'h pple, If hprong t rilesilted statement SPECIAI,CIRCUIT/MISC. i y Nath licensedpursuant the .p ' on of the Contractor's License Cr (Chapter9 0r �p (commencing withScti 70WHODAvisionl fth Business andProfessions Code)at TEMP.METER OR POLE INST. COMMERCIAL G y oy� that he is exempt therefrom and the basis far the alleged exempting Any vmatiar of - El NEW pLDG/ADDITION [I DEMOLITION �.r�0.N Section 91131.5 by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICES not mom then five hundred dollar($500). ❑TENANT ❑FOOD SERVICE dp ❑ I,vsownero0he property,army employees with wagexastmicsnle curamreming SWIMMING POOL ELECCRI IMPROVEMENT F will do the work,and theabonme is not moneded unripened for site(Sec,9044,Business ❑OTHER _ 3 and Professions Coda The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIX I '- F Property who builds ur improves Nmnem,and who does such work himself nr through L/ _ his own employees,provided that such Improvements arc not intended connected for NEW RESIDENTIAL ELECT R FT. :P sale.ILhowever,the bullJing nrimpmvemem is.add within ono yenrofemnpletinn,the@� FLOOR AREA $/ owner-boulder will have the burden of proving that he did not build or improve for pun ��� n ^fN P enfsale.). / G try El I,as owner of the properly,am exclusively contracting with licensed contrecmrr no TOTA construct the project(See 7044.Busi....nJ Prof siuns Cadnq The Commemrs Li- cm,,a Law does not apply er an ownerofpmpeny who builds or impmvevhecon,and QTY. PLUMBING PERMIT whoeomraas partner projects with a contracmr(s)licensed pursuant the Commcerz's - s License Law. PERMIT ISSUANCE 3 f2y_,.' EJ I am exempt under Sec. ,B&P C for this reason Owner AI:fER-DRAIN&VENT-WATER THAT VALUATION WORKERS COMPENSATION UF.CLARATION BACK PLOW PRUTF.CI'.DEVICE 1 hereby a fF and N Try of perj ry e f the f II 6 I f - ❑ Ih and it maintain C fi ole ofC tt If'n. f Workers Cmpen- DRAINS-FLOOR,ROOF,AREA,GOND. smio n p old for by Section 3]00 of th Later Code,f The p f m of the ST RIES TYPE CONSTRUCTION workf which this pen u ; d L FIXTURES-PER TRAP '�_O Z ❑I he d 'll maintain Micron's Compeo anon Insu see ax requ'rcd by Section 3]W ofthn Labor Code,for the perfotmanceof the work for which this permit is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GRWP AP MyWorker s Compensation Insurance carrier and Policy number are �"`/ �i 7 Carrier: Sz TB-�I4}�Policy No.: a4y l�X s GAS-EA.SYSTEM-OVER4(EA) /Z � 4 ERTIFICATE OP E%LMP I'ION FROM WORKERS' COMPENSATION INSURANCE OREASEANDUSTRI.WASTE INTERCEPTOR (This section need not he completed them permit Is porous hundred dollars($100) BUILDING DIVISION FEES nr,Ices.) GREASE TRAP PLANCHECK FEE evi ly that inihe perfirrmanecefthe work forwhich thlspermui,.issued.[shall SEWER EA.20f)IT. not employ any Perron in coy manner so as to - - became subject to the Workers'Curran- ENERGYME C) .Z Armon Laws of California.Dote WATER HEATER W/VENT/F.LECTR 2 Z Applicant GRADING FEE it h NOTICE TO APPLICANT:if,after making this Certific d,of Exemption,you should WATER SYSTEMTREATING a ~ become samern to the Workers Compensation provisions of the Labor Code,yon mon SOILS FEE W G forthwith comply with such provisinfour thi,sepail shall he deermdrevoked. WgTBR SBRVICE a Q D CONSTRUCTION LENDING AGENCY NEW RESIUGNTIALPLMB. SO 17. PND UO Ipahereby hi,halarm thatthereiso issued lendingagmmy for the performance of a Receipt# W � the work foe which this permit in issued(Sa.309],Civ.C,) Q U Lenders Name TOTAL: r RWi Lenders cadrcse p I unify that I hove read Ihls.,,Iiontion and crate the,the above information le TIN m7 enrrer. QTY. MECHANICAL PERMIT FEE building construction,and hereby nuthmize representatives of this city to enter upon the armee-mentioned property for inspection perpmex(Webaree m save,indemnif P yo pec g PERMITISSUANCE 3g neswhit hay in anwCit feu lstsai dined liabilities,judgmentsecostsvndexpencesmit. may in any way accrue again.a said City ALTER OR ADD TO MECH.In eonsegnenco of the gruntingof this permit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,NNICPM)SOURCE REyyy111��NLATIONS, EE���� EXHAIR AUST LING HOO)NIT W/DU VER Io,fNIB CPM) NTAX 9gna[ure of Pli uHAZAR HAZARDOUS Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO 100,000 BTU) as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety Cede,Section 25532(a)? HEATING UNIT(OVER 1010,000 RTU) El Your VENTILATION PAN(SINGLE RESID) PAID Will thea licoat or future building Date Receipt# pp g bythe Hluseev Airentactdevices whim BOILER-COMP(SHPOR 110,000 BTU) emit huzaMonx sic cOnmminantv nc of fined by the Hoy Ama Air Quality Munagetnem L Distinct? E]Visa No BOILER-COMP(OVER IW,INII)BTU) I have read the hazadet"mvtcdall texpomplents under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCP,DATE t--� poria Health A Safety Cride,Sedinns 25505,is noy and 25534.1 understand that it the NEW RESIDENTIAL MF.CIt. SQ.F-L mf dmng does not currently have b mmnL that n i"unn espf a Ce ity rmetonality thenc ear.. none regmmme wren tunxt be met�yixatianee nfa Cerlificate nraertpaney. XOwner nr oath ed agent Date TOTAL ISSUED BY: OFFICE