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S 2707APPLICANT-TOFILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY !� / CITY OF CUPERTINO BUILDING -ELECTRICAL /BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL BUILDING PROJECT IDENTIFICATION PERMIT NO. Q 0 J ' B;1D11C ODRESS.2I V 'Io�i�I V' SANITARYNO, APPLICATION SUBMITTAL DATE 3 OWNER'SQ/S NAME: PHONE: CONTRACTORS NAME: LIC NO: N/C ❑ CONTROLS N N E- ARCHITECIPENGINEER. LIC NO: ADDRESS: CONTACT. PHONE: BUILDING PERMIT INFO O ❑ Consultant Pees Paid by Applicant (Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONTRACTORS DECLARATION 1 hereby amnn that I am licensed under provisions of chapter 9 (commencing with Section 9000) of Division 3 rfthe Business and Professions Codgand my license is in full force end effect. License Class Lica Dnm' camrucmr QTY. ELECTRIC PERMIT FEE you -U� �ZuV1 LL n a y Z.. ^y{] C W d O L U 4. U In ry JOB DESCRIPTION RESIDENTIAL, ❑SFDWL ❑KI'T'CHEN REMODEL ❑ADDITION El PLUMBING RE -PIPE ❑MULTI -UNIT ❑ STRUCTURAL. MODIFICATION ❑INTERIOR ❑S IMMING POOL IMPROVEMENT SWIMMING POOLS ❑ BATA REMODEIJREPAIR ❑ DEMOLITION ❑ OTHCR AC I PERMIT ISSUANCE APPLIANCES -RESIDENTIAL ARCHITECT'S DECLARATION I understand m ypan. shall be used as public records PANELS UP'TO 200 AMT'S Ucensed Professional OWNER -BUILDER m the RA'T'ION License Law for the 1 haraby affirm 1 am exempt from the Cosions Code: fallowing rwsan, (Sectionro1]cont, Business and Professions Coac: Any city nr rosary which requires a permit Ir mmavun, neer. improve. demolish, nr repair any smwwm pnorm his issumc.,.Isu regc,m,lhe applicant ferwch panne mfileasignedaincencre 201-IBfNIgMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. q y'GO c y �y F Q O aaF LL7"� thot he islicensed pursuant do the pmvisiona of the Conductor'. rumors, LaA(Chapmr 9 (commencing wimM1 Section 9IXlBpd DsvisinnJ of the Business and Pmfn,ioa Qula)ar dant he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 90315 by any applicant for a per mit subjects the applicant to it civil penalty of nit mare than five hundred dollars ($500). I, as owner of me ❑ property, or my employees with wages as their cols compensininn. will dothewark,amd thestrucmre is not intendedoroffned forsale(Sec.]II44,Businns and Professions Codw The Contractors License Law does not apply m an owner of _ TEMEMETBRORPOLEINST. COMMERCIAL: ❑NEW BLDG/ADDITION ❑ DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT POWER DEVICES 11i SWIMMING POOL ELECTRIC/❑OTHER OUTLETS-SWH'CHPS-FIXTURE$ property who builds or improves thereon, and who does such work himself or through his o employees, provided that such improvements arc not intended or offered for NEW RESUMES TIAL ELECPR SQ 10. SQ. FE FLOOR AREA T. $/$Q. FT sale.If,mhowever, the huildingnrlmprovement is sold within one yearnfuumpledion,the will have the burden of proving that he did rot build or Improve for pm- p ceopu-I sale.). 1, n owner of the property, am exclusively contracting with licensed contractors 1. IGIAL' onnmu the project (Seo 7044, Business and Professions Cade) The Gmoacmrs Li- course nse Law does not apply to an owner ofperty prowho builds or improves thereon and QTY PLUMBING PERMIT FEE contracts for such projects with a Overreacts) accused pursuant to the Contractors PERMIT ISSUANCE License Law. ❑ Iamexampl under Sec. ,B& P C for this reason Own Date WORKER'S COMPENSATION DECLARATION AL's ER - DRAIN & VENT- WATER (EA) VALUATION BACK FLOW PROTECT DEVICE. 1 hereby affirm under penalty of pe jury one of the following dedamt... o, DRAINS- FLOOR, ROOF, AREA, COND. I have and will maintain a Certifeme of Consent to self -insure for Worker's Compeer cams, as provided sur by Section 3700 of the Labor Cads, for the performance of Inc STORIES TYPE CONSTRUCTION work for which In,, permh is issued. FIXTURES -PER I RAP ❑ I have and will maintain Workers Compensation Insurencc, as featured by Section 37004lhe Labor Code forme performance tithe work for which this pem,itix issued. GAS- EA. SYSTEM4 INC. 4 OUTLETS OCC GROH MIN My Worker's Compensation Insurance comer and Policy number am: Carrier - Policy Na: 5 1999 GAS - EA. SYSTENTOVER 4 (EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This serum need not he completed tithe permit is fnrone hundred dollars ($100) or lest.) GREASOINDUSTRL WASTE INTERCEPTOR BIjIL (VISION EEL'S GREASE TRAP PLANCHECK PEE ,� Z O o-zr ti Wti P A C.J 0 ti 0 U C.1 �' a .H.r(Z) V ,7. I certify that in the performance ofthe work for which this permit is issued, l shall not employ any person in any munner son to become subject to the Workers' Compere sabot Laws of California. Date Applicant SEWER -SANITARY -STORM EA, 200 FT. Y- WATER HEATER W/VEN'VELECTR GRADING FEE NOTICE TO APPLICANT If, afar making tis Certificate of Exemption, yomisheard became subject to the Worker's Compensation provisions of the Labor Code, you mast fornwim comply with such provisions or this Even, shall M: dcemedrevoked. CONSTRUCTION LENDING AGENCY l hereby Norm that here lanamstrucdilending agency for the performance rf the wars for which this Permit is issued 30 (Sec, 3(19], Civ, C.) Lender's Name WATER SYSTEMrFREATING WATER SERVICE SOILS FEE PAID NEW RESIUENTIAI. PUSH. SQ. FT. Date ceip H TOTAL: Lenders Address 1 cerify that I have fwd this vpplicaaon and ,are that the aMwe information is cormctl agree to comply with all city and county ordinances and state laws relining in building construction, and hereby authorize representatives of this city to came upon the TOTAL: BUILDING FEE QTY. MECHANICAL PERMIT PEE SBISMICFEE PERMIT ISSUANCE ELECTRIC PEE above-mentioned property far unspectivn purposes. (We) agree to save, indemnify and keep hamdess tiro City of Cupertino against ALTER OR ADD TO MECIL PLUMBING PEE ambilities, ludgmcnts, costs and expenses which may In any way come against said City in cu meyuence o[ dna granting of aria pammil. HANDLING UNIT (TO 10,000 CPM) MECHANICALF APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR SOURCE REGULAT AIR HANDLING UNIT (OVER 10,11110 CPM) CONSTRUCTION T X 'gnamre of A,,fi,mVComrmmr Date HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE HEATING UNIT (TO 100.000 BTU) ,Q Will the applicant or future building "ceupnnt,tire,, handle heouNous material n defined by the Cupertino Municipal Cade, Chapmu 9.12, trod the Health end Safety HEATING UNIT (OVER Hardly) BTU) PAID - Codc, Section 25532(a)? Y. 7777 VENTILATION PAN (SINGLE RP,SID) Dame Receipt S BOILER -COMP OHP OR 100,11011 BT U) Will We applicant or furore boiling rearrests, Ise equipment ar devices which .hit founder, or, ummaminter. as defined by the Bay Area Air Quality Management .District?/ El Yes _ BOER -COMP (OVER 100,000 BTU) AIR CONDITIONER ( have fwd the hazardCode.nu ctions 5505, 2immeno under 4,1 695 understand thethat Cali- fnmiu gdoesalth & Safety Cafe eahe r 2that i 255J3 and 25534.1 motith that a the building ares not eulrendrhaven,enamdt, mathia my reaprnxindhymnrdryme«cream ISSUANCE DATE / NEW RESIDENTIAL MECH. SQ. FT. st(me require eats wmm� royal be met rmrmms.nanw oracaniawte of occupancy. ISSUEDBY: T AL' 7) Owner nr uulhnrieW ngenl Date OFFICE APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING. ELECTRICAL BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL ✓y� 1 /1 In O I /N• /U��( A 1 ❑ Consultant Fees Paid by Applicant (Initial) ILICENNSIIILEED�- CONTRACTORS DECLARATION vVVJ 6 QTY. 1 batehy affirm that 1 am licensed under provisions of Chapter 9 (commencing ,cc, with Semiom7000)of Divi,ion3ol'the B.,ine,..nd Prof an mcale a dm Iieenseis FY� W 0 in full force and dfenCa0 I 6OU hlcens Cl 59 Lnc.p / y 7d- u] Dam 9 TS DE o F.'JN A T'ECPS DECLARATION y O N 1 understand my plans shall Mused as public reands OZ.N--0 WLicensed Professional OWNER -BUILDER DECLARATION p, 1 hereby affirm that 1 vat exempt from the Convector's License Law Ea We following reason. (Section 7031.5. Business and Professions Code: Any city or county fel 2 y which requires u permil to consumer, alter, improve, demolish, or repair any structure �� Error m lis issuance, olsorequmr,Ieappli... I such permil m fileasignednmement BSyai! axthat be is licensed pursuant to the provnsnans of the Contractors License Law Chapters) 00 (c'unmenenng with Siblum7000)of Division 3iflhe Busines,and Prufessioas GNe)or L y M [t that he is exempt therefrom and the basis birth, alleged exemption. Any violation of W.. ISN, Section 7031.5 by any applicant for o permit subjects the applicant m a civil pcoulty of f.. Z y not more than five hundred doll... ($500). Q❑ m E] I. as owner of the ppony,or my employees with wages as their sole compens.tion. Y will do the work, and lhestrucmre is not intended or offered for sale (See. 7044, Business 6 ce and Professions Code: The Contractor'. License Law does not apply to an owner of property who builds or improves (hereon, and who does such work himself or hrough his own employees, provided that such improvements are not intended or rRered far sale. If, however, the building or improvement is sold within one year of completion, the posacolmilder will have the burden of proving that he did tut build or improve for pur- e of sale.) ❑ 1, as be, of the property, am exclusively a,mmming with licensed eonnactms n, aconstruct The project tsee 7041, Business and PmRsaion. Cade,) Tea Cnmramnr, Li- cense Law dons not apply to an owner of property whe holds or improves thereon, sad QTY, who contracts for such projects with a contractors) licensed pursuant to the Contractors Lice se Law. ❑ 1 am exempt under Sec. , B & P C for this reason Owner Dam WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penally mf perjury one of the following dedemtiona: I have and will maintain a Cenilicme of Consent to self -imine for Womers Compen- .a mer m provided for by Somme 37M oI he Labor Code, for the ber mmnnce ti k Int which this permil is Issued. and will maintain Worker's Compcnsmino Insurance, as required by Section 3700 of the Labor Cede, for the performntice of the work for wbnch this percent is issu W. COMET NSATION INSURANCE (This secdrn decd not he compiered if the permil Is borrow hundred dollars ($100) er..) I artily that in the any rrmmmc f,ba s to become roe which this permit is issued 1 shall mm employ any person is any manner so as m became subject na the Workers' Compen- Q z .,ion Laws of California. Data 7 V) Applicant q ti NOTICEop APPLICANT: is after making this Cenilicme of Exemption, you should neuwith comply with the Worker's Coons or this provisions of the Labor G,ve you mux, [Taforthwith comply with such provisions or this permit shall N, declined revoked. 0 UZ CONSTRUCTION LENDING AGENCY U 0 l he rebywhichrm that there lsaedSecconstruction30 lending agency for the performanceof � Pthe work for which this Permit is issued (Sec. 3097. Civ. C) U Lenders Name ul Lenders Address 1 certify that 1 have read tbns application and score that rhe above information ns ta/] wrreu.I agree m comply who all ally and county oNinences and stem laws mladng In QTY. L) z budding consmndon, and hereby authorize represemntivea of,hi, eiym enter upon the above-marromed property for inspection purposes.71 (We) mascots save, nnden nify and keep hunnless rhe City of Cupertino again,, l imbililies,judgments, costs and expenses which may in any way accrue ag.inm said City in asequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NfyN-POI]dT HAZARDOUS MATERIALS DISCLOSURE. Will the applicant or future building ocsvpant store or handle hazardous material as defined by the Capennvo Municipal Cale, Chapter 9. 12, and ,he Health and Safety Code Section 25532(01 \UYes ❑No Will the applicant or future building occupant use equipment or devices which emit hazardous air canaminants as defined by the Bay Area Air Quality Management District! ❑Yes No 1 have read the h loodous matermis requirements under Chapter 6.95 of the Cali formsHealth & Safety Cade, Sections 25505, 25533 and 25534. 1 uodemmnd but if the building docs ran currently have a renin, that it is my resson, hilily to notify the occupant of he requirement which most M met prior m Nsuanca of a Cenifiame of Occupancy. Owner or authorized agent Date ELECTRIC PERMIT FEE PERM[ "r ISSUANCE APPLIANCES - RESIDEN UAL PANELS UPT0200AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUFrimisc. TEMP. METER OR POLE INST'. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES NEW RESIDEN'I'[A]. ELHCTR PERMIT -ISSU� ALTERDRAI&ENNRTIt� BACK FLOW PROTECT! & ,�� DRAINS - FLOOR, ROOD, AREA, , FIXTURES -PER TRAP W GAS - EA. SYSTEM -I INC.4 OUT: GAS- EA. SYSTEM OVER 4 (EA) SANITARY -STORM MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,001 CFM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (WMUCT) HFATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER -COMP IMP OR 100,000 B'RU BOILER-COMP(OVER lyff 0BTU) AIR CONDITIONER N17W RESIDF,N'I'I AL MSCI 1. SQ, FE FEE JOB DESCRIPTION reyyn Ntt. 2284 ^8sr NI'I'ARY NO APPLICATION SUBMITTAL ❑ KITCHEN REMODEL. ❑ADDITION Z -t `7- i NIC STRUCTURAL CONTROLtl MODIFICATION ❑INTERIOR El CHIMNEY REPAIR IMPROVEMENT BUILDING PERMIT INFO RLUG ELECT PLUMB MUCH ❑ ❑ ❑ ie JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL. ❑ADDITION ❑PLUMBING RE -PIPE ❑ MULTIUNIT❑ STRUCTURAL MODIFICATION ❑INTERIOR El CHIMNEY REPAIR IMPROVEMENT E]SWIMMING POOLS ❑ BATH REMODEUREPAIR ❑DEMOLITION ❑ OTHER L1 NEW BLDG/ADDITION ❑DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER SO, FT FLOOR AREA BUILDING DIVISION FEES PLA DECK EEE ,NERGV FF,E GRADING FEE SOILS FEE PAID Dare ov PtIf Q TOTAL: BUILDING FEF U SEISMIC FEE ELECTRIC PB i PLUMBING F MECHANICAL. T.. CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Dam Receipt p ISSUANCE DATE S/SQ. FT.