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29570 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL I'IiRMIT NO. g1�Q BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL LV 570 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: 1 SANITARY NO. APPLICATION SUBMITTAL DATE 1,015--Z1,015--Z- MAr u,,-, c 11 NER'S NAME: PHONE: NI'RACTOR'S N E: LIC NO: _ N/C C fHOLa TFaCT/P•iAAGI EER: LIC NU: ADIJRESS: ❑ r-rtsi)n Q NTA Ia�,� 40PPDONB_ S.^ .,, - BUILDING PERMIT INFO �(lLpa{� ❑ Consultant Fees Paid by Applicant(Initial) B ELECT PLUMB MECH LICIiNSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby afftrn tat lam reeved ower povishsn5 of chapter 9(crm rraciag JOB DESCRIPTION Se wit Sution]gl0)of Uivision3ofthe Business and Pmfasions code.and myliccnsc is ILL—O- infullfarce and effect PERMIT ISSUANCE NTIAL; W F, WL D KITCHEN REMODEL �UU Da euc Claes 1.ic.p APPLIANCES—RESIDENTIAL ADDITION EIPLUMBINGRE-PIPE Z a Dal[ 7'S DECLARATION ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL Z O'//Z I understand my plan.shall be used tax public records PANELS MODIFICATION N� OZ—� UPT02W AMPS [I INTERIOR GCHI!VINEY REPAIR F�,2" Licensed Professional 201-EXXIAMPS IMPROVEMENT �,neOWNIiR-BUILDER DECLARATION OVER I00OAMI'S D BATH REMODELIREPAIR DDEMOLITION C tY st I hereby affirm that 1 um exempt from the Commerce,,License Law for to O d U following reason.(Section 7031.5.Business and Pmfessions Code:Any city or county SIGNS ELECTRICAL D OTHER '3 LL which acquires a permit to construct.alter,improve,demolish,or repair any summit, F�Oa prior to its issuance,also maims the applicant for such Permit to file a signed statement SPECIAL CIRCUTDMISC. / r� that he is licensed pursuant)the pmmsinns of the Cumreaur's License Law(Chapter 9 _ X00 (eootnencingwithSeciion7UXgof Division3ofthe Businessand ProfessionsCwe)or TEMP.METER OR POLL INST �'ppp1ppp' •�Nj 6 n 0 Nat he is exempt lheafmm and the bail for the alleged exemption.Any violation ofall W. NENANTw 4DIU Cy DSD SERVICE Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES 1gJJ8) TSGnot more than live hundred dollies($5(Xp. IMInROVEMENT ❑I,as owner ofte pmpeny.or my emPloymswilt wages as theirwlc compensation. SWIMMING POOL ELECTRIC F, "ll Jo the work,and the amcume is not intindedoroffatal fnrmle(Sol.0W4,Business DOTHERY L3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES ' V VrCfl l IIYU pmrry ash builds or improves thereon,and who does such work himself or tgM1 his own employees,provided Thal such improvement am not intended or offered for NEW RESIDENTIAL ELECTS SQ FT. safe.If.however,the building or improvement is sold within one year ofutmplctim,the SQ FF.FLUOR RIA $/SQ,II'. owner-builder will have the burden of proving that he did not build or improve for the 1840 X.nEFbASIS AQ rO? pcacofnula). OO D L as owner of the props",am exclusively conmaming with licensed contractors to TOTAL: consumer the project(Sec.7044,Business and Professions Calc:)The—a—t-,Li- LL1 7{..1 (I I .Zj•1, cense Law does our apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEF, G.L 7 whocantmcts for such projects wit a conuacton s)licensed pursuant o the Contractors License law. PERMIT ISSUANCE D Into exempt under Sec. ,l{&P C fnr tisrtasmn •Owner Date ALTER—DRAIN&VENT—WATER(EA) VALUATION WORKERS COMPENSATION DECLARATION BACK FLOW PROTF.C'E DEVICE a �—a I hereby Rpen rm under ally of perjury one of the following declarations: ❑Ihmc and will mainminaCeniticmcof Cmnsenumself-insure for Workers Compcn- DRAINS—FLUOR,ROOF.AREA,GOND. STORIES TYPE CONSTRUCTION sallon,us provided for by Section 3]1X1 of the labor Gale,fnr the perlbnnance of the work for which this permit is issued. FIXTURES—PER TRAP D 1 have and will maintain Workers Compensation Insurance,as required by Section 37W ofte LeMn Code,for the performance of the work for which tis permit is issued. GAS—IiA.SYSTEM-1 INC.4 OUTLETS (KC.GROUT' APN My Workers Compensation Insurance carrier and Policy number arc: Carter: Policy No.: GAS—EA.SYSTEM-OVER 4 HEA) CER)'IFICAI HOF EXEMPT]ON FROM WORKERS' COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This section need not be completed if thepem b Is forams hundred dollars($10(b GSF.ASC'TRAE' s or IesrJ to FEE z old I certify tat mine performancri,fthe work far which,his permit is issued.lshall SEWER—SANITARY—STORM EA.200 FT. not enploy any person in any intoner sn as to become subject m the Workers Compen- ENERGY FEC s4C 0 Z salion Iris of California.Dam WATER HEATER W/VCNT/ELECTR GRADING FEE Z Q Applicant r NOTICE TO APPLICANT':If,after mu king this Cmiream of Lsemption,you should WATER SYS'I IWO'KF.A'I'ING F > become subject to the Worker's Compensation Provisions of to Labor Cade,you must SOH_S FEE Wforthwith comply with such provisions or this permit shall N,deemed revoked. WATER SERVICE 0. 0 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'hMB. SQ.FT PAID Dam ~— U O Ihereby affirm that Cert is a construction lending agency for the performance of the work fnr which this permit is issued(Sec.3097.Cie C.) �' (•' Lenders Name TOTAL: 6UW. Lenders Address TOTAL. BUILDING PEE Bendy 1 that 1 have read this application and slate that the above information Is F to coren.l agree mcomply with all<ity and county ordinances and stem laws relmingm QTY MECHANICAL PERMIT FEE '—A C-) z buildingnnstmction.and hcachy amhnrizc repacxemmives of Ibis city mentef upon to SEISMIC FEE too above-mentioned property for Inspection purposes. PERMIT ISSUANCE (We)ngacc m save,indemnify and keep hamticss to City of Concern.a8am,, ELECTRIC FCG liabilines,tal,tums,costs mod enpenece which may in any way scene against sail City ALTERORADDTO MECH. n consequence of the granting of tis permit.an FIiF. 130 Dq- APPLICANT UNDERSTANDS AND WILL COMPLY WIT ALLN N-POINT AIR HANDLING UNIT(TO 10.000 CFM) 5 tCF.RBGULATIONs. a� MECHANICAL FEE AIR 14ANDLING UNIT(OVER IB.(X()CFM) CONSTRULTIONTAX Sigmame calAppllcanVC nmmtor Dal EXHAUST HOOD(W/DUC) HOUSING MITIGATION FRF: H RDOUS MATERIALS DISCLOSURE Will the applicant or furore building occupant.aore or handle hazardous material HEATING UNIT TO 100.000 BTU) as defined by the Cupeninn Municipal Cade,Chatecr 9.12,taw the Health and Safely Cade,Section 25532(a)P HEATING UNIT(OVER IB),000 BTU) Yes Na D VENTILATION FAN(SINGLE,RESIDE PAID [)am HecciPtp Will the applicant or future building aaeupant use equipmc.1 of Jmices which emit hazardous air contaminants as defined by the Bay Area Air Quality Managemem BOILER—COMP L3HP OR 100.000 BTU) OFAL: District? C-1 Yea ❑No BOILER—COMP(OVER UX%(XM BTU) I have read the hazardous materials requirements under Chapter 6,95 of the Coli- AIR CONDITIONER ISSUAN , forma Health&Safety Gtde,Section 25505,25533 oral 25534.1 undem and that if the ,NEW RESIDENTIAL MECH. SQ.ET. building does not urrently have a tenant,that it is my responsibility to notify to occupant of to ma iremtenls which must be mel prior at ismanec of a Cenifiwte of Occupancy. Owner or authorized agent Dam TOTAL: ISSUCD BY: OFFICE G _ 2 - - K> 10 ` ; § Im - . 9 \ § ) ( ) ■ ` ) A ) � � 2 ( E \:- 7 ) \ ) ® ` c G - E MZ © 2 \ \ � g77 ` \ � � \ / � ) \ § ; \\\ § K ` | { ) . w % , ; ! g q ■ ) k ) \ , i @ | ° k}\ _ ® m ( q ° E b R A £ [®` \ }\�ƒ % ® = n | " ° § \\om_ ! _C: to©_ S_ rKZX - \- ". \/ ( / § z/ (\) " k \[ § % § 0 Q #_qH Mo0 \ . / , ! y \ A - - ®- 2 ` , .� ) m ))) _ � � \ \ \ \ ho m ` ( " \/\ | ¥ | e 2:q in . | . 0 e w . m .2 � � i | " ® � � S