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29569 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 295 (6 �9 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECnnNICAL RUILOIN PROJECT IDENTIFICATION BUI 10107 TIN A DRESb �� 1 SANITARY NO. APPLICATION SUBMITTAL DATE OWNER'S NAMii: PHONE:(�1 RACfORS A. ` LIC NO: NIC C N # nn ARC ITECDF, GINEER: C NO: A RP. S: ❑ NTALT PHONE BUILDING PERMIT INFO yea, 8AI¢n ❑ ConsultantFees Paid byApplicant(Initial) R x ELECT PLUMB MUCH 2 3 l LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I re achy affirm mat I am licensed urdar Provi,bm,.PChapter 9(cmnmerefng JOB DESCRIPTION ��O I^th Section 7000hofDivi e.9ofthelm,incz,mod Pmdessions Cale.undmy license is pERMiI'ISSUANCF, ID F m.- w fall force and affect. WL ❑KITCHEN REMODEL ¢UV 1.icenu Clnv Lic.N APPLIANCES-RESIDENTIAL ADDITION C1 PLUMBING RE-P[PE rF Q a Dae Contract., ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL Z C)r�Z I unJerswnd my plans shut]he tame as Public record, PANELS MODIFICATION O —Q UPTO 2N)AM PS ❑INTERIOR El CHIMNEY REPAIR F N.,~.a LicemeJ P..fivoonul 201-1000AMPS IMPROVEMENT OWNER-BUILDER DECLARA'T'ION law for the ❑ OVER Pon AMPS ❑BATH REMODELREPAIR DEMOLITION C w Q 1 hereby affirm that 1 am exempt from the Comma.,,License 5d a U following¢axon.(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER 1113 a ti which requires a permit to endorse,she,improve,demolish.or repair any ormone f0tn-5 prior to its issuance,elm requires theappllcoat I...ih perankm file asilondmame tent SPECIAL CIRCUIT/MISC. �oo but he is licensed pm,mam to the poo,,ida of the Contractor',1-cenre Law(Chnptcs9 {yvp0 (commencing with Section 7000)of Division 3 of the Business and Pmlcsoom QWe)or TEMP.METER OR POLE INSII COMMERCIAL: 6 60 2� that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION ❑DEMOLITION _re' Section 7031.5 by any applicant for a Permit subjects the applicantto a civil pU� M nedly of POWER DEVICES At more man rive hundred dollars($500). /t ❑I'OOD SERVICE. �ZY IEMENTti 6l-v =< wi LoI wtork,the pr same. mis emntended m offeed ftoshei'lee compensation. SWIMMING POOL ELECTRIC C will dothework,and the she C aranet,aa-mended Lawdofs no, G(114,Buumof DOW` a3� and Professions Coln:The Cnnv^oar's License haw Joe.%not.npplymint ownerM OUTLETS-SWI'1CHES-FIXI'UItES � � A Property who built,or improves thereon,and who Joc%such work himself 9r through �• y� Qn his own employees,provided that such improvements are not intended or offered for NEW RESIDEN IAL ELECfR SQ hT. sale.If.however,the building or improvement is sold within one yearofcomp]etion.the -SQ.'FT.PLOOR AR1LyA' $/SQ.FT. er-lmilder will have the burden of proving that he did not build or improve for puri IM A �--. Q •� 1,as owner of the property.ma exclusively contracting with Iittmed contractors to TOTAL: 4 rrrmed the Project(Sea.7194,13aoiazv and Professions C.deJ The Contractor's Li- nse Law dm,ern applytwm owner of property who builds or impmves thereon,and QTY. PLUMBING PERMIT FEE who contracts for such projects with a rsmmemr(z)licensed pursuant to the Contractors License Law. PERMIT ISSUANCE I am exempt under Sea .B&P C for this reason Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKERSCOMPENSATION DECLARATION BACK FLOW PROTECT'.UIiVICfi r 1` 1 hand will under Penalty of ofCon enc of the following for d orket' Co ❑Ihave provided! mainbyeCml37Wof Me LabrCode.for forerformace of Me DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION moron.as pnry thi for by Section 1700 of the fab.,CWc,for the performance of the work for which thin permit is i mFIXTURES-PER TRAP ❑ 1 have and will maintain Workxr`kers Compensation Insurance, inquired by Section ' 3A10 of the labor Code,for perfonuance of the work for whichh this permit is issued GAS-EA.SYS'RiM-1 INC.4OUTLETS OCC GROUP APN My Walker s Compensation Insurance carrier and policy number are: Cance Policy No.. GAS-EA.SYS'I FM OVER 41RA) CERTIFICATE 01:EXEMPTION FROM WORKERS' GREASF/INI3USTRL WASTE INTERCEPTOR COMPENSATION INSURANCE. BUILDING DIVISION FEES (This sectiunnced not be completed ifthe permit is fee..hundred dollars($100) GREASETRAP or less.) PLANCHECK FEF. Z I certify that in the pOfommereorthe work for which this permit is i11taid,l shell SEWER-SANITARY-STORM IiA.200 FT. fin aO our employ any person in any mm amr ve as to hecnnte subject to the Workers C open ENERGY PEE ,alio.lawssf Califnrma Dune WATER HEATER WIVENT/ELEMR y 2 Applicant GRMING O FEE NOTICE TO AI'PhICANT.If, making this Crntficae of Exemption,y u should WATER SYSTF,MOREVGNG I-" become subject to the Worker%Compensation provisions of the Labor CeIk,you must SOILS FEE fonbwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE. JUL 02 'I I� V a' CONSTRUCTION LENDING AGENCY NEW RESIUIiN'1'IAl.YLMB, SQ.FI'. PAID U z Dale Receipt# U O Iherthy uffrm that there is construction leading agency far he performance of W P me work for which this permit is issued(Sm.3097,Civ.C.) - - — " Lenders Name TOTAL: . O WLender,Name TOTAL: I 3AL GI edi ify thin 1 have read this application and oars mat me above informal.is BUILDING FEE 0 c.rr.a.I agree m comply with all city and enumy orJinnncm unJ sate Inws relating m QTY. MECHANICAL PERMIT FEE U4 building aroma,lis.. it henh,audorim mmmocomdvesof this city lomar open the SEISMIC FEC above-mentioned pr,peny,for inspection pmPoo,z. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cuperiuo against ELECTRIC FEC Iiabiiitie,.judgmerim costsand expenses which may irony way accomitImiroaxod City ALTER OR ADD TO MICH. �A L nttqumve 9f the Framing of thin permit. PLUMBING FEE •'4 `tl APPLI ANT UNDERSTANDS AND WILL COMPLY WITH LL N N-POINTAIR HANDLING UNIT(TO l0, MECHANICAL 1 (XXI CFM) 1 •A• SO/iliGUl ONS. Y ' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of App]icamlC intneor U,c EXHAUST HODD(W/DUCT) HOUSING MITIGATION FEE H ARDOUS MATERIALS DISCLOS E Will the applicant or future building occupant store or handle hasebas material HEATING UNIT DO 10LO011 RTU) us JeOned by me Cupertino Municipal Cale.Chapter 9.12,and the Health and Safay Crile,Section 25532(^)'! BEATING UNIT(OVER 10(1.1##1131'U) p Ye, ❑No PAID VGNTILAI]ON PAN(SINGER RESID) Dae Receipt# Will the applicant or future building occupant use equipment or Jcvims which BOILER-COMP(3HP OR IIX1,iXX1 BTU) emit hoarders air contaminants as defined by the Bay Area Air Quality Management TOTAL. District' BOILER-COMP(OVER 100,000 BTU) Vex ❑No I have man the hazy nous materials mquirements under Chapter 0.95 of the Cali- AIRCONDITIONER ISSUANCE DATE fomis Health&Safety Code.Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET, buildmgdo s nm cunenily have a tenant that it is my responsibility to unify the occupant of the requirements which must be met prior to issuance of a Certlfimm of Occupancy Owner or authorised agent Date TOTAL: ISSUED RY: OFFICE \ - - - - tea c � 2 - \ / 0- § - / ) } [ / 2 . \ ) \ , o m : [ § IM , § � G \ ( § m � , \ 2 / ' ; \(j , \ k ` . � ) , ƒ 2 - 0 (D 0 \ > 2 0 m § ' . | ` " ' 1 ° E )(� \ )\�ƒ K ` ) / | | , q § § - - = - \ o | ` 2 (D o E \\\ ; m / | ' . ■ & § - / 2 E ; � )\) > � / 2 © y , ) ; ! 7 \ ; ! 9 ; ! _ ; ! f )(� ƒ ! ! ; 7 j2G _ ` / ` E \ \ OM § | /\ & | \ | § %Qk / \\ vi / , ' / ( wB - . \ . }\ " | ` §§ � ,