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29561 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY XV '• CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMDNO, BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29561 BUILDING PROJECT'IDEN'1'IFICA'1'ION - BUIL©� �DI{ ,SS ��� �� SANITARYNO. APPIAC`CATION SUBMITTAL UA'I'I tei OWNER'SNAMEE::'J/iC,y�•r - p C�PS>1CSPHONL': 1 CONTRACTORS ME: LIC NO. Lt—4 � C 4 A 1 ' NIC CUNTkUL# ARCHITECT/ENGL EEk LIC NO: ADDRESS: '1 .] ❑ 1 •, CONTACT: • YHONF.: BUILDING PERMIT INFO `fit Coa emu 1 4cx•7AS•°:'4410 ❑ Consultant Estes Paid by Applicant(Initial) BI.>G EuiCf PLUMB MECfI LICENSED CONTRACTOR'S DECLARATION Ql'Y. ELECTRIC PERMIT FEE I nonny oily..hof vis I am Eaenwd rimer provisions on shaper v fm mmense is JOB DESCRIPTION O�Z with Sation]IX)p)of Division3 affair Nosiness and Professions Carl and my license is RESIDENTIAL ,100 PERMIT ISSUANCE 3 WL ❑KITCHEN REMODEL QUVfull furca and effect. License Class Lite.aAPPLIANCPS-RF'_SIDFNfIAL EFADDITION ❑PLUMBING RE-PIPE F�W Data Contractor F.D. DECLARATION PANELS ❑MUI-T4UNIT' ❑STRUCTURAL h [understand myplans,hull thereedaspublic records MODIFICATION OZ-O UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR I=�FW Licensed Professional 201-1000AMPS IMPROVEMENT 9sjf; OWNER-BUILDER DECLARATION OVER IIXXIAMPS [I BATH REMODEUREPAIR ❑DEMOLITION CL m Q I hereby affirm that 1 am exempt from the Contractor's License Law for the 1�3GU following reason.(Section]0310.Businessand Professions Code:AnY city or county SIGNS ELECTRICAL. ❑OTHER Yl LL.F" which respites a permit b construct.altar,improve,demolish or repair any structure1qq'�coo prior m its issuance,also requires the applicant for such penni to file a signed statement SPECIAL CIRCUITIMISC. y Y� that he is licensed pursuanno the provisions of the Conracna,License Love(Chapter 9 Ia+l�CO (commencing with Section]000)of DivisianJnf the Business anJ PmfessionsCede)or TEMP.METER OR POLE INST. COMMERCIAL: S ty m 1� the,he is exempt therefrom and me basis for the alleged exemption.Any violation of (:)NEW BLDG/ADDITION El DEMOLITION i� Section 7031.5 by any applicant for a Permit subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE H n cone than rive hundred dollars s5n)). F3a Las owner of he n.onn pees with wa es as their sole cpm nsatinn, SWIMMING POOL LLIiCtRIC IMPROVEMENT = Q Prop Y Ycrop > B 1'e ❑OTHER will do the work,and the structure is not intended oroffered ferule(Sec.7014,Business a 3 w and Profes>ions Code:The Cnntrucmr's License Law does not apply in an owner of OUT fJUS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such ireptnvemmnts arc not'mtendel nr offered tin NEW RESIDENTIAL ELECTR SQ FT. sale If.however,the building or improvement is sold within oncycar ofcompletion,the SQ.FI'.I LOOK AREA $ISQ.IT. owner-builder will have the burden of proving that he did not build or improve for purr- Nrlr"-. 14-s� QG•O�"iccof,aleyCJOEJ 1,ns owner of the property,am exclusively contracting with licensed contractors m TOTAL: Q construct the project(Sec.7111,Rwsiness and Professions Cal)The Contractor's Li- sy -ZZ AS cense Law docs not apply to an owner ofpmpery who builds or improves thereon.and Qn.. PLUMBING PERMIT FEE n•. who amnacts-for such projects with a centramor(s)licensed pursuant u the Contmmm's License Law. PERMIT ISSUANCE lure exempt under See. .If&P C for this reason (1 ALTER-DRAIN&VENT-WATER IBMjUL VALUAT7O Owner Date WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Of IhereM1y riff on under penalty of perjury one of the following declarations: t)c r C)Ihave and will maintain aCenificelcof Cnnsenuosell-insure for Wnrker'e Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES J 1:CONSTRUCTION Trillion,as provided for by Section 3700 of the Labor Code,for the fa rmarr amc of the work for which this permit is issued. FIXTURES-PER TRAP ❑ 1 have and will maintain Workers Compensation In pmnre,as required by Section 3700 of the lunar Code,for the perfonmmce ofthe work for which this permit is issued, GAS-EO.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN My Worker's Compn.mtion lnsurenea carrier and Policy number arc: Carrier: Policy Nor GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPr10N PROM WORKERS' GRFASF/INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FFFS (This wclioo nerdnot be,completedil'the permit is loot one hundred dolhtrs 0 Us) GREASE TRAP or Leos.) PL.ANCHECK 17EE ri I certify tboom the prfonnenceoftho work lin which this permitls issurod,[,hall SEWER-SANITARY-STORM F.A.200 FT not employ any Peron in any manner m as to become subject to the Worker'Compe t- ENERGY FEE 2-lbqt ,Z .cation laws of Culiromia.Date WATER HEATER WNGNT/ELECTR z O Applicant GRADING Frti NOTICE TO APPLICAN'r:If,after making this Ccrificenc of Exemption,you should WATER SYSTEMO-REATING (•-' ^ SOILS FEE hecne suuo bjecthe ker's WorCompensationpre visins bo oof the Lar Code you mus m �"— W forthwith comply sillbstich pmvisioro or this permit shall he deemed revoked. WATER SERVICE. a0 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL VLMB. SQ.FT. PAID L)0I hereby action that is a construction lending agency for performance of Dem fteceiptM the work for which this permit is issued(Sec.3097.Civ.C.) r 01•" Lwndcr'.s Nume TOTAL: WLender's Address TDT^I� aZ 0a I certify that I have read this application and state that the above information is BUILDING PEIih correct.l agree m comply with all city and county ardinereasond stem laws ealatingm QTY. MECHANICAL PERMIT IIff V Z building am,nac per,and hereby umborimrcpresenmtivesofthis city reenter upon the SEISMIC ItE 1 Nl'w+ ot#we-mentioned propry lin inspection purpnes. PERMIT ISSUANCE r-�a (We)agree m save.indemnify and keep harmless the City of Cupertino against ELECTRIC PLIi 1 ' I Coll liabilities.judgment..coasmal expenses,Hattie y in any way acemc against said City ALTER OR ADD TO MIiCH, PLUMBING FEF. % inammgpcmc is mfdm grantitalm permit. ` "),O Al'1'LI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P INT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL FEE i 3 C79 SO tiN1'.GUhAT VS. / / 9 AIR fiANDLING UNIT(OVER IQfXq CFM) CONSTRUCTION TAX Silland reef Applicam/Crm cmr I tc EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HALA DOUS MAI'BRIAI S DISCLOSURE Will the applicant or future building occupant store or handl hoarders material HEATING UNIT(TO 100.000 BTU) us dclined by the Caperton Municipal Code.Chapter 9.12,mrd the Hcalth and Safety Cale Seed.25532(a)'1 HEATING UNIT(OVER 100.01)BTU) Yea No VLNTILA'I'[ON PAN(SINGLE RESID) PAID Dube Rot# Will the applicant or future building occupant use ecapmem or devices which pO11.ER-COMV DID OR 100,000 BTID i mi0 hmurdous air comamiame,a delved by the Bay Area Air Qmlity Managcmem TOi'AL: Dann°? BOILER-COMP(OVER I00,000 BTU) ❑Yes [:1 No I have read!the huserdnesmare,ials requd imemm� under Choper 695 ofthe Cali- AIR CONDITIONER ISSUANCE DATE fomia f{ealth&Safety Cale.Sections 2!b)5,25533 and 25534.1 uedersmnd dent if the NEW RESIDENTIAL MITCH. SQ.FT. ms's building dues not currently have a tmmnt,that it is my respmsibllhy to Maley the occupant of the requirements which most M met prior to issuance of a Ceniricate of(Rcupancy. Darer or author mil agent Dam TOTAL: ISSUED BY'. OFFICE m 0 CJ G7 y N y ; ; m ; m O y m w < n m = n 0 D r n n m x n x y Zmy Ill r Z 0 Z N C nZ 0 O Z :1 C 5 Z y a o m 2 Z r m x c m n X i c F x c rn z c m m n'-'N O 31 Z T O m Z im m T Z Z T T y DFn 0� Z7 Z r m y r T N ,mi � w y �' �+ a F. M, m Z y D a 0 O1 c g g c c c f C R, 00o D i '� m N m m Y T N l0 p =Nm ""�� II a .. a a a / / I T n y II I O n N A b W A P (D cn< Nnc VV Ii Pay o <n n n w z m a II m �I I1I ° N A • Ip•+ W A z w 0 c c / I Z $ = n '' c II �I W fD N M N v O z p o g ^ m / D m o ((DD �I II IrS I O W (D O W FZC >- � Tsl v Z m m C I 11 M 1,• „ (D 5 m C oz O I I I H p H O im � W. A: Sf1 I I I� I nnu A rt N (D m z n m y 9 w �I II h N h r lD Z=!W o� a I fynrm 'll' Z N II 11 p� R �• fY W O M,Z_ ' o z ���rtyyy II �il II I (D O w O Z D Ch N N ppi r+ p. N W N omo `" > 97 nD7 �0 `n97 o�zAl h cn y 9 D m O c m c m c m y .yya0 Go MCL m �� D m II T m W D 'm Do N d a O ff 1 w U W Cl �+ D KDKm mo, NO m III O H Om2M0 P r O h FAQ- � v�m V H I1I u n y rA w m O m`= F� 1 m N m �I I I� I1 11I II II it o m d u 11 m< 00