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S0001 B 0242WOO_ IFllr Dan ZO2 oz Q r4tw SC2< LL� WGC a Pjo� yFZC iFC F oz a� a� UO O� (3I Lir �z E APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING PROJECT IDENTIFICATION BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL PERMIT No`0242 ^ 0 2 4 2 SOOOI 49 BUILDINGADDRM o c . SANITARY APPLICATION SUBMITTAL DATE -� � - OWNER'S NAME: PHONE - CO f OR �'sUE. p��+n LIC NO: / N/C ❑ CON'I'HOLN IARCHITECT 'WEER: LIC O: ADDRESS: CONTACT; PHONE: vJ i BUILDING PERMIT INFO x `7 -76 ❑ Consultant F.S Paid by Applicant (Initial) BLDG ELECT PI UMB MECH O� 3-2,- CV pit k 1 5 ❑ ❑ 09 ❑ LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 am licensed under previsions of Chapter 9 (commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION PERMIT ISSUANCE with Section ]000) of Division 3 come Business and Professions Code, And my license is in full force and eB L L3 RESIDENTIAI; ❑SFUWI. [I KITCHEN I. APPLIANCES-RESIDENTIAI. License ass Le. J Dote ' Contractor + REPIP ❑ADDITION ❑PLUMNING RE PIPE MULTI -UNIT ❑S'rRUCURAL MODIFICATION El INTERIOR [_1 CHIMNEY REPAIR IMPROVEMENT E]SWIMMING POOLS ARCHITECTS DECL.ARATION❑ I understand my plans shall be used as public records PANELS UP TO 200 AMPS Licensed Professional 201.1000AMPS OWNER -BUILDER DECLARATION I hereby wino that 1 am exempt from the Contractor's License Law far the following reason, (Station 703 1.5, Business And Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair Any sanctum ❑BATH RIiMODE PAIR I z 1.51 NER � eA-- MITION r,O.0 t2eOL A ri OVER I(NIIIAMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. Immmitsissunnegalso requires the applicant farmch permitao fileasigned statement that he is licensed pmsmmA t,, the provisions of Ne Contractors License Law {Chapter 9 (commencing with Section 7000) of Division 3 of the Business and lsrolessions Code) or TEh1P. METER OR POLE INST. COMMERCIAL' Ihat he is exempt Therefrom and the basis for (be Alleged exemption. Any violation of 0 NEW HI.DG/ADDITION [_1 DEMOLITION Section 7031.5 by any applicant for a permit subjects the applicant 4a a civil penalty of not more than live hundred dollars ($500). ❑ Las owner of the propery, or my employees with wages az their sale compensation, will do the work. and the swnurt is not intended or offered for role (Sec. ]014. Business POWER DEVICES ❑TENANT El FOODSERVICE IMPROVEMENT ❑OTHER SWIMMING POOL ELECTR OUTLET'S -SW H FI%TURES and Professions Cede: Thn Conomme, License law dons not apply to An owner of NEW RESIDENT R SQ FT. propmy, who builds or improves thereon. And who does such work himself or through his own employces, provided that such improvements are not intended or offered for ,site. IL lmweverme building orimprovement is sold within ane year o(cnmplenion, the SQ. IT. MOOR AREA $/SQ. FT. owner -builder will have The burden of proving (lint he did not build or improve for pur- pose of min.). ❑ I, as owner of the pmpery, am exclusively contracting with licensed contrnetors to TOTAL' consuuet the project (Sec. ttW/, Business And Profasimre Cade:) The Conwctsu's Li- ceme Law does not apply m an owner of property who builds or improves thereon, and QTY, PLUMBING PE FEE who contracts for such Projects with a contracm0s) licensed puna nuo dm Contractors PERMIT ISSUANCE License Use I.m exempt under $tt. , B & P C for this reason Owner Dole ALTER - DRAIN & VENT- WATI7R (Fa) VALUA'I ION WORKER'S COMPENSATION DECLARATION RACK PLOW PROI'F.CT. DEVICE 1 hereby nl under Certify of perjury one of (he following declarations: ❑Ihave and willmaintainetion 3700)of ComemmCode, for for mai erform,ce of th- moan, As provided for ri Section J]aB of the Lahr Code, for the performance of the work for which this Caron( is issued. DRAINS -FLOOR. ROOF, AREA, COND. STORIES TYPE CONSTRUCTION FIXTURES -PER TRAP h his porn l i Section ce,which ❑Ihave and will maintain Workers anceo Compensation work 7700 of the Latour Coals. for the performantt of Ne work far which this permit is issued. OCC. GROUP AIN GAS - EA. SYSTEM -1 INCA OUTLETS GAS - CA. SYSTEM -OVER 4 (1?A) My Worker's Compensation Insurance carrier And Policy number are: Carrier: Policy Na.: CERTIFICATE OF EXEMPTION PROM WORKERS' COMPENSATION INSURANCE GREASI%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES ("NatttionreednrnbecompletedHimparmit star an bondredd.H.ol($11X0 or less.) GREASETRAP PLANCHECK FEE Icetifythm intheperfamranceofthewmk forwhichthispeandahisued. l shall no employ any?g.� Ip W� y 999999pp�ppp00000ffffffso m ��¢¢ ,�� 1at w the Worker' Co.,.- ,anion Laws oI.CNIi36sin ll �'•�o s�� Applicant YY YY ✓✓ SEWER -SANITARY -STORM EA. 200 FT. ENERGY FEE WATER HEATER WNENT/ELECTR GRADING FEE NOTICE TO APPLICANT. IL after making (his Ccrificate of ExemP(ion, you should become subject to the Worker's Compensation provisions of the Labor Code, you must WATER SYSTEMITREATING SOILS FHE lanhwith comply with such previsions or this permit shall be deemed revoked. WAT17R SERVICE CONSTRUCTION LENDING AGENCY reof nat there isaconswction lensingugencyfortbeperfmwnc I hereby eIin(h NEW RESIDENTIAL PLMH. SQ. FT. PAID Date, - am At the work for which this pmnit is issued (Sec. 3097, Ci, CJ Lenders Name TOTAL: Lenders Address TOTA XINTg BUILDING F Ti 1 codify that I havered this Application And store that the above mnar.tion is QTY. MECHANICAL PERMIT t'f f- E F� SEISMIC FT.E correct, l agree to comply with All city and county ordinances and state laws relating in building consuuctinn. and hereby uuthorice representatives of this city ¢(enter upon the PERMIT ISSUANCE - ELECTRI EE .hove -mentioned property for inspection purposes. (We).,me to,ave, indemnify std keep harmless the City of Cuperiro Against habilities,judgmeno, cents and expenses which may in my way accmn against said City in consequence of the granting of this pcmtiL ALTER ORADDTO MECH. ) NG FF.F. NR HANDLING UNIT(T) 10.0110CFAB IT, MECHAICAL FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. -_ AIR HANDLING UNIT(OVER 10,001 CFM) "'CONST CONTAX Signature of Applicant/Cammctor Date HAZARDOUS MATERIALS DISCLOSURE EXHAUST 11001)(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT CTO 100.001 BI' UI Will the applicant or future building occupant store or handle hazardnu,material A, defied by an Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety Coda Section 255320)? HEATING UNIT (OVER 1(11,M) BTU) ❑Yes ❑No - Will the applicant or future building occupant use equipment or devices which I cant hamrdous air canttemnanis as defined by the Buy Area Air Quality Management ❑Yes [:1 No VP.NTILATION FAN (SINGLE RCSID) PAID - Dam Receipt N BOILER -COMP (311P OR 100,000 BTU) TOTAL:District? BOILER -COMP(OVER 100.000tlTll) AIR CONDITIONER I have read the M1mnNous materiels requirements under Chapter 6.93 of the Cali- hand. Health & Safety Code, Sections 25505.25537 and 25534. I uMero and .hat if the building does not currently have a brad, that it i, my responsibility m notify the occupant CHANCED E _% ` NEW RESIDENTIAL MECH. SQ. ET. of the requirement, which must be me( prior to issuance of a Cerificam of Occupancy. ISSUED BY' �+ TOTAL: Ownerm.,fli died agent Dote OFFICE