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29898 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. /N /N BUILDING DIVISION APPLICATION/PERMIT PIAIMRINC-MECHANICAL LVX 4J BUILDING PROJEQ'IDFINTIFICATION 1ff UILU�Q ADpkES.� SANITARY NO. APPLICATION SUliM11TAL DATE, NER'S NAME, y ONE: RS NAME: LIC NO: NIC CONTROL# URCHI'TECUENGINHER: LIC NO: D ESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE h 1 ereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION OZ withSccaion 7011L)1nC Oivisinn 3 oftbe Businesslod Profession,Code,andmylileme is RESIDENTIAL _ Y10 full PlikMl'i'ISSUANCE, Fug in Cls erW cRak ❑SPDWL ❑KITCHCN RIiMODEI. Q< U License Clow hieN APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE A 6 W Date Can tar M.7m ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL Z Oto 1 understand my plans shall be used as public record, MODIFICATION C G UP TO 200 AMPS El INTERIOR [I CHIMNEY REPAIR FSE". LicerneJ Professional 201-1000AMPS PROVEMENT Gy E_l OWNER BUILDER DECLARATION X 0.'C G 1 hemby affirm that I am exempt from the Comnisme,License law for the OVER 1000AMPS H RYMODEUREPAIR ❑DEMOLITION K O L U following reason.(Section 9031.5.Business and Professions Cade:Any city or county SIGNS ELECTRICAL El OTHER 613 6.y which requires a permit to construct,alta,Improve,demolish,or repair any onicmre Its. price in issuance.also requires the applicant for such Permit file a signedsmtemcnl SPECIAL Cl RCUHUMISC. EE} that he i,licensed pursuant to the provisias,of the Contractor'.I.acnxe Laos(Chapter 9 W^�Q (mmmencingwith Section 70W)of Division3nfthe Business and Professions Codgor TEMP.MEfIiR OR PULE[NST COMMERCIAL Q.a e C t"he is exempt oweelmm and the basis lin the alleged exemption.Any vid.tion of ❑NEW BLDG/ADDITION ❑DEMOLITION XX 4• Section Iy� 7031.5 by any applicant for o permitsuhjecn the applicant to a civil penalryof POWER DEVICES ogs s/t ❑TENANT ❑FOOD SERVICE of moa Nan five hundred dollars($5110). IMPROVEMENT 1,as owner of the property,onny employees with wages rev their sole compensation. SWIMMING POOL EL RIC wdldo the work,and theswnureisnot intcndW mofw does a,,, p,ec,,,ter loo;ss _a 11 OTHER 63m and Professions Calc:The Comocou,License Law docs na apply m un owner nC OUTLETS-SWITCHES-P rU PS propery who builds or improvev thereon,and who does such work himself or through his own employees,provided that Such improvements are not intended or offered for NEW RESIDENTIAL.ELECIR S Pf sale.If.however,the building or improvement is sold within one year Of completion.the SQ.FT.FLOOR AREA E/SO, T, caner-builder will have the burden of proving that he did not build or improve for par- Iaocn y E3 I.."owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.704cf.Business and Professions Code:)The Contractor's Li- censeLaw does notapplym ant Ofpropenywho buildstoirrlaysxowner.end waQTY. PLUMBING PERMIT FEE NAY 13 who comms for Nuch projects with a connr(s)licensed pursuant m the Commcmr's 1O^ Licse enlaw. PERMIT ISSUANCE 6 O l am unnpt under Sec. ,li&P C f,this rcmim Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hemby uffvm under penalty of perjury one Of the following declarations: Sic 1 have and,H maintain a Certificate Of Consent to%elf-insum for Worker's Contain DRAINS-FLUOR.ROORAREA,COND. STORIES TYPE CONSTRUCTION amiom,a provided for by Section 37M of the labor Calc.for she performance of the D work for which this permit is issued. FIXTURES-PER TRAP ❑1 have and will maintain Workers Compensation Insurance.as required by Section 3700 of HeLL.alnr Code,for thhe�performance of the work lot watch permit �i.s su J. GAS-EA.SYSTEM.I INC.i OU7R.ES OCC,GROUT' APN n,sfi 1 CWorill7nl-1--I•Tn_� -YJI cY Nr,yJAj.L+w-acs-I-J----/— GAS-EA.SYSTEM-OVER q(EA) CERhun TIFICATE OF EXEMPTION PROM WORKERS' GRF.ASFJINDUSTRi,WASTE INTIiRCEPTOft COMPENSATION INSURANCE BUILDING I VISIO FIiHS (TM1is,mtion need not he completed ifthe permit is for hundred dollerx(SI00) GREASE'rRAP or less.) PLANCIIECKFEE 1 [certify that is the perfammnec of Ne work for which this permit is issued.I shall SEWER-SANITARY-STORM persom EA.200 Fr. not employ any n in any manner as to become Subject to Ne Workers Compen- ENERGY FEE: OZ .tion Law,of Ciolorno.Dome WATER HEAi'ER W/VENTTd.CCTR GRADING FEE 2 Applicant y NOTICE TO APPLICANT.If.after making thin Cerdficau of Exemption,you,bould WAT17R SYSTEMO REA]ING become subja0 to the Workers Compensation provisions of the Labor Cade,you must SOILS TEE � > forthwith comply with such provisions in this permit.sholl be deemed revoked WATIiR SERVICE. Q CONSTRUCTION LENDING AGENCY NEW RES[DENTIA[.PLMB. SQ,Fr. PAID Dam Receipt# L)O I hereby affirm that there is u co ourcelion lending agency far the performance of D. F' the work for which this permit is issued(See 3097.Civ,C.) Lenders Name TOTAL: `^) tender's Address T I certify That 1 have read this application and.cute Nat the above information is BUILDINGFIRE F' rn anrca.1 agree to comply with all city and county ordinances and sum Laws relining to QTY. MECHANICAL PERMIT I°EE V Z building conshucliun,=it hereby authoriu representative,of this city to enter upon the SEISMICFEE ulcrvecnicalmned property far ins,,oan purposes. PERMIT ISSUANCIi (We)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC FEE Iiabilldes.judgmems,costs and expenses which may in any way accrue against sold City ALT[?k OR ADD TO MECH. a in onsequence of the granting of this permit. PLUMBING APPLE NT UNDERS'rA 'DS AND WILL COMPLY WITH AL1.NON-POINT qIR HANDLING UNIT('T010.OIN)CPM) MECHANICA FEE tF�iULAT10NS. 1 5 AIR HANDLING UNIT(OVERH)IpOCFMt CONS'IRUCI'I>NTAX Signawm of pplicam/Con for ate EXHAUST HOOD(W/DUCT) HOUSING MD "EE HAZARDOUS MATERIALS DISCLOSURE Will theapplicautorfumm buildingcecupam smte mbeadlchmaddousmaterial HEATING UNIT TO 100.000 BTU) m defined by(M1e Calculus,Municipal Cobc,Chapter 9.12,and the Health and Safety Cale.Section 255320)? HEATING UNIT(OVER 100J000 BTU) ❑Ycs No VENTILA'T'ION FAN(SINGLE RESID) PAID Will thea applicant or future building ant use equipment m devices which Dam Rmeipt a PP goaul emit M1arxrdou.v air comaminunn as JeOned by the gay Arca Air Quality Managemem BOILER-COMP(3HP OR 100.000 BTU) TOTAL: District? BOILER-COMP(OVER I01000 BTU) ❑Yes ❑No I hmemad the bw:udou.,mmeria0mquircntems Once,Chapmrfi95 of Nc Calm AIR CONDITIONER ISSUANCE,DATE: fomite Health&Safety Carl Sections 25505,15533 and 25534.1 understand Nal if the NEW RESIDENTIAL MECH. SQ.PT. building does not currently have a tenmm6 had it is my rcsrymsihility of rally the me Pa., of the requirements which must he met prior to issuance of o Certificate of Occupancy. Owner or amhunital agent note TOTAL: ISSUED BY'. OFFICE � � f �.. N. an •- 09 1 N D z 4 { J 0N3 it A Z C i T .� Ul rS LA LA n-- o