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S0001B0346 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BOMBING-ELECTRICAL PER O. APPLiCATION/PERMIT 1'I,UMIBNG-MECHANICAL, Q BUILDING DIVISION H1111,DING PROJECT'IDF,MI'IFICAI'[ON 5000 3 4 6 BUILDING ADDRESS: %ANITAH N(l. APPIACATION SURMI'ITAt.DATE r• / 105"1 �chh�h 1©N 0 O NER'SNAMIi: PILULAE: CON RACEOR'S NAML'. LIC NOo NIC CON'I'ROLa ul. �L�r �� ❑ •ARC I"E,CT/ENGINEER: LIC NO: ADDRESS: — k :1C. is CONTACT: PHONE: BUILDING PERMIT'INFO Q ❑ Consultant Few Paid by Applicant(Initial) BLDG I PLUMB MECH L �-. �l El I,ICBNSID CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby affum that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION �egZ with Section 7000).f Division 3 of the Business and Professinm Code.and my license is '? �I� RESIDENTIAL PERMIT ISSUANCE FDS in full l'omc mW dfcd. r ❑SFDWI, ❑KITCHENRENODEI. QUU 1.icemeLi-ss C=1� Lica APPLIANCES-RP_SIDENTIAI. []ADDITION El[COMBING BE FIRE N6y Data In'Q Contmclor ❑MULTI-UNIT El STRUCTURAL ARCHITECTS DECI.A A N PANELS ~. mand myplansshall leuealunpublic rccoN,, MODIFICATION OZX 1 undeN� UPT0200AMPS ZZ" ❑INTERIOR C]CHIMNEY REPAIR Lit,...aJ Pr.fmssinnal 20I-1000AMPS IMPROVEMENT' 0 SWININIING POOIS �ag OWNER-BUILDER DECLARATION OVER 1[X3 AMPS ❑BATA NEMOUEIJRf�'AIR �DY;MOIJTION 1 Initially aRnn that I am caempt from he Convenor's Liana law for he ❑OTHER �� following Teat...ISenion 7031.5.Business and Prnfessiuns Code:Any city or county SIGNS ELEC RICAI, 61��y which wtaine,a Peru,,( contract. (Irl p I Islo.or minor anystmcurc prim t t ado,recount.'he applicantf such Permit file a signed.mlonent SPECIAL CIRCUIT/MISC. Evrrmath licensed Pars a the P The c o t L 1 (Chamer9 COMMERCIAL �CGOQ he ar,,ngwitSecton70mfofD's"sim lot me Business and Prmfu',ion Code)m TEM R METER OR POLE I NST. Lac, that he is exempt theafrom and the basis lir the alleged exemption.Any smInsiou of EINE W NLDG/ADDITION ❑DHMOLI'f10N Section 7031.5 by any applicant for a permit subjects the applicantm a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE t mora than live noodred dollars($5(X). IMPROVEMENT =Q (]I,as owner of the PronY,nnnycmPlnyccs with wugesas thcirsolcuhmpcmalinn, SWIMMING POLI.171,ELTRIG ❑O'fHlat p: widdothework,andthcsvucmreisn rimendcdoroReadforule(Scc.7044.Business 63m and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURP ­ property who builds ur improves theary n,mal who does such work himself or through bill,..employes,provided tem such improvements one not intended or mffctsd fur NEW RFSIDENIIA].ELECI R SQ 14. sale.IL however the building or improvement is mid within one yearof completion.the SQ.FT.PIAOR AREA SSQ.FT. er"huilder will have thh Novell of proving that he did not M1uild nr inhprmvc f r Pur- pmscnf role.). 'IA EJ 1,us owner of the mProperty,am eaclu.ively contracting with licensed contractors to earml the p,,,jaR(Sec.70a4.Business and Profession,,Cale:)The Contmetors I.1- cause lawdoes no,apply its an owner of Property who builds or improves thereon.and QTY. PLUMBING PERMIT FEIi who ahmmels for such projects with a contractor(s)licensed pmsuanno the Contractors Linmrc Law, PERMIT ISSUANCE LJ 1 am exempt under Sce. ,B&P C for this reason ALTER-DRAIN As VENT-WATER IIiA) VALUATION Owner Data • WORKER'S COMPENSATION DE I-ARATION 11ACK PLOW PR(YI IiCT.DE ICE 1 hereby affirm under penalty of Perjury one of the following declarations: O [have and will maintain a Cenificme mf Cometh toself-insum for Workers Copier- DRAINS-MOOR.ROOF.AREA,COND, STORES TYPE C(INSTRUCfIOf satiom,as provided for by Section 3703 of the Labor Code,for the Performance of the work for which this permit is issued. FIXTURES-PER'I'RAP 1 have and will maintain Waro r'.v Compensation Insurance,as required by Section 3701 of the Lubar Code,l ir the Performance ofthe work for which this Permit is issued GAS-F:A.SYS1'libl-I INC.J OUTLETS OCG GROUP AYN My Workers Compensation lnsurancecarier and Policy numMr arc: GAS-EA.SYSTEM-OVER4(EA) Cartier: Policy No.: CF.RTI IECATE OF EXEMPTION FROM WORKERS' GREASEJI NDUSTRI,WAS'1'1:INTERCEPTOR COMPENSATION INSURANC17 —BUILDING OIVIMON FEES (This so,dwiaJ nosh compleadiithe permit is formne hundred dollars(5100) GREASETRAP rtNOHECKF Loy any mat in he Performance of theworkbecome mesubjectch to the ut Wislss'Com at, SIiW'ER-SANITARY-STORM IiA.NNI FT. not employ any perssm in anYm mbatona subjccnothe Wmkcn.'Compen- :V FI! z satil Taw fCa ergo as/ , WATER HEATER WNEVVELLICTR )ING ELI: - ti NOTICE TORP .CANt:H ter a ing this Certificate of Exemption.You should WATER SYSTEyvh TREATING S I;i. (•` ,aa le subject to the Worker's Compensation provisions of the Labor Code,you men moll,lit comply with such pmvioon,,nr t his Permit shall he datmcJ nvnked. WATER SERVICE Q I ID CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT 91 Data Receipt e a ) IherebyaRmh than themes a amamcticl lending agency for the prfommnce of U 0— the work for which his Perms Is issued(sat.3007,Civ.C.1 'I OIAL: Q Lender's Name TOTAL: C)U Isrdcr's Addres.,, BUILDING FEE G 1 candy that 1 have mad his application and slate that the alone information Ice F on camel,l agree m comply with all city and county ordinances and nae laws relating to QTY. MECIIANICAI,PERMIT FEE SEISMIC FEE U z building mm.antctinn,and heathy authnrim rePresenmtives of this city mcmcrugm he rhave-mentihmed property for inspection purposes PERMITISSUANCE ELECTRIC FEE (we,agree m save,indemnify and keep harmless the City of Cupertino against liabilities.judgments,costs and expenses which may in any wayaccmeagainst aid City ALTERORADDTOMECH. PLUMBING FEF, le aorwIpance of the goanting of his inaull. APPLICANT UNDERS ANDS AND WILL COMPLY WITH AI.L NON-POINT AIR HANDI.ING UNIT('TO FORM CFM) MECHANICAL.ITE SOURCE REGU TI S. vJ R/ AIR HANDLING UNIT(OVER 1111X3 CFM) CONSTRUCTION TAX Sig ere.17A PP icanUC tomcat" Date EXHAUST HOOD(W/DUCD HOUSING MI'T'IGATION IT IIA7A IDOUS MATERIALS DISCLOSURE Will the opplicant rot lumre building oceupam smrc or handle humrdous material HEATING UNI'('(10 1n),000 BTI) as Jedned by the CuPenino Municipal Ede.Chemo 9.12.and the Health and Safety HEATING UNFF(OVER Haddad BTU) Code,Section 25532(a)" ^! _ ❑Yas VENTILATION I AN(SINGLE RES ID) LAID Data Rcccipt if AMIIJI Wi11 the applicam 0r fumy building occupant use equipment or devices which BOII.ER-COME'(3HP OR IOU K)O RTU) mit hn>urJnns air cnnmminanl.at ddined by the Buy Ah<u Air Quality Management AL: District^. ❑,f(/ BOIL(?R-COMP(OVER I00JXX111'1G) ❑Yea AIR CONDITIONER ISSUANCE DATE 1 hath mad let h ash,Se.materials 5.M3 an under Chapter rom l the Cali- fomite Health& roma Code,Sections 25505.2551]and 25534.I umlcrztand him if the NEW RESIDENTIAL MECIi, SQ.FT. / (0 4e Q building Aoru not nmcn0y bout n tenant,that 11 is my reslmn,,ihiliry as amity the inney of the rego,cona L,,which must be met Prion.c uunre of a Cenilicum of Occupancy. Data TOTALt ISSUED BY: owme anhn' 'ge _ OFFICE