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29153 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OFC BUILDING.-ELECTRICAL PERMIT NO. OUILDINC DIVISION APPLICATIONIPERNIIT PLUM1iBING-MF.CNANICAI, n q BUILDING PROJECT IDENTIFICATION L 1 J BUI.qIN IIDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE AJ CIP(I` /_//I�/• N❑IC CONTROL# W� 1tl8' % LICNO� OLi6p OJPHONE: BUILDING PERMITINFO a' {,DNISPJlJer X. t �• ❑ Cansullanl Fees Paid by Applicant(Initial) BE PI.t1MB MIiCH LICENSEDCONTRACTORSDECLARATION QTY ELECTRIC PERMIT FF.E I hereby arfrn that I am licensed ander provisions of chapter 9(commencing JOB DESCRIPTION ��Z thllhuma]IX efecDivi5inn3of the Nusineasa fssions Code,andmylicenseia RESIDENTIAL: Fo, nth Sforce humanoid ij R PERMIT ISSUANCE �F.UZ j Licence Class_{!Lic.N `5 2- ❑SFDWL ❑KITCHEN REMODEL VI R! Bar' _ Cnmranor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE ZOr Z�' ARCHITECPSDECL RAT N ❑MULTI-UNIT ❑STRUCTURAL I understand my plans shall he used as public records PANELS , MODIFICATION O ZUPTO200AMPS O ❑INTERIOR ❑CHIMNEY REPAIR Fwtfsl Licensed Professional 201-I000AMPS IMPROVEMENT OWNER-BUILDER DECLARATION CmitaON OVER]"AMPS a�Q I hereby affirm that 1 am exempt from the Contractor's License Lnw for the ❑BATH RP.MODEI/REPAIR ❑DEMOLITION aIU V following reason.(Section]031.5,Business and Professions Code:Any ciry nr counD SIGNS ELECTRICAL ❑OTHER tL which reluims a permit to consumer,alter,improve,demolish,or repair any structure prim to its issuance,also requires the applicant for such onto,to fileaaignedsutement SPECIAL CIRCUIT/MISC. } that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 a0� (commencing with Section 000gof Division Sof the Business and Professions Code)to ]AMP.MIDER OR POLE INST. COMMERCIAL' a y o y that he is exempt rhercliom and the ends for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Section 7031.5 by any applicant fora Permit subjects the applienat ma civil penalty of POWER DEVICES ^aOm ❑TENANT El FOOD SERVICEoat more than five hundred dollars y employees ❑ Las owner of the property,mmyo,itim eestwith wages aatheir Ner.compensation, SWIMMING POOL ELECTRIC IMPROVEMENT will do mework.and Neswcmmistot inrticense aae does at apply 1. Business ❑OTHER and Professions Cade:The Cnnwctors License Law rites not apply to an owner of OUTLETS-S WITCHES-PIX ES progeny who builds or improves thereon,end who dyes ouch rink tar thmogh his own rimplmyees,provided that such Improvements we nm intended m or offered for NEW RESIDENTIAL ELECT ti owner-builder %ill have de burdenprovement that he id n one year of compleinn,Ne SQ.LF,B Eh.00,(i® $/SQ.FT. nwnerhuilder will have the burden of proving tbm he Aid not build nr improve for Dur- pose of sale^)` �+- ❑I,ssow rofrheprogeny.an,Business embracing with licensed atm`tors i. TOTAL: = construct th<pmject ISec96i t,Business end Professions CtrteJ The Contractor Li- L- all cense Law does not apply to an owner of property who builds or improves thereon and QTY, PLUMBING PERMIT FEE s a t s 1996 who contmcn for such projects with a commands)licensed pursuant to the Contractors License Low. PERMITISSUANCE ' ��f LUN1 AI 1 em exempt under Sec. B&P C for this lemon Owner Dam ALTER-DRAIN& - ATEVENTA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. •//yIJ O� I hereby affirm under penally of perjury one of the following declarations: [JI ❑Ihave and will moinmine Cenificam nfCanxntmself-insure for Workers Cnmpen- DRAINS-FLOOR,ROOEARE ND station,as provided for by Section 3700 of the Labor Cade.for the performance of the STORIES TYPE CONSTRUCTION Alfor which this permit is is red. FIXTURES-PER TRAP have and will maintain Workers Compensation Imumnce,m required by Section ]l cif the Lahr Code,tribe perfnrmme.1'the work for which this permit is isamd, GAS-EA.SYS TEM.I INC.4 DUE LETS OCC.GROUP APN My Carrier C pens Ion I nce earner and Policy o Cartier. J�gg••�Vy����`�W��`�J�aynpdPNo.: GAS-EA.SYSTEM-OVER 4(EA) ILAliRMP1I(�,V FROM WORKS S' COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR GEis section need not be completed if the permit is for one hundred dollars IS 100) BUI IVISION FEES or IessJ GREASE TRAP PLANCHECK IEE Loy any person in mymapermonnerofs tohme rnmesuk for ichatio rise W kers'Coope . SEWER_SANITARY-STORMEA.200FL not employ any person in any manncrma mhecnmc suhjen to rise Wnrkeus'Cnmpen- ENERGY Flf ,z s tion Lows of Coddamm.Data WATER HHAXER WNFNT/CLECTR 2Applicant GRADING P NOTICE TO APPLICANT:If.alter making this Certificate of Hxemption,you should WATER SYSTEMEORF.ATING become subject to the Winders Compensation provisions of the Labor Code,you must SOILS FE. Qforthwith comply with such provisions or this pe.itehall he deemed revoked. WATER SERVICE �z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPI-MBSQ.ET. PAID L)Q fconstructionI hereby om that there is aconstruction lending agency for the Performance of Dam Receipt, V. L••t the work for which his permit is issued(Sec.309],Civ,C.) O F" Lenders Name TOTAL: GUiI Lenders Address TOTAL: yt 1t 1 certify that I have read this application and state that the above information is BUILDING FF. �f�e r N counsel.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE V z bulldingeonsauction,and herebyamhmim represunmtiven of this city menterupn the SEISMIC FB tti above-mentioned property for inspection purposes. 19 (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE. ELECTRIC FEE ludo lies,judgments.costs and expenses which may in any way accrue against said City ALTIiR OR ADD TO NIECE 1.in consequence of the granting of this permit PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Iq(XIII CIV) SOURCE REGULATIONS, MECHANICAL FEE AIR HANDLING UNIT(GVHR IO,ODIICFM) CONSTRUCTIONTAX Signature of Applicant/Comractor Uate EXHAUST HOOD(W/DUCT) HOUSING MITIGATIO EE HAZARDOUS MATERIALS DISCLOSURE Will the applicontmfu...re building a:cupant sunenr handle meardnm material HUXI'ING UNIT TO 100,000 BTU) as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Code, ion Sm25532(a)] HEA'1'INC,UNIT(OVER 100,110t)BTU) ❑Yea Ko VENTILATION FAN(SINGLE BESIDE PAID s Will the applicant or future building occupant use equipment or devices which Date R r X emit momdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 100,001 BTU) District? �� TOTAL: ❑Ya d'••.m., BOILER-COMP(OVER U1000 BTU) I have mad the haeardoua materials requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE. form Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT holding does not contritely haves mount,that it is my mspmsibility to runty the occupant of the It�`ems which must be met Prior to issuance of a Cyy�ate of(kynm.)pfy. �f� O]L✓ ::l Owren a nzedagent Date TOTAL: ISSUED BY: OFFICE.