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29982 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT P.EN�ONLY' CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMfr NO. /1 /N t.8 L^/N BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL . L V4 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE G OWNER'S NAME: PHONE: CO RA OR'SN Er LIC NO: / - vr�r z�/ NIC CONTROL# r � ARCHITECT/ENGINEER:' LIC NO: ADDRESSlot: ❑ /' CONTACT. PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG g ECT PLUMB MECH ICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT EE p 1 hereby offtrm that 1 am licensed under provisions of Chapter 9(commeucing JOB DESCRIPTION a2 pWWwith Section 9000)of Division3ofthe Brsinossaad Prefesaimn Code,and any ficense I, in full force and effect. PERMIT ISSUANCE RESIDENTIAL - License ClassLic.# ❑SFDWL O KITCHEN REMODEL i76 Date _ Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE ARCHITECT'S DECLARATION F7'z PANELS ❑MULTI-UNIT El STRUCTURAL , ,Z O f/17, - 1 understantl my plans shall he u.wd us public recoMs - MODIFICATION OZ::iiq - - _ UP 10200 AMPS ❑INTERIOR ' ED CHIMNEY REPAIR ��M Licensed Pmfesalined 201-IOWAMPS IMPROVEMENT OWNER-BUILDER DECLARATION OVER IfH10 AMPS W I hereby affirm N:a I am exempt from the Conductors License Law for the ❑HATH REM R IR - D ip5t d U following reason(Section 9031.5,Business laid Professions Cade:Any city or comity SIGNS ELECTRICAL ❑OTHER W F' which requires a permit In construn,alar,improve,demolish„m repair any structure .. Prior to its issuance,also requires the applicant for such permit to flea signed statement SPECIAL CIRCUIT/MISC. that he is licensed pursualto the provisions of the Conductors License Law(Chapter 9 - 00 (commencing with Section 7”)of Division 3 of the Bushossand Professions Code)or TEMP.METER OR POLE INST. J+ COMMERCIAL' a c that he is exempt therefrom and the basis.for the alleged exemption.Any violation of Section 9(131.5 by any applicautfor apermit subjectstheapplicranInc ,,it penalty of POWERDEVICESr El NEW BLDG/ADDITION L1 DEMOLITION not mere than five hundred dollars($500). O TENANT ❑FOOD SERVICE SQp ❑I,as owner of the property,or my employees with wages as their sale compencdion. SWIMMING POOL ELECTRIC IMPROVEMENT will do the work,and the structure is not Intended or offered for sale(See.9044:Business - OOTHER and Prefer:ions Code:The Contractor's Lieene Law it.,not apply to an owner of OUTLETS-SWITCHES-FIXTURES A' property who builds or improves thereon,and who does such work himself or through . his own employees,provided that.such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. h p sale.If,however,the building or improvement is sold within one yearofcompletion,the - SQ.ET.FLOOR AREA ti g�, $/SQ.Fr. owner-builder wilt have the burden of proving that he did not build or improve for Aur- pose of snleJ, A� 7 ❑I,as owner of the properly,am exclusively contracting with licensed cmtmeton to e Y y•,[T amerced the pmJwt(Sec.9044,Business and Professions Codo:j The Canureon's Li- reuse i- i� (� nI /yin does net for suepplyman with aofproperi who sedporimproves Chown,and QTY PLUMBING PERMIT FEE of�jw Ix79L who contracts for such pmjeda with a cantmnar(a)licensed pursuant m the Cummemrs (Jp License Law. EALTER E UI/I CrJ - ❑lamexemptunderSee. ,B&PCfur this reason Jf4U , VENT-WATER ILA)Owner Date e VALUATION WORKER'S COMPENSATION DECLARATION • ECT.DEVICETherebyaffirm❑ Ihaveandwill maintain a Calificaa ofCca,cat w self-inure forWorkers Camer- RUDE,AREA,GOND. STORIES TYPE CONSTRUCTION sation,vs provided for by Section 3900 of the Labor Code,for the performance of thework fur which this petioli is issued. s RAP ❑I had and will maintain Worker,Compensation Insurance,as required by Section 3900 of the labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS My Walk s's Campers lion loam nee carrier and Policy n}i� �e OCC GROUP. APN CladecV�� Policy No.: •xrv/I�AI•J ON(� GAS-EA.SYSTF,M OVBR4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE GREASMNDus,rkL WASTE INTERCEPTOR ('Bis section need not he mmpined ifihe permit is forono hundred dollars($100) - - BUILDINGDIVISIONFEES- orless.) GREASETRAP ` PLANCHECK FEE I certify that in the pertmmanceoffie work forwhich da,vmil is issued,l shall SEWgR-SANITARY- ot em lc an a n STORM EA.200 FP. p y y peracn in any mm r t s t o 1'd m the kers'Comped- - ENERGY FEE z sotion Laws of Califomi. at O A locant IL WATER HEATER WNEN'I'/ELECfR .. FC) PP GRADING FEE ay NOTICE bj APPLICANT:the IL Cray making is tate of Exemption,you should WATER SYSTEM?BEATING �^ become subjecttothe Worker's Compensationpro ms of the Labor CMe,you most SOILS FEE [>a n✓y forthwith comply wish such provisions onhia permit ehvll be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,ET. PAID U O Ihereby affirm that thea is a consdvetirn lending agency for the performance of Dore # Lr the work for which this permit is issued(Sec.3099,Civ.C.) , Lender's Name _ O x� Lender's Address TAI-' LL 1 readily that i have read this application and stmt that the above information is BUILDING FBE V) comet.I agree to comply with all ciryond aunty ordinances and store laws relating to QTY, MECHANICAL PERMIT FEE U ,Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC PEE above-motioned property for inspection purposes. (We)ug.um save,Indemnify and keep harmless the City of Captain.against PERM ITISSUANCEELECTRIC FEE liabilities,judgments,costs and expenses which may in any way cattle against said City ALTER OR ADDTO MECH. In consequence of the grading of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to,"CPM) SOURCE' EG'LATIONS:, MECHANICAL FEC• _ AIR HANDLING UNIT(OVER 10,000 CPM) (Q� CONSTRUCTION TAX Si alureof Applicam/Co m Rf pas' EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HAZARDOUS MATERIALS DISCLOSURE Will Rio applicant or future building occupant store or handle hazardous mlaedal HEATING UNIT(TO 100,000 BTU), as defined by the Cupertino Municipal Code,Chapter X9.12,and the Health and Safety Cede,Section 25532(a)^ t HEATING UNIT(OVER 100,000 BTU) - ❑Yee ONo VENTILATION FAN(SINGLE RESID) PAID Data Receipt# Will the applicant or[alum building occupmt use equipment or devices which coal lizlmlus air contaminants as defined by the Bay Area Air Quality Management .BOILER-COMP(3HPOR 100,000 BTU) , District9 - - TOTAL: ❑Yes ON. - f BOILER-COMP(OVER 100,000 BTU) ' I have read the hazardous mvmeivis requitement,under Chapter 6.95 of the Cali-. AIR CONDITIONER ISSUANCE DATA famia Health&Safety Cole.Sections'25505,25533 and 25534.1 understand that if the NEW RBSIDBN'[IAL MP,CH. SQ.FT building does not currently have a round,Nal it is my responsibility to runty the vacation . " - of the requimmn 1,which must be met prior m issuance of a Certificate of Occupancy. Owner or auNonud agent Date TOTAL: ISSUED BY: OFFICE