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B 0155 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUFERTINO BUILDING-ELECTRICAL PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0 BUILDING J0001 X0155 PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. 7APP,CA] T'A ION SUBM ITI.DATE *66tz OleC v �_.�Ti.vo 7000 OWZL // ��/Y �PHON7OVi CONTRACTOR'S NAME, LIC NO NIC C. 'fROLp Clill'ECfI GINEER: "LIC NO: ADDRESS: ❑ - CONTACT: PHONE: BUILDING p Q BUILDING PER INFO qL S, ��Kz Yo P 893_ J gg ❑ Consultant Fees Paid by Applicant(Initial) BLDG ECT PLUMB MECH ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FCC 1 hereby affirm that I am licensed under presidiums(if Chapter 9(commencing - JOB DESCRIPTION W0ZmfmOction d�)dMuvision 3oflhe Business and Professions Code,and my license is PERMIT ISSUANCE O RESIDENTIAL: O hard UZ 1'" License Claes - Lic.N TOWE ❑KITCHEN REMODEL MDate Common, APPLIANCES-RESIDENTIAL CADDITION El PLUMBING RE-PIPE yy ARCHITECTS DECLARATION _ ❑MULTI-UNIT []STRUCTURAL H.z I understand my plans&ball be used as public retards PANELS MODIFICATION �y'/jQ _ UPT0200AMPS El INT HRIOR [_1 CHIMNEY REPAIR W Licensed Professional 201-Intro AMPS IMPROVEMENT E]SWIMMING POOLS � J OWNER-BUILDER DECLARATION R1 hereby,alarm that am exemptfmm the Cdnnn aare License Lew for the OVER I1000 AMT'S El BATH REMODEIAREPAIR C DEMOLITION iWWiyy following reams.(Section 9031.5,Businessland Prnfessions Cade:Any city or ammy SIGNS ELECTRICAL. C OTHER 1++ 0 which requires a permit to colo el alter,improve,demolish,or repair any structure prlono its issuanceals000,im,the applicant for such Permit to Theo signedstatement SPECIAL CIRCUIT/MISC. 2 ,1 that he is licensed pumuani m the Pmvninms of the Contractors License Law(Chapter9 6� (commencing with Section]0110)ofDivision 3 ofthe Business and Professions Code)or TEMP.MEIER OR POLE.INET. COMMERCIAL: that he is became therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGADDITION C DEMOLITION W^h Section'10AS by any applionl for a permit sobject,theappljdhnl to a civil penalty of POWER DEVICES []TENANTCFOOIJ SERVICEF. Z, more than five hundred dollars($500). IMPROVEMENT d i.as owner of the prorty,peor my employee,with wages etheir sole wnperrsmion, SWIMMING POOL ELECTRIC F,� ill do the work,a ad tuagracmrc is not intended or offered for sold Fica.9044,Business ❑OTHER m and Professions Calc:The Contractor's License Law does rat apply to on owner of OUTLETS-SWITCHES-FIX'I ORES ,,.,mywho builds or Improves thereon,and who does such work himself m through his own employees,provided that such improvements are not intended m offered for NEW RESIDENTIAL ELECTS SQ FT. - saleIf.however,the helium,.,improvernme i„old within,be year to completion,the SQ,FT,FLOOR AREA S/SQ.PT, owner-builder will have the burden el proving that he did not build or improve for per- Pool co sale). - 143 ❑ a I,as r of primary,e prmpenam exclusively contracting with licensed eonetm TO ramrod the pr jeer(Sec 1044.Husines,and Pmfasmans Code)The Contmdors ase Law does not apply it)an owner of property who builds or lmproses thereon,and QTY.' PLUMBING PERMITFEE whoeommds fo muco projects whit a contractor(,)licensed purwanuo Iba Canaorti License Low. PERMIT ISSUANCE ❑1 or.exempt under Sea ,B&P C Sa this ancon ALTER-DRAIN&VENT-WATER(EA) VALUA TION Owner Dam WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby affirm under penalty of perjury ane of the following declarations I have and will maintain a Certificate of Consent no sell'-insure for Worked&Compen- DRAINS-FLOOR,ROOF,ARBA,CON anon,as provided for by Section 3700 of the Labor Gale,fnr the performance of the AMBLES 'I'VPE CONSTRUCTION work for which this petro is Issued. FIXTURES-PER TRAP ❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 other Labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP ARK My Worker's Compensation Insurance carrier and Policy number am: Carrie: Policy No.. GAS-EA.SYSTEM-OVER 4(EA) -CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR „ s (Thseection deal ant be completed lithe permit is room,hundred dollare($100) B ILDING DIVISION FP.F?S or lam) GR IASE'1'RAP PLANCIIECK FEE I certify that in the performance to work for which this permit is issued,I shall SEWER-SANITARY-STORM P.A.200 FIL am employ aion tiny prin any mm m manner so became object er.J C o the Workompee- ENERGY FERP Z cation laws of California Data WATER HEATER WNENVELGC'US T 0 Applicant iI GRADING FEE 1za r~N-a NOTICE.TOAPPLICANT:If,ager making This Certifcan nl'Exemption,your should WATERSYSTEMTREATING SOLISFF become ,object m the Workefs Compensallon provision,of the Labor Gyle,you must forthwith comply with such provision..or this permit shall be deemed revoked WATER SERVICE sJ A � Z CONSTRUCTION LENDING AGENCY NEW RESIDEN TIAL PUSH. SQ.FT. PAID d11Y_L�LVUt I hereby affirm that there is a acclamation lending agency for the pafonnenw of the work for which this permit is issued(Sec.3097,Ci,C.) Lender's Name 'I'O'1'AL: C) Lender's Address I 'TOTAL: rti k1 1 certify that 1 have mail this application and state that the above infnmwtion is BUILDING FEE F-a Vi correct,i agree to comply with all city and county onlinances and state laws reining to QTY. MECHANICAL PERM[rr FEE L) ZZ. building contraction,and hereby authorize representatives oflbiscity teener uponthe SEISMIC FEE above-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to ave,indemnify and keep harmles,the City of Crucial.spread PERMIT THE llabilres,judgments,tints and expenses which may in any way accord against said City ALTER OR ADD TO MECH. wasequense of the granting of This permit. PLUMBING FIT; APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT Dro 10,000 CFM) SOURCE REGULATIONS. MECHANICAL FEF. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of AppOcanVContmetor Dole EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATTERIAL 9 DISCLOSURE Will the applicant or future building ocenpant store or handle hazardous national DEAL[NO UNIT(TO 100,000 BTU) a,defined by the Cupertino Municipal Code,Chirpier 9.12,and the Health and Safety Code,Sudiod 25532(a)T HEATING UNIT(OVER 100,000 BTU) [I Y. EJ No PAID VENTILATION FAN(SINGLE kESID) Data Racier,N Will the applicant or future building eacepanl use equipment or devices which BOILER-COMP LOT OR IOO,000 RTU) tit hazardous air admonitions is defined by the Bay Are.Air Quality Management TGTA5 ,r© stride 0Yce E]No BOILER-COMP(OVER 100,000 B'PU) 1 have rood the heznrdams materials requirements CONDITIONER,under Chapter 6,95 of the Cali- ISSUANCE DATE humid Health&Safety fide.Sections 25505,25533 and 25534,1 ondernand that If the NEW RESIDENTIAL MECH. SQ,Ef. / — C building does not currently have a tenant,that it is my responsibility m ratify the amupam of the requirements which must be met prior to issuance of a Cehificam of Occupancy. !!((( Owner or authorized agent Date TOTAL: ISSUEDBY —/� Is OFFICE