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28542 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMrTNo. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL HUILDING PROJECT'IDENTIFICATION ' BUILDINGADDRESS: SANITARY NO. IAPPLICATION SUBMITTAL DAIS OWN 'S E: PHONE: CONTRACTOR'S NAME: LIC NO: ,(o-'C��y N/C CONTROL# NXTE T/ENGINE R LIC CNO: ADDRESS: - �rVVG�— CONTAC`E - GPHONE:r_ HUILDING PERMIT INFO 7_`��dlf�I .Q Consultant Fees Paid by Applicant(Initial) R F1ECT PLU MECH LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby affirm that 1 em licensed under provisions of Chapter 9(commencing JOB DESCRIPTION O3 with Section 9000)of Division 3of the Business and Professions fide,and my license is O O PERMIT ISSUANCE RESIDENTIAL �Vin full fomass effect ❑SFDWL. [I KITCHEN RF.MOUEI. License Class Cotta APPLIANCES-RESIDENTIAL. )DITION El PLUMBING RE-PIPE yZ)� nate T's DECLARATION l E.�un A,shallRCIM DECLARATION PANELS ]MULTI-UNIT ❑MODIFICATIO y0 Iuedersmnd my plans shall be use]vs public remNs MODIFICATION 0z UP T021XIAMPS ❑INTERIOR ❑CHIMNEYREPAIR H Fq'W Licenced Professional 201-1000AMPS IMPROVEMENT ,S d2 OWNER-BUILDERI maemptfrm Ce Cannaor OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION yyx C 1 hereby affirm that 1 Bxempl from the DECLARATION Licenxc Law B+r the U fallowing reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL . ❑OTHER which r,.aea a permit to mnumct,alter,improve,demolish,or repair any sw mm qq 3 prim w its issuance,also reyuirntheapplicam for such permiuo Dleasiloedslutement SPECIALCIRCUTI'/MISC. '2 a� thin he is licensed pursuant to the provisions nithe Cmuagors License lyw(Chapter 9 kkGG''ii (commencing with Section 7001h or Division 3 of the Business and Professions Code)or TEMP.METHRORPOLEINST. COMMERCIAL' d p�e C that he is exempt therefrom and the basis for the alleged exemplian.Any violation of El NEW BLDG/ADDITION ❑DNMOLITION iWC Y. Section 9031.5 by any applicant lot a permit vubjects the applicant to v civil penalty of POWER DEVICES lei []TENANT ❑EGOU SERVICE } not more than five hundred doll.($500). IMPROVEMENT C]1,as owner crude property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC will do the work,and the stmcmre is not intended oroffered forsale Ser.7044,Business ❑OTHER L3 and Profexsions Code:The Cantmetnrs License law does not apply m an owner of OUTLETS-SWITCHES-FlXTDRiS property who builds or improves thereon,and who does such work himself or through his own employes,provided and such improvements am not intended or offered for NEW RESIDENTIAL ELEC R, SQ FT. sale.If,howeveethe building or improvement is sold within one yeaofmmpletionJhe SQ.PT.FLOOR AREA $/SQ.FT. owner-builder will have the burden of proving than he did not build or improve for par- 1 \"' attain.). (Iv?faO(/g I,ns owner of the property,um exclusively contracting with licensed contractors to _ construct the project(Seo.9144,Business and Professions C(xle:)The Conbaemr's Li- cense Law does not apply loan owner nfpmpety who builds or improves thereon,and QTY PLUMBING PERMIT FEE , who enntmeds for such projeb wish v contractors)licensed porsuu ann the Commetor's ;cc`2T License law. PERMIT ISSUANCE l am exempt under Sec. ,B R P C for this mason ALTER-DRAIN&VENT-WATER(EA) VALUATION wncr De¢ WORITERS COMPF SATION DECLARATION BACK FLOW PROTECT.DEVICE n �� I hereby affirm under penalty of pedury one ofthe following declarations: (A ] I have unit will maintain a Cetilicate ofConsem to self-insure for Warker's Carrion- DRAINS-FLOOR,ROOR AREA,CON D, STORIES TYPE.CONSTRUCTION Sudan,as provided for by Section 7701 of the Labor Coale,for the performance of the work fm which this pemal is issued. rI,rI URES-PER TRAP I have and will maintain Workers Campcnxation Insurance,as required by Section J](gl ofthe Labor-Code,for the Performance ofthe work for which this permit is issued. GAS-HA.SYSTEM-1 INC.4 OUTLETS My Worker's Compensation Insurance certier and Policy number arc: OCC.GROUP APN Cinder. Policy No.: GAS-HA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPHON FROM WORKERS' COMPENSATION INSURANCE GRRASVANOUSTRL WASTE.INTERCEPTOR or 1<u) (Thissetion need not be completed ifuhe pemdt is forces hundred GREASE TRAP dollen($I00) B G )I ISION PIS PfANCHECK Loy any puddra the in Perany drmvncenf the work for whichthisperthe Wosissued, onapeshall SEWER-SANITARY-STORM P.A.2W PI'. not employ any person in any menncru:evo become subject to Wnrkm.'Compen- F.NENGYFc ,7s an, Laws of California.Date O O Applicant WATER HEATER WNENT73LP.CTR GRADE r a NOTICE TO APPLICANT:I[vfmr mskin this Cenifcatc of Excnnplinn,you should beeeme subject to the Workcrs Cma esu on WAl'IiN SYSTEM/I'REATING a , ps provisions of the Labor Cole,you must SOILS IEEE 0.� � forthwith comply with such provisions or pcmm shall betlemW revoked. WATER SIiNVICE 0 .U7. Z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.PI'. PAID V 0 work which thatthemi.canmswc.30 leading agency for the perfannvnce ofU. Dine Recipt f" the work for which Nis permit is issued(Sec.3(19],Cih,C.) Q V lender's Name TOTAL: ISP Lender's Address T A fy n 1 unify that 1 have read this application and state Nm the uMwe information is BUILDING FEE ,� M s rrcet.I ogres ro comply wim un city and county nNinnnces:rod nmm lows relining n. QTY, MECHANICAL PERMIT FEE V 4 huildingcon.ummien,andfamby mahoim representatives ofdhicciy u.ender upon the SEISMIC ME utawe-menlionW properly for inspection purposes. (We)ogive to save.Indemnify and keep harmless the City of Ceperllno against PERMIT ISSUANCE ELECTRIC HE ` liabilities,judgments,costsinl expenses which may in say way aunacti uistodCity ALTHR OR ADD TO MECH. in consequence of the granting of this permit, PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR DANDLING UNIT(TO 10.gp CIM) MECHANICAL FEE SOURCE REGULATIONS. AIN DANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAXI p T Signatureof ApplicartAontracto Date EXHAUST HOOD(W/DUCT') HOUSING MITIGATION PEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or furore huilAing:Kcupvm store ur handle haeuNnux mmedd HEATING UNIT ITO 110,000 BTU) as defnod by the Cupertino Municipal Code,Chapter 9.12,and the Heaah and Safety 11 Cede.Section 25532om? HEATING UNIT(OVER 100,000 BTU) ❑Yes- El No y fit- . VENTILATION FAN(SIPGLE RESID) PAID Date-lir s.Reel d# �5 Will the air conlat or furore building xehe B use equipment or devices which p.� mit hazardous air contaminanu as defined by the say Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU) SumcB TOTAL. ❑Yes 0 N BOILER-COMP(OVER 100,"DTD) I have real the hazanlous materials AIR CONDITIONER re,25533 an under Charter rsta of the if ISSUANCE.DATE fomia Health&Safety Code,Sections255(15,istoyand255]0,1 to rally th thatif the NEW RESIDENTIAL MECH. SQ,P. buildingdoes uirements ticallywhich must be met'llooro isms responsibility cficarear theoincy. t s '• ofthe requirements which moat he met�prinr to issuance Cetilicmo nr(lccupancy. ^ -I. Owner or authorized agent Date \O ISSUED BY: OFFICE