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31292APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY' OFFICE CITY OFCUPERTINO BUILDING - ELECTRICAL PERMITNO. a] '�n BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL J G BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: - �•Yry - - O "7 Ccl SANITARYNO, APPLICATION SUBMITTAL DATE r -77 WNER'S NAME:' '' PHONE: CONTE CTOR'S NAME:• LIC NO: 41 NIC ❑ CON ROLM - ' It- ARCHITECT/ENGINEER: LIC NO: ��. ADDRESS:' CONTACT, `1 B..oFy PHONE: 1(p /.•.+ �P3 ElCOnaultaat.Peee Paid by Applicant (Initial) BUILDING PERMIT INFO BLDG, - ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATIO 1 hereby affirm that I am licensed ander provisions of Chapter 9 (commencing with Section 7000) of Division 3 ofthe Business and Professions Code, and my license is m full farce rehouse Cloys Lic: W Date (r�Con DEC. ARCHITECTS DECLARATION I understand my plans shall be used as public records - QTY ELECTRIC PERMIT PEE MWz { 00 F O mWF G Oz U yd� F, p y N q vi 9z vi q 4] 04i,`gl C4 6 3- 0 y 00 W p y ^y ❑da 0i JOB DESCRIPTION RESIDENTIAL ❑SFDWL ❑ KITCHEN REMODEL CIADDITION ❑ PLUMBING RE -PIPE ❑MULTI -UNIT El STRUCTURAL MODIFICATION ❑IMPROVE j}CHIMNEY REPAIR IMPROVEMENT ❑ BATH RCMODELIf2EPA1R (] DEMOLITION ❑OTIiBR (L ��—j Iwo ,. PERMIT ISSUANCE - -AFPLIANCES-RESIDENTIAL • PANELS - '_ UP 10200 AMPS Licensed Professional • OWNER BUILDER m DECLARATION, 1 hereby off that 1 pt from the e i t L La for the whichog es(Scroll]IVIS B: :, dP f _CD Any 'ty county which "a p 't b a t Paan t nuance, also regmrcsthhappl wm for such permit mFile asigned statement that be is licensed ptmuam m the provisions of the Comment," License Lnw (Chat, 9 (commencing with Section]000) ofDivision3 note Business and Professions Cnde)ar that he is exempt therefrom nvd the basis for the alleged exemption. Any vlolotinn of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mare then F, so hundred delta,,(S500f EI I, as owner of the property, or my employees with wages as thelrsole compen_ shim, will d.hw work, and mr....dere is not intended oroffhrhd fill sale (Sec.7044, Business and Professions Code: The C rmrmmrs License Law dee, not apply m an owner of property who builds or improves thereon, and who does such work himself or through 2rll IOW AMPS - OVER 1000AMPS SIGNS ELECTRIC + SPECIALCIRCUIq TEMP. METER OR POLO INST. -COMMERCIAL [I NEW BLDG/ADDITION El DEMOLITION - OTENANT El FOOD SERVICEyp. IMPROVEMENT ❑ OTHER - POWERDGVICES - - SWIMMING POOL ELECTRIC OUTLETS -SWITCHES -FIXTURES ' his own employees, provided shot such impnwements are not intended nr offered for NEW RESIDENTIAL ELECTS SQ UC " sale. If, however, the building or improvement is sold within oneyearof compldnon,the ef-builder will have the burden of proving that he did not build or improve fca lam. SQ. FT FLOOR AREA $/SQ. FI'. ps,seotmlt ) ' TOTAL: ❑ 1, as owner.f Iheproperty, am exclusively contracting with licensed o.mmomm u, nswet the project (Sec. 701 Business and Professions Cede) The Convactnr's Li- �� + QTY, PLUMBINGPERMIT FEE cense Law does not apply to an owner nfproperty who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Commeters - PERMIT ISSUANCE License Law. I am exempt under See. ; B & P C for this reasov ALTER - DRAIN '& VENT- WATER (EA) nor Date VALUATION _ WORKER'S COMPENSATION DECLARATION I herebyaffirm under penahy of perjury ane of,ha Fallowing dedmmions: BACK PLOW PROTECT. DEVICE Ilrr YDS Q� 1rY'h-,U DRAINS- FLOOR, ROOF, AREA, COND. El I have and will maintain a Certificate of C.nsmn to self -insure for Worker's Camper- soilsp , as provided for by Section 3700 of the Labor Code, far the performance of the . S ORIGS TYPE CONSTRUCTION FIXTURES -PER TRAP ' work far which this permit is issued. © 1 have and!will maintain Workers Compensation Insurance, as required by Section 00ifihe Lobar Code, for the perl'ormanceofthe work for which this permit is is.sued, My Wnrk C n ensatint tsumnce courier and Policy n�uQ��heparo' or GAS - EA. SYSTENUI IN O OCC. OROUP APN GAS - EA. SYSTEM�OV (A) Carol ,`Policy Ne, jsLW faI2'7/1' ih ' Z O xbeware ' CERTIFICATE 41 EXEMPTION PROM WORKERS' COMPENSATION INSURANCE C*jg, OAS, (ThissectionneWnht be completediftha permitisromne hundred dallnm ($I(10) on leix.) Icertify the, its theperfonnanaofthe work for which thiapennit is timed, TOOPLANCHBCK imemployory,...;a in any manners. as m become subject to the WorkerComer- sedan Lucas of California. Dace p Applicant GREASEIINDUS9'RLW STEINTF,RCP.PTOR - ,,-' -, BUILDING DIVISIOY Tic GREASETRAP / PGE- SEWER -SANITARY- STORM EA. 20x1 FT. ENERGY FEE WATER HEATER WNENq'/ELECTS GRADING PEE .. NOTICE TOAPPLICANT.IL.hermakingthis Cenifiwmof Excrtaimi youshould sutiJact to the Workers Compensation provisions of th. Lahr Code, yon must . WgTERSYSTEMITREATINO ILS FEE Y Q J O fnnhwith comply with mch provisions ur Nis permit shall he Aeemed revoked. CONSTRUCTION LENDING AGENCY tharwhillido,hauhemissue agency f.nheperformence ofReedplMthe WATER SERVICE NEW RESIDENTIAL PLMB. `D �6 Cing (Sri. work for which tis permit is issued (Sec. 3f19], Civ. CJU Lenders NameTOTAL:Lki LendersAJdtess - - 1 county that I have reed this application and smut that teaboe information Is churc. I agree to comply with all cityand contyordlrrncesandstate lawsadeting to building cnnmmction, and hercM1y uuthonze representatives of thiscitymenterupon the LDIN FEE t,00 QTY. MECHANICALPE,%.. SM PF.Eaove-men,loned *- property for inspection purposes.PERMIT agree nfsnve, ivdemvi[y and keep harmless the City of Cupertino agaln,n ISSUANCE(We) FEBliabilities,judgments, costs and expenses which may in any wry accme against said City consequence of the granting of this permit. ALTER OR ADD TO MCCH.in MBIN EBAPPLICANT HANDLING UNIT (TO 10,(IO CPSOURCE UNDERSTANDS AND WILL COMPLY WITH ALL NON:POINTPIR REGULATIONS. HANICAL :E - AIR HANDLING UNIT VP.R IO STRUCTIONTAX Signawre of Applicant/C.mracmr 'Heear HAZARDOUS MATERIALS DISCLOSURE EXHAUST HO ( D HOUSING MITIGATION FEF. HEATING ONI XL BTU) Will the applitavmr future building.reepantsmre or handle hazardous rame'al' - as defined by the Capacious, Municipal Code, Chapter 9. L1, and ,he Health and Snfdy 11 sillll6ode, Settlors 25532(a)7 HEATING UNI (OVER 10000 BTU) tkoin❑Yes 151 No Will the applicant or future building occupant use equipment or devices which it hazandous air contaminants os defined by the Bay Area Air Quality Management c,11 PAID , Dale . Receipt st VENTILATION FAN(SINGLE REMD) BOILER -C P(3HP OR I fit" BTU)TAL: BOIL-COMP(OVER 100,000 BTU) El Yea In - AIRCONDITIONER I have read the aromatic matrial. requirements nrk.f Chapter osa that if be fomta Heats no 9uruy Cod Se i 25505,25533 ar 1 d 25594, I tone w d that if be building does not currently have a, rant thatrt 'yrepb'I'ry, notify the occupant o&he mements whth a,beme, prior m issuance ofa Certificate of Occupancy. hr� _ IS U NCE T �__• J _ rxs '�(I ISSUED BY: rC A ` O NEW RESIDENTIAL MECH, SQ. IT. - Owal: Named agent 6 „ ° TOTAL:Y OFFICE