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29536APPLICANTTO FILL IN INFORMATION WITHIN REDLINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO•• RUILDING - ELECTRICAL ❑ Consultant Fees Paid by Applicant (Initial) PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMPING -MECHANICAL ❑ ❑ ❑ x91 LICENSED CONTRACTORS p DECLARATION I hereby off rte Wm 1 nm licensed undo provisions of Chapter 9 (commencing withScnion 7lp07 of Dlvlslon3o[We Puniness and Prnfcoions Codaandmyliceacis full force and effect. License Class LICtr Dam Contractor BUILDING PROJECT IDENTIFICATION JOB DESCRIPTION RESIDENTIAL', ❑SFDWI. ❑PLUMBIN RE -PUT. ❑ADDITION E-1 PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION El INTERIOR ❑CHIMNEY REPAIR IMPROVEMIiNT ❑ PATH REMODBUREEPPAITR [I DEMOLITION PERMIT ISSUANCE BUILDING ADDRESS:- �'0,41'L 4 All CvPcrrs'? o/ 'e,4 9So l SANITARY NO, - APPLICATION SUBMITTAL DATE. ?, 435 5 (q1V OVER I1E)AMPS y SPECIALCIRCUI'P/MISC. P 1 4,, 2Q COMMERCIAL' ❑ NEW BLDG/ADDITION ❑ DEMOLITION []TENANT FOOD SERVICE IMPROVEMENT El OTHER - NUR'S NAME: PHONE: MA rnov0 SHAM"M(f`—ZS .OMRACTORS NAME: Ownrr LIC NO: SWIMMING POOL ELECTRIC r OUTI.R'fS -SWU CHAS - FIXTURES 16b� r q NIC CONTROL kCHITECT/BNGINEER: LIC NO: I ADDRESS: - ❑ OFFICE _........ .......... ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MITCH ❑ ❑ ❑ X00aez �WO F.ODEL UF�] �+aa LICENSED CONTRACTORS p DECLARATION I hereby off rte Wm 1 nm licensed undo provisions of Chapter 9 (commencing withScnion 7lp07 of Dlvlslon3o[We Puniness and Prnfcoions Codaandmyliceacis full force and effect. License Class LICtr Dam Contractor QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION RESIDENTIAL', ❑SFDWI. ❑PLUMBIN RE -PUT. ❑ADDITION E-1 PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION El INTERIOR ❑CHIMNEY REPAIR IMPROVEMIiNT ❑ PATH REMODBUREEPPAITR [I DEMOLITION PERMIT ISSUANCE APPLIANCES -ItLSN1iNTIAL pm 2 rr-LL 02- _ ARCHITECPS DECLARATION I understand I hit Teased blit.cords ypnns,a pu PANELS UPT02g1AMPS gij�OWNER-HUILDER yS Dd a d U LLWI 0. �k�0y }that Licensed Professional DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law far the following reason. (Smion ]011.5. Business and Professions Cade: Any city or county which requires n permit to en31.5, H, cher, land Pr, d dais, C de repair imy st county prior to its issuance, also requires We applicant for such pemdno file a signed statement he is licensed pursuant m the Emissions of the Commnoh License Low (Chupter9 201-I)p AMPS OVER I1E)AMPS ti1GN5 ELECTRICAL. SPECIALCIRCUI'P/MISC. P 1 TEMP, METER OR POLE INST. COMMERCIAL' ❑ NEW BLDG/ADDITION ❑ DEMOLITION []TENANT FOOD SERVICE IMPROVEMENT El OTHER - G0 6 IN c K -,m S^Si+ Qp(]I, a f.. (commencing with Section 70(m) of Division Sof the Bmxlnee,and Professions Cdc)or that he is exempt diercfmm and the basis far the alleged exemption. Any violation of Section 703 IS by any applicant for a permit subjects the applicant to a civil penalty of .not mac than Eve hundred dollar (SSW). es owner o(We prnpeny. nr my employes wiNwagesestheirsolecompens�ti�n, will do the work, auddadontur, is nm intendedoroRered snk fe (So, 70U, Business and Pmfessinne Cale: The Cantracmr's License law does Out apply to no owner of POWER DEVICES SWIMMING POOL ELECTRIC r OUTI.R'fS -SWU CHAS - FIXTURES 16b� r 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 R17SIDEWIAL ELF.CI'R SQ FT safe.IL however, We huilding or improvement is sold within one year olbompletion,the SQ. Ff. FLOOR AREA S/SQ. Fr. owner -builder will have We burden of proving that he did not build or improve for nt pur- Poof side.). ❑ 1, as owner of We pmpeny, am exclusively contracting with licensed contraaory In P ..w y 4 .. TOTAL: construct the project (See 7040, Business and Professions Core, The s Li- censeLuwdoesnotapplytounownernfmopertywhobuildsorimprovesthereon,and 291996 QTY, PLUMBING PERMIT FEE e a onurnewns) licensed purounm omn t the Ctctm's PERMIT' ISSUANCE License law, Ej nes to 1&P C for Nis renam _ /■ry'p1" / (!?,,I jr t..n t_,I I ENO Owner � Date ALTER - DRAIN & VENT- WATER (EA) VALUATION WORKER'S COMPENSATION DECLARATION 1 hereby a1Rrm under penalty of perjury one of the following declurntlon.: BACK FLOW PROTECT, DEVICE DRAINS- FLOOR, ROOF, AREA, COND. ❑ I have and will maintain a Certificate ofConsenuo self -insure for Workers Canapes ,.tion, as provided for by Section 3](10 of the Labor Cade, for the performance of the STORIES TYPE CONS'THUCIION FIXTURES-PEik'TRAP work fm which this permit is maimed. C3 1 have and will maintain Workers Compensation Insurance, as required by Section 37M niche Lubar Code, for the performance ofthe work for which this permit is issued. Worker's Compensation Insurance carrier and Policy number are : GAS - EA. SYSTEM -1 INC. 4 OUTLETS UCC. CROUP AI'N Carri Ca er. Policy Nn: GAS -CA. SYSTEM -OVER 4 (PA) ' CEinT FICATE OF EXEMPTION FROM WORKERS' Oz z O COMPENSATION INSURANCE (This sectineedm b ne completed if the permit is fore hundred dollars (Slip) or less.? I certify that in the perfnrmnncenf Wework forwhich chi, Ectatic Basted.l0mll not employ any Person in any manner so as m become subject n the Worked Compen- otinn Lawsof Calificau. Date Applicant GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES GRF.ASIi TRAP PLANCHECK PEE SEWER -SANITARY -STORM FA. 2W FT. ENERGY FEE WATER HEATER W/VIiNT/ELECfR GRADING FEE _ NOTICE TO APPLICANT: If, afar making this Ceniftctae of Exemption, you should becoom subject to the Workers Compvnsa n it pmvl,ivnx of the Labor Code, you and forthwith comply with such provisions on his pe.it hal) be dcemodow.ked. CONS atthe isaconNLENDINGAGENCY l her Which mnhenherc iso ed(Scetimt lending agency for We performance of work for which this permit is issoed(Sec. 3097, Civ. CJ Lender's Nome Lenders Address WATER SYSTF,MG7REATING Ir FN -t U z L) Q Lks Fthe U W O SOILS IrIlB WATER SERVIC17 PAID Date Rtteiptp NEW ItI?$IDP.N'I'IAL PhMB. - SQ. EC r - ' 'TOTAL: 1 certify But P hove read Wis npplicaion and emm that the above information is BUILDING FEE QTY. MECHANICALPERMIT FEE I U correct. l agree it) comply with all city and county ordinances and state laws relwingm building construction, and hereby authorize representatives ofthis city to enter upon am SEISMIC FEE an keep es. (We) (We7 agree m save, indemnify and keep hannlms the City of Cupertino against )agree to save indemnify PERMIT ISSUANCE 17 'Lr RIC PEE ALTER OR ADD TO MUCH. Iiabilities,judgments,cu,ta and expenses which may in anyway reame against said City in anscquence of the granting of,hi, permit. PLUMBING ME APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. x - ' AIH HANDLING UNIT (TO 10,00p CPM) MECHANICAL FEE , AIR HANDLING UNIT LOVER 10.000 CFM) CONSTRUCTIONTAX Signature of AMlicanVCommdn, Una HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT (TO 100,00) BTU) Will the applicant or future building Occupant stare or handle haaanlons material as defined by the Cupertino Municipal Cade. Chapter 9,12, and the Health and Safety Coda Section 2553200] HEATING UNIT (OVER I00,000ITTU) '- ❑Yes ❑Nu Will the nit licantcomm nfoam building by the B use eyui it Qj or device, which Disic,'t ous air nmaminan0 as Defined by the Bey A. Air Quality Management Dinricft PAID Date Receipt# VEN'T'ILATION FAN (SINGLE RESIDE BOILER-COMP (3HP OR Iw,rvp BTU) TOTAL - OTAL:❑Yes BOILER-COMP(OVER I00,000BTU) 7 Y.7 N .. AIR CONDITIONER , 1 hove mad Ne h;uallous mmeriats p reyuircmems under Chu tar fi 95 of the Cali- forma Health & Safety Code, Sections 25505, 25533 and 25534. 1 undersand than d We Vernon.uilding does not currently have a nnon. that it is my resrymsibility m notify the occupant of Ne cquicanevts which must he met prior to iseuanco of a Cedi Ecme of Occupancy. ISSUANCE DARE — NI? W RESIDENTIAL MECH. SQ. IT. OFFICE