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28759 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. APPLICATIONIPERMIT PLUMBING.MECHANICAL 287 Q BUILDING DIVISION BUILDING PROJECT IDENTIFICAI'I ION v BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL UK X&;- 1-13 s � a r,4- CN. �- OWWNNBER'SNAME: 1 PRONE: �J�p C/TOR/SNA ': ,ILIC NO V zA S L C xJ'OSR 13 — (O �� C l . r(` `SVCI -17� 4 NIC CONTROLp �ARCHITECT/ENGINEER: LIC NO'. ADDRESA3T? Ditt-A Avo 56UkA S ❑ FD PHONE: JJ BUILDING PERMIT INFO 4 SJre� ��3y ❑ Consultant Facts Paid by Applicant(Initial) BLDG ELECT PLUMB MECH U ❑ ❑ ❑ uceaslt1)coNl'kncmks DECLAkn'noN QTY ELECTRIC PERMIT FEE affirm that Loan licensed under provisions of anger 9(commencing JOB DESCRIPTION Q 4'Z )of Division 3 ofthe Business and Profusions Candle,andm license is W00 y PERMIT'ISSUANCE RESIDENTIAL: F effee, GUU cad LOLica ❑SFDWL El KITCHEN REMODEL HZW contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE.P[M ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL Z o y.Z. 1 undasnand my plans shall be used m public records MODIFICATION Oil FO 200 AMPS P�2t:w Licensed Professional Cl INTERIOR [I CHIMNEY REPAIR 201-IMAMPS IMPROVEMENT a � OWNER BUILDER DECLARATION OVER 1000 AMPS ❑BATH RF,MODEUREPAIR ❑ EMOLITION CC a 1 hereby affirm that 1 am exempt from the Cnmruclor's Licence Law for the x4�t I- following malson.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER 0 19 F ly'3 which requires a permit to conlter naw ,a ,improve,demolish,or repair any su icume pri�rmits issuance,also rcyuirea theupplicam for such pnmiuo Neuzigned statim°m f } SPECIAL CIRCUIT/MISC.that he is licensed pursuanuo the provisions of the Contractors License law(Chapter 9 HMO (aommenciny with Section 900Bof Divisio l3ofthe Husinessand Profla"ianzCWe)or TEMP M I.I ER OR POLE INST. COMMERCIAL• 6 a c tG that be is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEN'BLDG/ADDMON ❑DEMOLITION �y Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES not more than rive hundred dollars 5500). ❑TE:NANT ❑FOOD SL'RVICE IMPROVEMENT MEE 0 I.as owner of Neproperty,ormY employees wish wages as their sole marcensation, SWIMMING POOL ELECTRIC d•F. will do the work,and the structure is not intended or offered for%ale(Sec.9UJ1,Business ❑OTHER W and Professions Code:The Conhaaurs License Law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES 0.3 pmpeay who builds or improves Location,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. sale.IL however,the building or improvement is sold within one year ofecmpletion.the SQ.FT.FLOOR AREA J/SQ.FT. owner-Wilder will have the burden of proving that he did not build or improve for Law- posc of micJ. ❑ 1,as owner of the property,am exclusively contracting withlicensed convenors to TOTAL: reaction the pmject(Sec.70H4,Business and Professions Cadet)The Contractor's Li- oeme Law does not npplym an owneraf progeny,who wild,or improves daemon,and QTY, PLUMBING PERMIT FEE who contracts for such projects with s cumractons)licensed pursuanuo the Comiuma rs License law. PERMIT ISSUANCE I um exempt under Sec. ,B&P C for misremon ALTER-DRAIN A,VENT-WATER(EA) Owner Data VALUATION WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE I hereby affirm under pcnahy of perjury one of the following drelemtions: ❑I baveand will mairwit.Cerifcamal'Consenuo self-tore far Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCf10 Worn.ns provided for by Sectio 3700 mthe Labor Code for the performance of the work for which this permit is issued. FIXTURES-PER TRAP i]1 have and will mzinmin WnrIcA Comcensaion Imumnre,as limited by Section 3700ofthe LaborCWe,forthe performanccofshe work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN My Workers Compensation Insurance Gamer and Policy mumbo are: Grtirn Polley No: GAS-EA.SYSTI?M-OVEk4(E {f) CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSFl1N LWASTEIMERCEPTOR Y COMPENSATION INSURANCE UILDING DIVISION FEES IThis vection need net bocomplcted if the permit is forme M1unJrcddollars(51(x8 GREA TRAP or less.) t PLANCHECK Pat 11 9 U 199 I cent fy that in the performance of the work for which this permit is issued,I shell SE ER-SANITARY-STORM IIA.2W FT not employ any perum in any mann55 s�been.•s to the:Workers'Compere ENERGY PEE ,z, ,arum lass99((C:�tfr,mr ate, y,R io'�4 �}' f I � 0 Applicmm�Jfk,� J AT[R HEATER WNENT ECTR -_ ,z res `---F "^'^•`!�`•' GRADING FEF, r fT I y NOTICE TO APPLICAM':Il.after making this Certificate of Exemption,yaw Aould WATER SYSTEh AT a ; became subject to be Workers Compensation provisions of she Liber Code,you must J, SOILS FEE W forthwith comply with such pmvrnonsar this pem,it.vhall he derated revoked. WATER SERVICE f1 Q U z CONSTRUCTION LENDING AGENCY NEW SID N L FT. PAID I hereby which this Permuhat te issued(See 30lending agency for the performance of Doc ReeeiptN tzsC) Ur. she work for which thin permit is issued(Sec,l09],Civ.CJ Leaders Name WLendcr'x Address TOTAL o TOTAL: F0. I comfy that I have road this application and.pate that the above information is BUILDING FEE fA correct.l agree m comply with all city and amntyordimmens:md.dam lowsrclwingm QTY. MECHANICAL RMIT V Z building construction,and hereby authorize representatives of this city to enter upon the FEE SEISMIC FEE above-mentioned property for inspection purposes. (We)agree to nave,indemnify and keep hmmlcss the City of Cupertino against PERMI SUANCE g ELECTRIC FEE fiabiinconsequenc of mecostsanJ expenusmit. may in any way wcrve against vend City ALTER ORA MECH. consequence of the 6reming of this permit. PLUMHING FEE APPLICANT U LRSTANDS AN W .L COMPLY ITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFMI 3RfiREGIA TIONS MECHANICAL FEE ) AIR HANDLING UNIT LOVER I u.un)CI'M) CONSTRULTIONTAX Shealowe of ApplicanVComracmr Date EXHAUST HOOD(W/DUCl HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION ME Will the applicant or future building oceupam store or handle huzardoos material HEATING UNIT G Q 100.000 BTU) as defined by the Coplanar,Municipal Code.Chapter 9.12,and the Health and Safety Code.Section 2553200 HEATING UNIT(OVER I(l0.odd 131 U) LD Yl, 1 No VENTILATION FAN SINGLE RESID) PAID Will the applicant or fusers building use equipment or devices which Dam Receipt a emilhteardous air conmminams as defied by nby are the Bay Arca Air Quality Managemrnt BOILER-COMP(3HP Ok IUB,IXIO BTU) District? Al.; ❑Yes CIN. B OILER (OVER IW,(xq B'fU) I have mad the hazardous matenul,mat ireanea under Chapter 6.95of the Cali- ER ISSUANC DATE fomiu Health S Safety Code Sections,tied it is my and 25534.1 uWotify I Lha if the MECH. FMIAI building does sot is medywhich have o tenant, oro is sea ce Of a Cerry ca notify Ne occupant of the requirements which must he mut poor to issuance of a Certificate of Occupancy Owner or authorized agent Data ISSUED BY: OFFICE